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The online version of this article (doi:10.1186/1471-227X-14-24) contains supplementary material, which is available to authorized users.
The authors declare that they have no competing interests.
HS conceptualized and designed the study, obtained research funding, supervised conduct of the trial and data collection, managed the data, takes responsibility for the integrity of the data and accuracy of the analysis, drafted the initial manuscript, and approved the final manuscript as submitted. AD contributed to the design of the study, interpreted the results, revised the manuscript and read and approved the final manuscript as submitted. DG contributed to the design of the study, interpreted the results, revised the manuscript and read and approved the final manuscript as submitted. RFM collected data, supervised conduct of the trial, revised the manuscript and read and approved the final manuscript as submitted. RDM designed the study, obtained research funding, supervised conduct of the trial and data collection, interpreted the data, revised the manuscript, and read and approved the final manuscript as submitted.
Early detection of compensated pediatric septic shock requires diagnostic tests that are sensitive and specific. Four physical exam signs are recommended for detecting pediatric septic shock prior to hypotension (cold extremities, mental status, capillary refill, peripheral pulse quality); this study tested their ability to detect patients who develop organ dysfunction among a cohort of undifferentiated pediatric systemic inflammatory response syndrome patients.
A prospective cohort of 239 pediatric emergency department patients <19 years with fever and tachycardia and undergoing phlebotomy were enrolled. Physicians recorded initial physical exams on a standardized form. Abstraction of the medical record determined outcomes including organ dysfunction, intensive care unit stay, serious bacterial infection, and therapies.
Organ dysfunction occurred in 13/239 (5.4%) patients. Presence of at least one sign was significantly associated with organ dysfunction (Relative Risk: 2.71, 95% CI: 1.05–6.99), and presence of at least two signs had a Relative Risk = 4.98 (95% CI: 1.82–13.58). The sensitivity of exam findings ranged from 8–54%, specificity from 84–98%. Signs were associated with increased risk of intensive care and fluid bolus, but not with serious bacterial infection, intravenous antibiotics or admission. Altered mental status and peripheral pulse quality were significantly associated with organ dysfunction, while abnormal capillary refill time and presence of cold, mottled extremities were not.
Certain recommended physical exam signs were associated with increased risk of organ dysfunction, a rare outcome in this undifferentiated pediatric population with fever and tachycardia. Sensitivity was low, while specificity was high. Additional research into optimally sensitive and specific diagnostic strategies is needed.