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Evidence Based Charm:
Coffee & Conversation: Let’s Talk Sepsis

Listen to “Evidence Based Charm: Coffee & Conversation: Let’s Talk Sepsis ” on Spreaker.

October 18, 2024

On today’s Evidence Based Charm, Courtney welcomes Dr. Gabi Hester as they merge community and pediatric-centric health worlds to review and discuss sepsis – a dual-faced threat to children’s lives. From definitions to diagnostic tools, listen as they meander through this often-overlooked infectious phenomenon that kills more children per year than cancer.

Transcript

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Kade Goepferd. On today’s segment, Evidence Based Charm: Guidelines with Courtney, hospitalist Dr. Courtney Herring informs us of the latest evidence-based, expert-driven clinical practice guidelines. Alongside her informative guests, she takes us through all the steps of care, from ambulatory to inpatient and back again with a sizable dose of Southern charm.

Dr. Courtney Herring: Welcome, everyone to Evidence Based Charm. I’m your host, Courtney Herring. On this episode, we will ring the bell on a covert killer among us, 25 million children experience sepsis worldwide, with 75,000 in the United States each year. With a mortality rate reaching as high as 40% in severe cases, sepsis kills more children than cancer. Yet, we struggle to build awareness in the public and even in our healthcare community.

Dr. Gabi Hester: Courtney, stop just for a second. I want to emphasize something, I think. You mentioned that more kids die every year in the United States of sepsis than of cancer. And not to throw shade on cancer or anything, obviously a very serious disease, how many celebrity commercials have you ever seen raising money for sepsis awareness? Jennifer Aniston. What is it, Ray Romano? Everybody’s raising money for cancer, but what about sepsis?

Dr. Courtney Herring: Great call-out. I see your Jennifer Aniston ads and raise you that for one, I think defining pediatric sepsis has been difficult with pediatric unique physiology and as well as infectious instigators. The creation of pediatric-centric definitions, including criteria and surveillance, seems to have been a journey that we’re continuing on at this point. I think that’s where we’re led off with hopefully today some updates in pediatric sepsis.

Dr. Gabi Hester: Right. It seems like we’re always forgetting the kids in the equation. We have it well-defined for adult sepsis, how you manage it, how you recognize it, all that kind of stuff, but the kids get left behind sometimes in the research. And so I’m really glad that there is some emerging research, which is good, but why do kids always get shortchanged? That’s what I want to know.

Dr. Courtney Herring: And I think we’ll take a second to maybe introduce this…

Dr. Gabi Hester: No, sorry, I’m getting ahead of myself a little bit here.

Dr. Courtney Herring: This glorious, what seems to be co-host, which I’m so excited to have today.

Dr. Gabi Hester: No, no, totally your episode. You got this. I will not interrupt anymore.

Dr. Courtney Herring: No, I love it. No promises and nor should you. For today, I just want to introduce Dr. Gabi Hester. Gabi is a pediatric hospitalist with over a decade of experience in health services research, quality improvement, and bedside care. In a previous role as medical directory for quality improvement, she alongside one of our nurses, Melanie Kuelbs, led the implementation of an electronic health record screening tool for sepsis at Children’s Minnesota. So I am so excited to have Gabi back here in the studio at Children’s today with me. Gabi, so lovely to see you.

Dr. Gabi Hester: Good to see you, Courtney. And I will stop interrupting your intro. Sorry about that.

Dr. Courtney Herring: Well, I think we’ll see because I welcome it. I’ve always enjoyed our clinical dialogue that we’ve had as partners, but also just as friendly rapport that we continue to have, even though you are up in Duluth, Minnesota currently doing an amazing job as a hospitalist up there.

Dr. Gabi Hester: Community hospital up in Duluth, so a little bit of a different world that I live in now.

Dr. Courtney Herring: Yeah, which I think again calls out a great topic in sepsis.

Dr. Gabi Hester: Yeah, exactly.

