ORIGINAL ARTICLE
Emergency Department Presentation of the Pediatric Systemic Inflammatory Response Syndrome Timothy Horeczko, MD, MSCR, FACEP, FAAP and Jeffrey P. Green, MD, MAS, FACEP
Objectives: The epidemiology of the systemic inflammatory response syndrome (SIRS) in children is poorly understood. We sought to determine national estimates of the incidence of pediatric SIRS and its corresponding clinical etiologies presenting to US emergency departments (EDs) using current definitions. Methods: We analyzed ED visits by children younger than 18 years from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey. We used a Bayesian logical framework of prior probability distributions for white blood cell count result to make minimum, moderate, and maximum estimates for pediatric SIRS. Results: Taking the minimum and maximum estimates as modified credible intervals, we report an overall incidence of pediatric SIRS presenting to the ED to be 21.7% (95% modified credible interval, 18.1%Y25.4%). The national moderate estimate of pediatric ED visits presenting with SIRS was approximately 6.2 million per year. Children with SIRS and without SIRS had similar baseline characteristics, but SIRS patients were younger (2.9 vs 5.5 years; P G 0.0001), had higher triage acuity (emergent, 9.0 vs 6.3%; P G 0.0001), and were more often admitted (7.0 vs 2.4%; P G 0.0001) than children without SIRS. Based on the moderate estimate, infection was the most common (53%) associated etiology, followed by trauma (10%). Other traditional categories of SIRS were extremely rare. Of note, 35% of children with SIRS did not fall into any of the previously established categories. Conclusions: Pediatric SIRS is common; its associated clinical contexts include potentially dangerous etiologies; many cases of pediatric SIRS can be recognized in triage; and there is significant heterogeneity in the etiology of pediatric SIRS. Key Words: pediatric systemic inflammatory response syndrome, SIRS, pediatric triage, pediatric vital signs, pediatric sepsis (Pediatr Emer Care 2013;29: 1153Y1158)
SIRS should not be diagnosed only by the combination of an elevated heart rate and respiratory rate.3 Previous studies on pediatric SIRS were conducted before the consensus conference report4 or were limited by sample size5 or a single institution.6 No previous study of the epidemiology of pediatric SIRS has focused on emergency department (ED) patients. We sought to determine national estimates of the incidence of pediatric SIRS and its corresponding clinical etiologies presenting to US EDs using current consensus definitions.
METHODS Study Design This was a retrospective analysis of data collected in the National Hospital Ambulatory Medical Care Survey (NHAMCS). The study was approved and determined to be exempt from full review by the institutional review board, as the data are deidentified and publicly available.
Study Setting and Population The population studied was based on ED visits made by children younger than 18 years from 2007 to 2010 in the NHAMCS, a national, representative, 4-stage probability sample of visits to US nonfederal, general EDs conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics.7,8 The time frame was chosen because 2007 was the first year to include all vital signs at triage; 2010 is the most recent year for which data were available. The numerator in this study is ED visits by children who meet criteria for SIRS; the denominator is all ED visits made by children in this time frame.
