Identifying Sepsis in the General Pediatric Setting

Also, is sepsis something that could happen, like some of the survivors of the flooding, the horrible?

No. No, okay. No, I don't know if you saw the announcement. We didn't get anybody from those areas. Yeah, so, I mean, drowning, you know, we just had a drowning episode, you know, did that episode. But, yeah, no one, yeah, it was so quick. Not a lot of survivors, it sounds like. Yeah, if they survived, they were able to find a tree to hang on to. Or get into high ground, but everyone just got swept away.

I don't know. I haven't read all the ME reports yet, but I suspect it's either just overwhelming drowning and just being crushed. Yeah. Oh, it's so terrible. Yeah, it's like a terrible way to pass away. Yeah, it's just unbelievably awful. Yeah, right. No, I mean, if it is, it's like being in the hospital for long periods of time and getting septic that way. I'm Holly Wehment and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.

Click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on our topic or podcast. Pediatrics Now is brought to you by the Department of Pediatrics at UT Health San Antonio and University Health's New Women's and Children's Hospital. Today, back on the show is Dr. Ted Wu. He works with our pediatric critical care team. He's been in this field for 19 years and works in our PICU.

Dr. Wu, thank you so much for being back here on the show and in the podcast studio. Yeah, thanks for having me. Last week, we covered the tough topic of drowning, and today we're talking about new research in sepsis and sepsis in general. And there's new research that could make treatment of sepsis more tailored. Yeah, just kind of wanted to define a little bit about, you know, sepsis.

And we all know that it's kind of this huge immune response that we see to infection leading to organ dysfunction. And, you know, these are the type of patients we usually see in the ICU. It's challenging for our pediatricians because it happens most worrisome to our little ones, our neonates and infants, right? And they actually are the toughest ones to diagnose. So some of this research really uses genetic markers to categorize our patients with sepsis.

So these would be all patients that we know have a clinical presentation of sepsis and that there are genetic markers that we could categorize them. The type of technique that they use is acronym is called JEDI. And it's able to categorize patients to very, you know, few categories, usually three or four categories, and that we were able to see whether or not each category can be, have the management tailored for them and kind of have some characteristics of that.

So it's really at the infancy of this test to kind of see how it's at. You know, this is all coming, work coming out from Cincinnati Children's, you know, so more to come, definitely. But bottom line, depending on what that patient needs, that sepsis treatment may change. Correct. Correct. Right now, we treat sepsis very similarly. It's very much early recognition is really key.

And being aware, hyper aware about that can really start even in the pediatrician's office or in the urgent care or in the emergency room, right?

Just having that kind of keen attentiveness and being aware and ready to start interventions can make a difference, a way bigger amount of difference. And Ted, so a lot of times it's a patient who has the early signs of sepsis may be going to see his or her pediatrician. So it's really crucial and great for our listeners today to hear about what what are those warning signs, a refresher? What what should we be looking out for? Because, of course, you don't want to

alarm a family, but not miss even that one patient, of course. Yeah. It's challenging, you know, as a general pediatrician, because how many children do they see that have come in with fever and, you know, kind of your upper respiratory infection symptoms? Right. And a lot of times. Yeah, exactly. A lot of times, especially during cold season and there are, you know, most of the time it's caused by viruses. Right. So what.

What out of all of that makes you more aware that maybe we need to look in a little bit more deeply, right? And we should definitely be in more tune, definitely for our neonates and infants, right? So not only fever, it's poor eating, just lethargy, right? Just something is off. And using our caregivers or parents as also a guide that they actually would say, you know, there's something off about my baby, you know, and that might clue you in.

And maybe we should do more of a workup for those types of patients. Should it be after, because as you said, those sound like common symptoms.

It sounds like it could be the flu. It could be a respiratory virus. Should it be if it's continuing after a certain number of days? Or really, would that, you know, be the huge red flag if the caregiver is like something's not right? Yeah. And I guess, you know, it definitely varies with the younger patients of neonates.

Definitely, like if they're not eating, you know, even in half of a day, that warrants some interventions at that time, either needing for fluids or IV fluids or, you know, some kind of hydration for those babies. Of course, older children can probably tolerate a longer period of time observing them for three or four days. But after five days, usually they're still having fevers and all those symptoms.

All those probably should go to the emergency room and, you know, deserve a workup for blood work. And depending on what other symptoms they have, more imaging if necessary or other diagnostics as well. So if a child has had a fever for more than five days, say go to the emergency room? Definitely, you know, having communications with your pediatrician, right, or your parents, you know, it's a good practice to, you know, communicate with them on a daily basis.