Dr. Courtney Herring: I think another big piece of sepsis, we’ve done some numbers already talking about the population of 75,000 cases a year in the United States alone. Go one step further, long-term disability is found in 20% or one in five survivors of pediatric sepsis, but this also accounts for 7,000 deaths per year, which is the current outcome and still counting, with definitely data showing increase of almost 8% of cases per year that we’re seeing and at least defining.

For me, one of the key things is around, how do we define sepsis, which seems to have been a moving target. It’s had several iterations. And as you already alluded to, Gabi, it’s got a lot of adult-driven data as its background. Well, that’s really changing. The simplest definition I can provide you in current state is a life-threatening organ dysfunction associated with an infection.

This is really coming out in actually early 2024, and we’ll talk a little bit about that. But really the bare bones, and this is in brief, sepsis is this bizarre cycle of pro-inflammatory and anti-inflammatory, which is immunosuppression, activated pathways that are in constant cycle of influences between pathogen and host factors. And that’s a lot of words to say. There’s a lot of things that are giving positive feedback of causing destruction.

And so what it really leads into is this hyper-metabolic response that produces hypoxic induced cell death. And in the end, you have end organ damage that’s book-ended with complications of microvascular thrombosis leading to a disseminated coagulopathy. That’s a big one-liner. There’s so many other levels here, molecularly and cellularly.

Dr. Gabi Hester: That is a big one liner. I usually explain it to families and patients just as it’s the body’s overwhelming response to an infection, because I honestly can’t keep in mind or remember all of the cytokines involved in that inflammatory cascade. So for my own brain, I just need to simplify it to that, body’s overwhelming response to an infection.

Dr. Courtney Herring: And a great call-out to who is your audience and how we always talk to our families is really important to make sure they are able to ask questions and also get a better understanding of what’s going on with their children.

Dr. Gabi Hester: Courtney, I’m glad that we’re moving away from the SIRS or severe sepsis nomenclature, it sounds like, but is there a formal diagnostic scoring system that you look to when you’re taking care of patients?

Dr. Courtney Herring: Yeah, it’s like you’re leading to the trough and I really enjoy you for that. Oh yeah. So I’ve been really excited to share at least in this episode around really new information and data out of January 2024 publication. Simply, it’s based on the Society of Critical Care Medicine in the United States in a shared consortium international task force that was convened that evaluated criteria for pediatric sepsis and septic shock, specifically in the pediatric population.

And what was birthed, pun intended, was the Phoenix Sepsis Score. So this Phoenix Sepsis Score is several years in the making. It’s validated by using a large international database and survey, systematic review and meta-analysis, and then importantly, at the end a modified Delphi consensus approach with this large consortium of experts.

And what it really is is this veno type based criteria that scores four organ system variables to identify life-threatening organ dysfunction, which is the new definition of sepsis. So the main ones are in cardiovascular, respiratory, coagulation, and neurological. Those are your four systems of import in this scoring system.

Dr. Gabi Hester: I think it’s good to be aware of the Phoenix Score and I’m glad they put it out there. As I mentioned, I’m up in Duluth, Minnesota now at more of a community hospital, and I’m wondering how I actually incorporate that into my patient care. When I was reviewing this article, I was really thinking about it as for me at least in the setting that I’m currently practicing, I think the Phoenix Score might actually be more of a rear-view mirror check.

So was that clinical suspicion I had that that patient had sepsis or is getting sicker, did it prove to be true? Because I see that it involves at least part of the scoring, you can incorporate arterial blood gases and calculating some ratios of things. And I promise you, at my health setting, kids are not getting ABGs as they come in the door.

So I think it’s important to keep in mind as we’re looking at this or talking about it that this really isn’t a screening tool, and they actually talk about that in their paper, but it’s a way to look after the fact after you’ve already started your management of yes, was this in fact a case of sepsis that I’ve been treating.

Dr. Courtney Herring: As we all struggle even in pediatric centric care hospitals and healthm care organizations about identifying sepsis and then moving the algorithm forward of management.