Study Protocol
T
he epidemiology of the systemic inflammatory response syndrome (SIRS) in children is poorly understood.1 Although commonly associated with infection, SIRS describes a clinical response to a variety of acute insults such as pancreatitis, ischemia, trauma, hemorrhage, and immune-mediated organ injury.2 First described in adults, the International Consensus Conference on Pediatric Sepsis modified the original definition of SIRS to reflect age-specific physiology (Table 1).3 As in the adult definition, a patient with 2 or more criteria has SIRS. In distinction from the adult definition, pediatric SIRS requires either an abnormal temperature or leukocyte count to be present; that is, pediatric From the Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA. Disclosure: The authors declare no conflict of interest. Reprints: Timothy Horeczko, MD, FACEP, FAAP, MSCR, UC Davis Medical Center, 4150 V St, PSSB 2100, Sacramento, CA 95817 (e
Emergency Department Presentation of the Pediatric Systemic Inflammatory Response Syndrome Timothy Horeczko, MD, MSCR, FACEP, FAAP and Jeffrey P. Green, MD, MAS, FACEP
Objectives: The epidemiology of the systemic inflammatory response syndrome (SIRS) in children is poorly understood. We sought to determine national estimates of the incidence of pediatric SIRS and its corresponding clinical etiologies presenting to US emergency departments (EDs) using current definitions. Methods: We analyzed ED visits by children younger than 18 years from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey. We used a Bayesian logical framework of prior probability distributions for white blood cell count result to make minimum, moderate, and maximum estimates for pediatric SIRS. Results: Taking the minimum and maximum estimates as modified credible intervals, we report an overall incidence of pediatric SIRS presenting to the ED to be 21.7% (95% modified credible interval, 18.1%Y25.4%). The national moderate estimate of pediatric ED visits presenting with SIRS was approximately 6.2 million per year. Children with SIRS and without SIRS had similar baseline characteristics, but SIRS patients were younger (2.9 vs 5.5 years; P G 0.0001), had higher triage acuity (emergent, 9.0 vs 6.3%; P G 0.0001), and were more often admitted (7.0 vs 2.4%; P G 0.0001) than children without SIRS. Based on the moderate estimate, infection was the most common (53%) associated etiology, followed by trauma (10%). Other traditional categories of SIRS were extremely rare. Of note, 35% of children with SIRS did not fall into any of the previously established categories. Conclusions: Pediatric SIRS is common; its associated clinical contexts include potentially dangerous etiologies; many cases of pediatric SIRS can be recognized in triage; and there is significant heterogeneity in the etiology of pediatric SIRS. Key Words: pediatric systemic inflammatory response syndrome, SIRS, pediatric triage, pediatric vital signs, pediatric sepsis (Pediatr Emer Care 2013;29: 1153Y1158)
SIRS should not be diagnosed only by the combination of an elevated heart rate and respiratory rate.3 Previous studies on pediatric SIRS were conducted before the consensus conference report4 or were limited by sample size5 or a single institution.6 No previous study of the epidemiology of pediatric SIRS has focused on emergency department (ED) patients. We sought to determine national estimates of the incidence of pediatric SIRS and its corresponding clinical etiologies presenting to US EDs using current consensus definitions.
METHODS Study Design This was a retrospective analysis of data collected in the National Hospital Ambulatory Medical Care Survey (NHAMCS). The study was approved and determined to be exempt from full review by the institutional review board, as the data are deidentified and publicly available.
Study Setting and Population The population studied was based on ED visits made by children younger than 18 years from 2007 to 2010 in the NHAMCS, a national, representative, 4-stage probability sample of visits to US nonfederal, general EDs conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics.7,8 The time frame was chosen because 2007 was the first year to include all vital signs at triage; 2010 is the most recent year for which data were available. The numerator in this study is ED visits by children who meet criteria for SIRS; the denominator is all ED visits made by children in this time frame.
Study Protocol
T
he epidemiology of the systemic inflammatory response syndrome (SIRS) in children is poorly understood.1 Although commonly associated with infection, SIRS describes a clinical response to a variety of acute insults such as pancreatitis, ischemia, trauma, hemorrhage, and immune-mediated organ injury.2 First described in adults, the International Consensus Conference on Pediatric Sepsis modified the original definition of SIRS to reflect age-specific physiology (Table 1).3 As in the adult definition, a patient with 2 or more criteria has SIRS. In distinction from the adult definition, pediatric SIRS requires either an abnormal temperature or leukocyte count to be present; that is, pediatric From the Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA. Disclosure: The authors declare no conflict of interest. Reprints: Timothy Horeczko, MD, FACEP, FAAP, MSCR, UC Davis Medical Center, 4150 V St, PSSB 2100, Sacramento, CA 95817 (e