Just, you know, when they're ill like that. And if there's no change, yeah, it's kind of directing them to the emergency room is probably the next step. Because if the, or if the child still has a fever, but it's getting less or the symptoms are improving, then the fever is lower.

Correct. Less needing to go to the hospital, right? It's that when the fever persists, patient's not really eating too great. Definitely signs of altered mental status, just not, or just being more somnolent and harder to arouse or wake up. Definitely need more incentive to go into the emergency room as well. Do we know why it causes loss of appetite? Is it just feeling terrible? That's a great question. You know, I think my theory has always been your body is using all its energy to fight

an infection, right? So it's actually using actually a lot of energy. So all that blood flow is to your immune system organs, things like your spleen and your lymph nodes and your heart and lungs just kind of consuming that energy. So once you have no blood flow to your gut, because your gut, you know, usually uses a lot of blood or blood flow to absorb all the things that you eat. It just doesn't go as much blood there.

So you're not going to eat, you know, in the hospital when we're treating for sepsis, we'll see this. You know, we actually don't feed when they're when they're acutely septic, you know, Even though we're always worried about the gut flora having bacteria that could translocate into the bloodstream and even make things even worse, right? So sometimes we feed very gently, very small amounts just to keep that bacteria at bay.

But yeah, that's probably the biggest thing is that you're using energy and no blood flow is in the gut and you just don't feel like eating, you know? And your gut really just slows down. So that's why babies and toddlers, they tend to just throw up because whatever, you know, you try to, they feel hungry, but then it just doesn't move and they'll just kind of vomit any kind of stimulus, you know, so that happens. And the fever is our body doing its most important work, trying to fight that

infection. Yeah, exactly. So that's, you know, elevating the body's core temperatures is one way to kind of kill bacteria. Actually, there's a lot of cascades that starts off and actually optimizes the immune system so that it works better in those environments. Yeah. So there's a lot of protective things for fevers. It's not that fevers are bad. And in this case, it's just kind of indicative that the body's fighting off an infection.

At that point you just need to support the body right you're just going to lose a lot more, fluids through just the heat alone right off your skin so you just need to constantly be hydrating them so sometimes because they're throwing up they don't want to or they don't want to drink or eat anymore we have to give it through their intravenously at that point, Ted, does sepsis sometimes get better on its own or does it always require medical intervention or do we know?

It always requires fluids. Whether you give it through the gut or through the IV, it always will require some kind of hydration to get through it, you know. So in this day and age, antibiotics is also will save people's lives because of that. You know, when you look at countries that don't have access, health care access, and they don't have access to fluids and antibiotics. Patients die or kids will die at home. Yeah. So when they get septic. Yeah. So and usually, you know,

the common things are common versus viruses that are easily contractible. Right. And then it kind of builds up after that, meaning like you have a lot of congestion, a lot of.

Those are the next symptoms. Yeah. the next in congestion and mucus uh and then you kind of it's a harboring for a lot of bacteria build up within your airways and then you're always just kind of have all this kind of gunk and then the bacteria that lives in your airways just kind of get lives and is able to grow and then kind of you get infected in your lungs so that's one of the things that can happen and then once it translocates into your blood because it's just

an over amount of growth in or blood, then it can get, that's where it really cascades in this kind of inflammatory process, as we know as sepsis, right? So all the other things that we have, worry about lung infection, ear infections, all those that we can treat for antibiotics. And usually patients, they just feel terrible. But when that bacteria becomes overwhelming and spread through the bloodstream, that's when everything starts going into dysfunction, right?

Your heart starts dysfunctioning and dysfunctions your kidneys as well. So, or your liver, you know, everything's gone on high, high, you know, reamed or high, you know, revved up, revved up because of the inflammatory process that it got started from the bacteria itself. And Ted, as a doctor on the front lines in the pediatric ICU, do you often see kids that are in the late stages of what you're talking about? Yeah.

Yes. Actually, when they when they come to us, they're in their late stages. We call late stage sepsis when patients start developing hypotension or low blood pressure and they need vasopressors, which are medications that are continuously infused, things like epinephrine and norepinephrine or vasopressors. And they need to be constantly infused in order to maintain good blood pressure.

If you don't have good blood pressure, you start shutting down your organs, things like your kidneys and your liver. Your body's really good with preserving blood flow to your heart and your brain. Those are the two things that it cares about. And if those things start shutting down like your heart and not able to perfuse your brain as well, then it starts really shutting down. And that's what we really worry about.