Dr. Gabi Hester: Obviously I know since I helped implement it, but I know you have a screening tool here embedded in your electronic health record. But beyond those tools that you can utilize, when you’re talking to say a medical student or a resident and teaching them about sepsis, what are you telling them are the key signs or symptoms that you’re looking for?

Dr. Courtney Herring: One of the features of pediatric sepsis, which is somewhat unique from adult, is that blood pressure readings are unreliable in children. Partly, one, just more physiologically is that hypotension is really a end game. It’s a late diagnostic criteria of even shock. And so being aware that that’s not really what you’re picking up on.

So to get back to your original, it is truly a primary survey of the patient, including heart rate, but perfusion over blood pressure. And I think that’s a key takeaway in that cardiovascular part of sepsis, so I’ll call that out. But I think again, it’s all about the signs and sequelae that you’re seeing in physical exam that really call to attention sepsis.

Dr. Gabi Hester: I also think of temperature, being an elevated temperature. And I think the Phoenix Score, Phoenix is hot, so a hot patient, maybe that’s how we can remember it. So your patient often will be febrile, have some of those other vital sign alterations. But I also just think of it as a gestalt almost like they’re acting funny. They’re acting really fussy. They’re being a little loopy. The parents might say that they’re not being themselves. And so I think it’s important to take into mind some of those less objective criteria as well.

Dr. Courtney Herring: And I think clinically we objectively call that potentially altered mental status, but contextually talk about uniqueness of pediatrics, what does that mean age and development wise? And a call-out to temperature is always very relevant because one of the most unique populations of sepsis care is neonatal, which also is quite the foundation of a majority of patients with pediatric sepsis.

As you and I practice medicine in the pediatric centric care, it is one of those things where you can have hypothermia over hyperthermia, so low versus high. And so again, not that doesn’t happen in adults, but it’s fairly unique in pediatrics. We would be remiss in not mentioning that labs and diagnostics are not equally, but they are important in the workup and further management of sepsis.

So Gabi, as you did really play a huge part in our sepsis guidelines currently at Children’s, when you were looking at labs, what were the highlighted pieces that you said, these are absolutes?

Dr. Gabi Hester: Most of them are really basic labs that would be available in lots of different healthcare settings, so a CBC with differential, some sort of inflammatory marker, and that may vary depending on the institution, but a C-reactive protein or calcitonin can be really helpful. Something to look at your organ status. So at the very minimum, getting a basic metabolic panel so you can see how the kidneys are being affected and then any electrolyte issues that you’re having.

You may also if you have the opportunity to look at your liver function test by getting a complete metabolic panel, that would be appropriate as well. Often a blood gas and a lactate, those can be helpful in determining is there a level of metabolic acidosis at play. And then looking at your coagulation, so a PT/INR, a PTT, maybe a fibrinogen, those would all be potential labs that you’d be getting.

Plus, of course, one of the most important things would be a blood culture. So I had no idea how challenging it was to obtain a blood culture in some patients until I changed my roles and really I’m at the bedside more, to be honest, and watching the process of getting the labs. And that can be tricky. So I think one thing to focus on or to highlight when talking about labs is that we shouldn’t delay treatment until we obtain the labs or until we get the lab results.

Because sometimes I’ll see that they’ll place an IV but not be able to get the labs yet, and so I would prioritize the IV over getting of the labs. In a perfect world, we want that culture before we start antibiotics. Of course, we do. But if it’s a matter of needing to delay the initiation of the antibiotics to get that culture, don’t. Go ahead and give your antibiotics to get started.

Dr. Courtney Herring: And on the subject of blood cultures, which we cover a fair amount in some of our other infectious guidelines, even the idea in sepsis, which is slightly unique from adult sepsis, is that it’s a fair amount of negative blood cultures, and there’s multiple variables to that. You already alluded to the difficulty of getting blood cultures. We’re more of a blood sparing phlebotomy rule of thumb in pediatrics understandably.

