PDF(Pubmed)
Abstract：
Clinical algorithms used in the assessment of febrile children in the Paediatric Emergency Departments are commonly based on threshold values for vital signs, which in children with fever are often outside the normal range. Our aim was to assess the diagnostic value of heart and respiratory rate for serious bacterial infection (SBI) in children after temperature lowering following administration of antipyretics. A prospective cohort of children presenting with fever between June 2014 and March 2015 at the Paediatric Emergency Department of a large teaching hospital in London, UK, was performed. Seven hundred forty children aged 1 month-16 years presenting with a fever and ≥ 1 warning signs of SBI given antipyretics were included. Tachycardia or tachypnoea were defined by different threshold values: (a) APLS threshold values, (b) age-specific and temperature-adjusted centiles charts and (c) relative difference in z-score. SBI was defined by a composite reference standard (cultures from a sterile site, microbiology and virology results, radiological abnormalities, expert panel). Persistent tachypnoea after body temperature lowering was an important predictor of SBI (OR 1.92, 95% CI 1.15, 3.30). This effect was only observed for pneumonia but not other SBIs. Threshold values for tachypnoea > 97th centile at repeat measurement achieved high specificity (0.95 (0.93, 0.96)) and positive likelihood ratios (LR + 3.25 (1.73, 6.11)) and may be useful for ruling in SBI, specifically pneumonia. Persistent tachycardia was not an independent predictor of SBI and had limited value as a diagnostic test. Conclusion: Among children given antipyretics, tachypnoea at repeat measurement had some value in predicting SBI and was useful to rule in pneumonia. The diagnostic value of tachycardia was poor. Overreliance on heart rate as a diagnostic feature following body temperature lowering may not be justified to facilitate safe discharge. What is Known: • Abnormal vital signs at triage have limited value as a diagnostic test to identify children with SBI, and fever alters the specificity of commonly used threshold values for vital signs. • The observed temperature response after antipyretics is not a clinically useful indicator to differentiate the cause of febrile illness. What is New: • Persistent tachycardia following reduction in body temperature was not associated with an increased risk of SBI and of poor value as a diagnostic test, whilst persistent tachypnoea may indicate the presence of pneumonia.
摘要：
儿科急诊科发热儿童评估中使用的临床算法通常基于生命体征的阈值，发烧的儿童往往超出正常范围。我们的目的是评估退烧药后降低温度后儿童的心脏和呼吸频率对严重细菌感染（SBI）的诊断价值。2014年6月至2015年3月期间在伦敦一家大型教学医院的儿科急诊科出现发烧的儿童的前瞻性队列，英国,已执行。包括700名年龄在1个月至16岁的儿童，他们表现出发烧和≥1个SBI警告信号，并使用了退烧药。心动过速或呼吸急促由不同的阈值定义：（a）APLS阈值，(b)年龄特异性和温度调节的百分位图和(c)z分数的相对差异。SBI由复合参考标准定义(来自无菌部位的培养物，微生物学和病毒学结果，放射学异常，专家小组)。体温降低后持续呼吸急症是SBI的重要预测因子（OR1.92，95％CI1.15，3.30）。这种效应仅在肺炎中观察到，而在其他SBI中没有观察到。重复测量时，呼吸圈>97分的阈值达到了高特异性（0.95（0.93，0.96））和正似然比（LR3.25（1.73，6.11）），可能对SBI的裁决有用，特别是肺炎。持续性心动过速不是SBI的独立预测因子，作为诊断测试的价值有限。结论:在给予退烧药的儿童中,重复测量时的呼吸急症在预测SBI方面具有一定的价值，并且对肺炎的统治很有用。心动过速的诊断价值较差。过度依赖心率作为体温降低后的诊断特征可能没有理由促进安全出院。分诊时的异常生命体征作为诊断SBI儿童的诊断测试价值有限,发热改变了常用的生命体征阈值的特异性。•退烧药后观察到的温度反应不是区分发热性疾病原因的临床有用指标。体温降低后的持续性心动过速与SBI风险增加无关,且作为诊断测试的价值较差,而持续性呼吸急症可能表明肺炎的存在。