So then it needs medications and other therapies, including ECMO, in order to kind of improve that perfusion. So yes, in ICU, we see the kind of late stages. Our inpatient pediatricians are the ones that deal with a lot of the early stages of sepsis, right? And it's usually, we don't think of it that way, but we always teach our trainees to always think about that because it's always the brachiolytic that becomes really dehydrated, right?

And it becomes really tired and lethargic, right? And they just look listless. That's a kid in beginnings of what we call shock, right? The lack of perfusion. That can progress into sepsis, kind of a form of early concerns for sepsis, right? So usually they get fluids early on in the emergency room and get antibiotics and then a monitor in the inpatient, right?

If they don't progress or don't improve, and if the blood pressure starts dropping along with having high heart rates, then they'll come to the ICU after that. And so some of what you'd say for a respiratory virus or the flu, getting fluids and rest, that could really be help, that does help in this case. Yeah, and that's really for, you know, our outpatient pediatricians, you know, just being astute about that, right?

Some are, I know the practice might not be there as in giving IV fluids in the clinic, you know. But in urgent care, you might get IV fluids in the urgent care kind of setting in order to hydrate somebody. If the child seems dehydrated. Yep.

Yep. Is there an easy test for that? Like to make sure for for sepsis or dehydration or dehydration? Not like an overwhelming test. You know, we always when we're teaching our residents, you have to account for the whole whole picture. Right. Things like dry mucous membranes, sunken fontanels for babies, you know, dry skin or turger, turger, skin turger. Right. Low urine output, even, you know, alter mental status. Those are all kind of signs for dehydration.

There are tests. Sometimes we look at Buen and creatin, if you want to be kind of formal about it. Looking at a kind of blood chemistry and electrolytes, you can make that diagnosis. But usually you already have the story beforehand and in your own exam and looking at the patient and kind of knowing, okay, this patient's dehydrated. Yeah, so. Can sepsis be treated in the general? Pediatric setting, say with antibiotics and the fluid, you advise taking it, taking that patient should go to the ER.

Yeah, they usually need to be observed. When we're talking about sepsis, it's already kind of all the signs of the fever and low blood pressure and high heart rate. You know, those things are already kind of set forth already. They, more importantly, they need to be admitted to the hospital to be observed as well, right? The challenge is sometimes when they go to the emergency room, given the interventions and they seem to be doing okay, right?

It's whether or not they should be discharged or not, or just be observed overnight, right? Definitely the younger patients like our neonates and infants, they all stay overnight to be observed because they, one, it's hard to communicate to them, right? And really just being, and they are more susceptible to infections, right? So sometimes we have astute parents that just really know, you know, their child or just a really well read, right?

So sometimes we'll let them go home, but we're really vigilant in following up with their pediatrician in those cases. Yeah.

So. Is there one antibiotic that's the first line of therapy or does it just vary depending on the case? It's very broad, you know, it's more, it's more age, age dependent. And we kind of look at, you know, all our medical students know that usually in the younger age, like neonates and infants, we usually start with ampicillin and cefotaxime or gentamicin. So it's a very broad range. And then everyone else gets like ceftrioxone, you know, kind of very broad range things.

Sometimes our children with chronic diseases or patients that have our oncology patients or transplant patients, those require some additional antibiotics, say like vancomycin that we worry about for more resistant type bacteria because those children were in the hospital. They were exposed to so many different things and antibiotics as well. So they've already kind of been exposed to some drug resistant bacteria. Can you explain to us what causes sepsis? What is happening in the body?

Yeah, so it's usually bacterial and bacterial related. Sometimes we don't find the cause, like the actual cause, but they all present very similar. And where the body has this huge inflammatory response to the bacteria and causes what we call this process where it generates a lot of capillary leak where you have become really swollen. And a lot of your fluids just become linking into your interstitial fluids. So a patient can get really swollen that way.

And it's in response also that your body's trying to fight this bacteria. This bacteria is kind of overgrown as well. So the antibiotics is one method to kill the bacteria, but then it doesn't kind of, so you're treating the cause, but you're still dealing with the inflammatory process, right? So some folks might say, hey, it's an inflammation. Can you give steroids for that? Because steroids used to be kind of this anti-inflammation.

That's what we use a lot for, for a lot of different diseases. We don't do steroids just off the bat. Now we just really use it if the child has adrenal insufficiency or they have low cortisol levels, then we'll give steroids for that. Because it lowers the immune response, right? It lowers the immune response, but always the caveat is that sometimes that immune response is what's fighting the infection, right? So you don't want to tamper, you know, that response.