There’s also that viremia is a real situation for sepsis, which is again, a little bit more prominent in the pediatric population than you will see in an immunocompetent adult. Those couple of areas of how do you look at what’s going to be helpful, it is so absolutely imperative to consider blood cultures for diagnostics. But at the same time, don’t expect it’s going to always change your management.

So moving forward from identification and hopefully early recognition, which is always the goal of again looking what is the goal of early recognition, and one, of course, is preventing morbidity and mortality. So Gabi, from your side of things, where you’re in the emergency department clinic, is harder in regards to resource orientation. But when you’re in a resource rich environment, how do you look at stabilization?

Dr. Gabi Hester: It should look pretty similar regardless of the level of resources in the environment because the initial steps are pretty basic. So the main thing is to get access. So you need to get a peripheral IV. If you can’t get a peripheral IV, you’re looking at it like an intraosseous line. And most places, even the non-pediatric facilities or non-pediatric specific hospitals, they’ll have a legend in the hospital, the one person that you call when you need a pediatric IV.

So it might be an anesthesiologist. It might be a former NICU nurse, who now works in the adult ICU. There’s often someone that you can call. And so if you’re that provider there, knowing those local resources is really important. But the basic stabilization is getting that access and then getting fluids and antibiotics going.

And I think another call-out or important thing to keep in mind with fluids, when we say a bolus as a provider, we may have one thing in our mind of what that means to us and we have to make sure that we’re translating that for the person who’s actually physically giving the bolus, which is often the bedside nurse. With sepsis, your bolus is actually very different from say dehydration from gastroenteritis.

You need to get that bolus in fast. And so that might be actually pushing the fluids in by hand via syringe, or it might be using a pressure bag system, which not all hospitals have, and even some pediatric units might not have specific training on using that pressure bag system. So I think it’s really important to make sure you’re being really, really specific about your orders and what you need.

This is an IV fluid bolus. We need this run over 20 minutes. It needs to go in because you’ve got that one hour window in most cases, a one to three hour window, depending on how sick the kid is, however you want to define that. Time is really life in this situation. So the faster you get things in, the more likely you are to have a really good outcome.

Dr. Courtney Herring: What we’ve learned at least in projection is that with every hour of deferral of intervention for sepsis, it’s about an 8% increase in mortality rate. So that’s obviously something to be conscientious of when you’re the first-line provider and care team. But again, back to how do you identify the sick from the really sick, and I think that’s still a work in progress for most of us.

Dr. Gabi Hester: Think a little bit about that time to that first intervention, and I think it’s important to factor in too, what is that journey like for that patient to get to wherever you are? Their journey may have started long before you. And so I think that there’s an element of recognition that needs to be happening at home to begin. And so we think about the parent or caregiver may be noticing that their child is acting a little funny.

And often it’s not the first call is 911. Often the first call is to a family friend, maybe a neighbor, a family member and saying, “My kiddo is not acting normal. What should I do? What should I be worried about?” Obviously educating the public is really important in this so that people are aware of sepsis. There’s some great campaigns about how to recognize stroke and how to recognize a heart attack and what to do.

It’s been a little bit slower to get that going for sepsis. There are some good organizations that are working on that. We can mention those at the end. But I think educating the public a little bit as an important factor. And then two, their next step in their journey might be to a local clinic, a rural urgent care or emergency department.

Dr. Courtney Herring: A clinic nurse line, right?

Dr. Gabi Hester: Exactly. Exactly. And so building systems that help identify kids, whether that’s screening questions that nurse triage lines might be prompted to make. And I think the other thing is erring on the side of treatment. As many of our listeners know, I used to do Guidelines with Gabi as a series in this podcast, and a lot of what we talked about there was stopping doing things. So I think I became a little known as like the “don’t do this and don’t do that.”

And I think with sepsis it’s really important to recognize it’s different. It is actually a do this and do this fast. And I would much rather have people err on the side of over treating, so to speak, putting a few more IVs in, giving a few more fluid boluses maybe to kids who ultimately, once you’re in that hindsight or rear-view mirror look, maybe they didn’t have sepsis, but they got a fluid bolus and it didn’t hurt them.