You want that response. Yeah, you need it. Yeah, it's not, it's not, it's a very shotgun approach because you're basically shutting out all the immune system, right? So you're not, you're not tailoring it. So that's why we don't give steroids just to anybody. We just give steroids really for the patients that are not responding to vasopressors, you know. So that's usually when we start thinking, okay, they need to be stressed for that cell.

Ted, is sepsis often missed in the general pediatric setting? Yeah, I mean, we always worry, you know, when, you know, I see it on a different end. I see it on the end of the patient that has seen sepsis. Different pediatricians or different urgent cares and kind of the same response is, my baby had a fever or my child had a fever, didn't go away. We tried antibiotics. It still kind of came back, never really gone away. Look, he's kind of getting worse.

And, you know, parents get really frustrated in that situation, of course. But when we see that, we see it on the other end. Okay, they've kind of failed a lot of different therapies. Is there something else that's going on? But we would treat the sepsis and support the patient's body to kind of fight this infection is usually what we'll go through. You know, we work at a ICU that has to think about, you know, what made this patient susceptible.

You know, those research topics that we were talking about earlier, we don't have access to those things. So we need to kind of think outside the box that maybe this patient was born with, We had to rule out any kind of congenital inborn errors of metabolism where this made this baby or patient susceptible to infection. So we always have to think about those diagnoses as well. So super rare. Yeah. But we see it in our ICU. You see what is super rare?

These inborn errors of metabolism or congenital disease where they don't respond to infections well. Like they lack the response to infections. Right. Most children, they respond appropriately, you know, and, you know, even through sepsis, they're responding appropriately and they just need the support to get through.

It's usually the babies or children that have congenital diseases like that, then we also have to think about, okay, like, why are they getting so sick just from a simple bacterial infection, you know? So, like, they're not responding how we usually see them respond. But if a child is otherwise healthy, it wouldn't be usual for a bacterial infection to turn into sepsis? Or is that how it starts? That's how it starts out.

Always. Yeah. Any sort of bacterial infection? You have the potential to becoming septic. Wow. Yes. Yeah. Another thing to worry about as a parent. Yeah. I mean, that's why antibiotics kind of go so freely out there because that's what we, and that's what changed, you know, like antibiotics were made in the beginning of the 20th century and it changed everything. In the sense of made a huge impact that children didn't die from bacterial infections, you know? Yeah.

So that and vaccines, right? Yes. Those made huge impacts.

More than, you know, more than doctors, right? Oh, it was amazing. It's like a public health, you know, endeavor that just changed our world, right? Yes. Yeah. It's amazing. I know you recently went on a trip with the med students to Guatemala. Mm-hmm. And... We're there at the people can buy antibiotics, though, over the counter. So that creates its own problem. Right. Yeah. So they have access to things like linazolid, which is a very powerful antibiotic. It's a very good antibiotic as well.

But with that, it kind of builds resistance. And we were our med students who were their project was educating the public or at least the clinics that we're going to about the dangers of antibiotic resistance in their community when they did that. Right. Because, you know, you take antibiotics, it doesn't all get degraded. It goes into our sewer systems and it goes back, you know, to the water and goes back to our animals or cattle and stuff. and it just goes back right in the system.

So it kind of, the bacterium kind of just feeds itself, right? So antibiotics, though life-saving, causes some other unintended consequences, right? Yes. And we have an episode on antibiotic stewardship with Dr. J.B. Canty, pediatric infectious disease. He was the first doctor to be double-boarded in neonatology and infectious disease. Yeah, yeah. So that's in this news feed. but.

What about, there was a pediatrician yesterday, she was telling me she's seeing a lot of hand, foot, and mouth disease. Like, could something like that that's very common turn into sepsis, or I don't... It can, in the sense of, you know, usually when folks, it still comes from a virus. Yes. And it transgresses to some kind of bacterial infection, say, usually like a skin infection, and then progressing into getting infected into

the bloodstream. That would be kind of the extreme case of that, right? So, or, yeah, some kind of nidus that causes more infection that leads to a bacterial infection.

Yeah, so. Do you want to mention anything about key updates in the latest surviving sepsis campaign guidelines? Yeah, I mean, these guidelines came out in 2020 and it's all about early recognition, right? And once you recognize that patient that you're concerned about, it's the first hour is so important, right, of interventions, right? And fluids is the big thing. giving fluids to the patient orally or IV, right?

So if you're in the emergency room or urgent care, getting fluids to them is so critical that you actually will decrease mortality in that first hour. It's kind of a survival curve during that time. So it's challenging, right? Because IVs in children are not always easy to get, especially in small babies. So we've created other devices, one called the intraosseous needle, which actually goes into the bone marrow in order to give IV fluids or IV drugs that way.

So some people might feel that it's extreme, but it is, we sometimes, if we can't get anybody because get IV access because of dehydration. An IO is actually very important and vital. You will save someone's life using that gun. If done correctly, and most of us that take PALS or Pediatric Advanced Life Support, we learn that skill. It's whether or not we're proficient at it, right? So ER physicians all learn how to do it.

They don't all learn how to, you know, practice as well because it's rare to do it in practice, right? But being astute enough to get an IV or use an IO to give fluids is really important in that first hour. And did you say is it like an actual gun that goes, like it's not a... It comes as a drill. It's actually a device that was developed here in San Antonio. Really? Yes. Here at the UT Health Science Center, actually, yes. And the creators are, you know, they've done well for themselves.

I think I heard about this. They're very rich now, right? Well, it's a device that's used internationally, and it's a drill. Because we used to have to use our hands to kind of just push this needle through.

Now you use a drill. It's a drill specifically for this needle, and it makes it very quick and very easy if aimed correctly, right? And you have to put it right, it goes right to the bone marrow? Right to the bone marrow, right. Yeah. So for children, it's usually in the distal femur and or the proximal tibial. And then here in our health science, they did it in the humerus. They also did it in the sternum for adults.

And they showed it didn't have pain. They actually have YouTube videos where they showed it in adults and they did it live on them and it didn't hurt. They didn't use any kind of local anesthetic or lidocaine for that. Yeah, and they did fine with it. And they were able to give fluids and medications through it. How is that possible? Wow, that's amazing. Because the bone marrow has a lot of blood flow and blood capillaries through it.

So you're able to kind of disseminate blood, get things in the bloodstream pretty quickly that way. So as an emergency technique, we use it all the time. You know, EMS people will use it a lot as well. So you've done a lot of those, I take it. We do it, yeah, on the other end when, you know, usually our children, they, you know, we have a lot of skilled nursing and physicians are good with IVs.

And if we can't get it, we're going to other places and use other techniques to get, you know, get access. We use that drill. We use that, use that for emergency. And then we use other kind of devices to give medications more long term if we need it. Yeah, it's a kind of a much more short term device used only for like 24, 48 hours like that. And then usually our patients need something else. And you mentioned ECMO earlier.

That's basically where the machine can take over and breathe for the patient. Is that correct? Yeah, so ECMO, yeah, ECMO, again, it's kind of a heart-lung bypass machine, right? So if patients become, sepsis becomes so overwhelming that the heart can't pump itself, the lungs are not working from ARDS, it can't get oxygen, it can't go blow off CO2. So then what ECMO does, it doesn't treat the sepsis. It just helps support the body while it's fighting this infection.

Give it oxygen, take out the CO2, and pump blood throughout the body. That's what the ECMO machine is doing. So that's revolutionary as it's all. ECMO got developed in neonates back in the 70s, and that's where that technology is slowly kind of built up, built up. And now what's phenomenal about the technology is that it's become a lot safer. It used to be fraud with a lot of clotting and bleeding, And it was really difficult getting these tubes or cannulas into patients.

All that's changed. And to be honest with you, it's because of adult COVID and adult SARS, if you remember that pandemic that happened, it's because of that. And that's where the industry really changed and made that available safer for patients in general. And then we've been benefiting that for neonates and pediatric patients now. Wow, that's so interesting and so amazing. Yeah. So many things go back to COVID, it seems like.

It's changed the world. I mean, it's kind of, in the sense, it's kind of like our moonshot, right? In the sense that we designate a lot of resources in the research, right, to develop a vaccine and then to put so much resources in the, not only in the diagnostic, but the therapy. You know, that was huge. So, yeah. That is huge. Ted, how important is point-of-care lactate in initial evaluation, and how should it guide therapy?

Yeah, that's also in the Surviving Sepsis Guidelines is checking lactate levels, right? The unfortunate thing when that was published, we did have point-of-care lactates, meaning like if you could get a finger stick blood and then send that off. It looked like an acu-check, right, a glucose glucometer, and you can check the lactate level.

And lactate levels have been shown. That's the only way that we can tell if a person is not getting enough oxygen to their major organs, like their brain or kidneys, then that's a problem. And we need to kind of optimize that. Now, because that device is not available, the company that made it just, it wasn't, it lost its FDA approval for the cartridges. Oh, really? Specifically for it. Yeah. And this happened actually before COVID.

And then, but now every hospital has lactate levels readily available. Like you can send it off pretty quickly and you'll get the results pretty quickly. So that's very beneficial for ER medicine, folks. So that leads us to this next question. I know we've covered some of this, but bottom line, what is the most critical thing a general pediatrician can do in the first 10 minutes of recognizing pediatric sepsis? Yeah, once they're recognized is optimizing fluid and starting antibiotics.

I think that was the other thing in the surviving sepsis. Those two things, initiating in the office while you're sending them off to the ER or calling EMS to get them transferred to ER will save their life, you know.

So sometimes it's difficult to have those kind of emergency, you know, kind of things in the office. I know it's challenging as well. But giving antibiotics, you will also save their life. Sometimes giving a shot like Rocephin early on is also beneficial, you know, so in order to do so. Any other antibiotics you want to mention or would that be the first one?

No, that's usually the first one, you know. There's probably, that one is not usually recommended for, you know, babies less than six weeks of age. So send the baby to the ER. Yep. Send the baby to the ER. And then give that antibiotic to the older kids, a shot of it, but still send the child to the ER. Yes. Once it's recognized that the patient has sepsis. Yeah. And a level one trauma center like University Hospital? Usually a pediatric emergency room like at University Hospital.

Hospital, yes. Which a lot of people don't realize. They think that they... Or know that it's a pediatric, we have pediatric ER doctors, it's a pediatric ER. Right. And the only level one trauma center in San Antonio other than BAMC, right? Yep. The military hospital. Do you want to walk us through an ideal first hour management scenario for pediatric sepsis? Yeah. We, in the first hour, once they arrived at the hospital,

we definitely attempt to get some sort of IV access or IO access for them. and administer fluids. All our trainees know giving 20 cc's per kilo of some kind of isotonic fluid, which is usually normal saline or plasmalite or lactated ringers in the first hours is critical.

So, and then more importantly is not walking away, but reassessing after that first bolus, right, of fluids, kind of watching their vitals, see if there's changes in their heart rate, Any changes in their blood pressures or in their altermental status, right? Or even urine output and capillary refill. That's kind of the clinical exams that we use to assess and reassess how patients are responding to the therapy.

That's what we teach our residents and fellows right to once you do something go ahead and reassess right away because the clinical exam is the one things that you'll get response like you'll see the results right there at bedside faster than any test than you do right so and i always joke or not joke but in the icu we're always a hypothesis driven physiology lab so meaning like if you think it's this try this and you want to see the response and then kind

of be ready when it doesn't respond what you think it will do, right? So usually they're giving fluids and then if it doesn't respond or still kind of persists, we usually give another 20 cc per kilo bolus. And after that, if that is not a response in that first hour, usually we start thinking, okay, maybe this patient needs to start on some what we call vasopressor drips, which is epinephrine or norepinephrine. They can always be started into a peripheral IV.

Ordinarily, they should be starting into what we call a central catheter, which goes directly into a main vessel of the body. But that needs to be placed by, you know, someone who has experience with placing those catheters, either an emergency room doc or ICU doc. So usually we do that, try to get that at least established within the first hour. So that seems like a little bit, like three things, but an hour goes by really fast, you know.

I bet. Yeah, because in that you need to find a nurse that's or a physician that's skilled enough to place an IV into the patient. And then you're also drawing labs at that time, right? You're getting a CBC, a chemistry and lactate level or COAG levels as well to kind of assess the patient and see how severely sick they are and where they're at.

Ted, is there one message you want every pediatrician who's listening to take away from this episode about sepsis? I know we've covered a lot here. Yeah, I mean, you know, those are trainees that go into general pediatrics. I go, never underestimate like your ability to sense if this baby or child doesn't look right. And or if you get the history from the parents that doesn't look right, it's OK to kind of do the workup, start the workup or even start antibiotics at that time.

I mean, if you're suspicious that this patient is moving towards being septic, right? So is that hesitancy? And really, our pediatricians kind of, this is one of the things that keep them up at night, is that did they send home that kid that was sick and would get worse and go to the emergency room? You just feel terrible. I mean, you kind of advise parents about that, right? So being vigilant when you're kind of, your senses are going off when a child is sick like that. Mm-hmm.

And no pediatrician, of course, wants to send a family or child to the ER unnecessarily. So there's that stress and pressure there. Yeah, it's kind of that balance, right? Where do you find, you know, it's true. A lot of the things that we see in the general pediatrician's office are easily treated and reassured parents to go home, make sure that they're well rested, get fluids.

But yeah, what makes a difference? And sometimes it's time that you need time to kind of let it get this disease kind of sorted out. But after that, it's really being communicative with the families, right? But if your spidey senses are going off, just go ahead and send them to, you know, the pediatric emergency room. And have someone or call the family the next day or have someone from your clinic. Clinic follow up. Yeah, exactly. I'll see you back in a couple days.

Yeah, that's a good process and good practice to do, you know. Yeah. So some practices allow that easier, right? or built that in that some kind of assistant follows up, right? So some smaller practice, they do the actual calling, you know? So, but it's just being that vigilance, you know, is always there or suspicious. It's always in the back of our minds, right? Are there blood tests that can be done in the general pediatric setting?

Or is it, I know you said, send the child to the ER for the blood workup or sepsis. Yeah, no. That's what you reckon? Yeah, they used to try to advocate for some of the things, but end up now doing blood work in the pediatrician's office is hampered with a lot more regulations because you have to validate that the staff is trained to do all those tests. And so, yeah, a lot of pediatrician's office are not going to take that liability or that amount of work to sustain that.

So urgent carers might do that or some urgent carers are next to a lab. They might be able to do that. And we have, the doctor I mentioned earlier, Dr. J.B. Canty, is working on a project with the NIH where we have a phone number that I'll put in the text for this podcast. So for baby patients, if listeners are wondering, does this baby need antibiotics, you could call or text this number and get right through to ask him about that.

So I will put that in. Yeah, I mean, that's the dilemma that a lot of ER docs kind of have, right?

They get it they get it's always the age group they'll get like a two-month-old because it's right outside this one who's febrile but looks okay how much of a workup do i need to do on these on these children right so it's the spinal tap blood draws and urine right those are the three things that we check so that's what this project is really kind of geared for is for those practitioners that kind of encounter that yeah well

ted this has been so fascinating and it's such an honor to talk to you here in the podcast studio today. Is there anything else you want to mention before we wrap up to the pediatrician listener? No, I think we said it before as in how much, you know, a gender pediatrician kind of is able to see and they offer a lot of reassurance for our parents and guiding a lot of uncertainty. And yeah, just being vigilant about being those kids that you're really uncertain about.

And maybe say to the parent, I just want to make sure if you're doubting it, but let's rule this out. At least go to the ER, have this checked out. Right, right. Yeah. Having that discussion, you know, with your families, you kind of have to gauge, you know, how much some families are willing to kind of go through to kind of have that reassurance or that peace of mind, right, to go through those tests. That is also a tough discussion to have sometimes. Yeah. So.

Because when the child gets to you, it's a lot harder to treat. Yeah, it's a lot harder to treat, especially if we're already behind. Yeah, so we're kind of playing catch up, you know, especially from a fluid standpoint. Sometimes patients can become really dehydrated from sepsis. They just don't want to drink and they're staying out. They don't want to drink or they didn't get enough fluid when they're resuscitating at whatever facility

they were at prior to coming to our unit. Yeah, so that happens. When it's missed too, do you see it a lot where the parent didn't bring the child to see the pediatrician or does it just vary? It varies. Yeah. Either way, the families are extremely guilt, feel the amount of guilt, you know. So tough. Yeah. And you kind of have to also reassure them that, you know, you did the best that you knew. And it's really, those are the things that are really hard to predict, you know.

So, but yeah, we just help our families kind of navigate through that as well. Well, in this high-stress, high-burnout career and all of the difficult things you do on a daily basis in the PICU, I like to talk about having a life outside of medicine. And you went to UCLA, and so you've worked on films, I hear. Yeah, yeah. I mean, it was in Hollywood, right? So they offered extra work, being on extra on movies or film.

Yeah, so I was able to, you know, being a college student and even just being paid by food was a treat, right? So, yeah, I was able to work on this old cartoon show or this old kid show, Mighty Morphin Power Rangers. I'm being an expert on that. Yeah, so that was fun. It was really tedious work, though. So were you one of the Power Rangers? I was not with the Power Ranger.

Actually, because I'm a stocky guy, short, stocky guy, they got me to wear one of the costumes of the villains because they were these big costumed heads. And I basically wore it on my shoulder and then wore this thing and just kind of acted it out. So, yeah, I got paid a whole extra meal. All right. Which helps when you're an undergrad. Yeah, when you're an undergrad. Exactly. Exactly. So, yeah. So that's kind of some fun facts. Wow. In my career of odd jobs that I've had, yeah.

The Power Rangers. Yeah. And then did that help form a love of film for you? Or you realize like how tough it is to make a film? Oh, yeah. You know what? You know, I don't know if it's being in California or L.A. But yeah, no, I've always enjoyed films and been a film geek myself. So you're from California. I'm from, yeah, from Los Angeles. Yeah. So I don't know, having family in film, maybe that had something to do with it. But I really enjoyed the art of it.

You know, I both enjoyed the popularity of things, but also kind of all the artsy stuff. So just really enjoy that kind of medium, you know, but knew how hard it was, you know, and in order to kind of pursue that and the amount of creativity and that it takes. So I was like, oh, man, I don't I don't know if I'm wanting to put myself through that much uncertainty, you know, so. But yeah, no, I think it's a it's a it's a very interesting field. That's for sure.

So and you have a relative who was in some films. Yeah, yeah. He was an actor. He's an actor as well. He's in a Mortal Kombat. His name is Robin Shue. So now is a, now people do recognize him because I thank God for, for streaming and Netflix and, and that movie being on, on, on constant stream, but it's based on an old arcade game from the nineties, you know, so that's always constantly being remade.

So, but yeah, he's, he's enjoyed that kind of celebrity life or, you know, where he's going to comic cons and, and then signing the autographs. So I'm sure he enjoys that kind of.

That life yeah so for our san antonio listeners he is coming to comic-con this year in october yeah that's right to sign autographs make an appearance that's right that's right ted as a film buff is there any any film that's on your mind or one that you recommend or do you have it's hard to i think it's hard to choose a favorite film when you really like from uh oh as a oh you my favorite film yeah my favorite film still is it's a wonderful life that's a great one yeah so So I really enjoy,

it was an old way of movie making. Frank Capra just captures a lot of Americana in it, which is really fun to watch. Yeah, so you don't see those things. And there's so many subtleties in that movie of how the, about appreciating the little things in life, right? So it's led me to appreciate a lot more about it. The other one that's always on my mind. Do you bring that to your family, your two kids, your wife? Yeah, yeah.

I mean, sometimes I'll talk about it, you know, but maybe not in my daily life. It's hard to do that in a daily life. Yeah, exactly. The other one that's hit me, I always think about a lot, and maybe because I'm more of a father, it's Interstellar, a Christopher Nolan movie that just kind of, I know it's about space and sci-fi, but it was really about like generational impacts, you know, and how we're viewed by our children.

You know and I thought that was just like such well made in that bringing that sense you know in you know so that'd be a good one to watch I have not seen Interstellar oh you haven't seen Interstellar is it for adults or adults and kids or. Kids might find it maybe a little bit boring. I haven't shown it to my kids yet, even though they would like the sci-fi aspects, because there's some time traveling going on.

But not in the, it's like hardcore time travel, like, you know, so with black holes and stuff. But yeah, it's a good watch, though. I want to see that. Any other films you want to mention that you like?

Film review. No, no. I mean, those are the two that, you know, I've been thinking. TV shows, I think, recently, like, of medical-related is The Pit. I've heard good things about that. Yeah, I've heard good things about it, too. I've watched maybe one episode. And, you know, it just brings back the show ER, I remember, back in the day. And that had a lot of impact on me. I didn't know how much it did, but it really did, I guess.

I remember watching it, too. Yeah. But I did, like, there was a really old show called Emergency.

Emergency it was just about paramedics and it was made in the 60s i believe yeah i remember watching that i really like watching people going to you know helping out in emergencies maybe that that has more impact for me going into medicine you know kind of being that person that's available to help in emergency that to me it was like really intriguing for for so many different reasons you know just kind of being on the spot and being able to react in emergency

situations yeah so that helped inspire you to do what you're doing today yeah definitely yeah so i know that's a little bit a little bit weird you know yeah but no i i always knew i was growing up i was a kind of an anxious kid that never really showed it or nervous but definitely as i gradually grew into the career i found myself really calm during really stressful situations so i felt that was okay i can i can do these and i enjoyed it i kind of gravitated to those moments you know

um so and really able to think clearly through those moments so i thought that try to find places i could use that to you know to my benefit or or you know anyone's benefit bring so in those moments so well that's great where you're thinking quickly and you're not panicking and you're able to just stay focused Yeah, yeah, yeah. Like Superman. That's the other big movie coming out. I mean, I think you guys are getting a movie plug.

My kids keep talking about it. Like they want to see that as soon as possible. Yeah, it's like the seventh reboot or something. It's supposed to be a good one. I don't know. Like, I don't know. Yeah. I think you guys are superheroes, what you do on a daily basis. It's just incredible. Well, thank you. Thank you. And our pediatrician listeners, of course. Ted, thank you so much for being here in the podcast studio again on Pediatrics Now. Music.