Obviously you can think of some rare exceptions where sure, hypothetically, you could fluid overload a kiddo. That’s so rare. What you told me in the intro is that sepsis is not rare. I think it’s something like 18 kids are dying in the US every day of sepsis, and so that’s not rare. We should be looking for it.

Dr. Courtney Herring: What we’re really talking about is that 40 to 60 milliliters per kilogram finale of like is the patient going to be fluid refractory or no too, and then looking at other interventions as well, and recognizing there are going to be patients in that severe shock phase of sepsis that are going to be refractory to fluids and even catecholamine refractory. And that’s really not in scope of this, but is really a call-out again to that first primary assessment and what do you do now? And then I think bigger is around stabilization of getting them potentially to the right place at the right time.

Dr. Gabi Hester: Exactly.

Dr. Courtney Herring: And so it leads into how this is really a glorious opportunity because you have great experience in a tertiary quaternary pediatric center healthcare organization, and then you have obviously chosen to go community-based care of pediatric hospitalizations and how that looks and the resources are different. It doesn’t mean they’re less in many ways, especially in primary assessment, but it is a call-out to how do you assess what you have and how do you use that.

Dr. Gabi Hester: One of the biggest things that I wouldn’t have anticipated or maybe was a little naive to before I went into a different setting was the challenge of transporting a patient. We, unfortunately, in our healthcare system, obviously there are a lot of resource limitations, and one of those is ambulances and trained medical personnel to run those ambulances.

And so a lot of times when a child is already in a hospital, whether it’s in the emergency department or say they’re in my hospital on our medical surgical pediatric floor where we don’t have an intensive care unit for children, they’re deemed as being in a hospital.

So it’s different than someone who’s getting medical help at home. So ambulances actually prioritize that call to the house because that person have any healthcare yet or any medical care. So hospitals actually are pretty low on the totem pole.

Dr. Courtney Herring: Yeah, they assume there’s care being had.

Dr. Gabi Hester: They assume that I can treat pediatric sepsis and manage that child even though I don’t have an intensive care unit or those types of resources available. So it’s really important to become familiar at least with where would I go for that information for those next steps? And there are great tools out there as far as people I can call. I can always call the Children’s Physician Access Line to speak with an intensivist here.

There are a lot of other resources that I can tap into to get some virtual support, so to speak, because it might be, in some circumstances, hours. I’ve had issues where it’s taken 12 hours to transfer a patient who needed intensive care. And that can be challenging obviously for us as providers, but for the patient, the family, everybody.

Dr. Courtney Herring: We would not be completing our discussion on management style outside of fluids without talking about antibiotics. That is the second, but equally important step in looking at treating sepsis as you continue to navigate the journey of these patients. Talking about antibiotic stewardship is always a hot topic and should be as we look at a growing resistance in the community of bacterial pathogens and antibiotic resistance. But in here, you’re talking about efficiency to care and context of the patient. So how do you look at antibiotic stewardship or just antibiotics in general for sepsis?

Dr. Gabi Hester: I think I look at it differently depending on where I am. So I know when I’m here in my moonlighting role at Children’s, if I’m practicing at the bedside, I know there’s a really great sepsis guideline with some really specific tailored antibiotic recommendations initially drafted by Dr. Christina Koutsari, an infectious disease pharmacist, and Dr. Bill Pomputius from infectious disease, and really looked at what’s my suspected organ system and how do I think that might determine the level of coverage or the type of coverage that I have.

So if I’m thinking intra-abdominal, you need to be covering more of those gram negatives that I might not be doing if I’m thinking of a pneumonia, for example. Alternatively, if I’m in a different care setting, perhaps I’m in a more community-based site, I’m going to reach for a broad spectrum antibiotic that I have on hand and then I can get quickly. Because as we mentioned before, time is crucial, so time is life.

Often that’s going to be turning to an antibiotic that is used really commonly, so like a third generation cephalosporin, for example, like Ceftriaxone. They use that frequently in different emergent settings. And that would be, I think, an appropriate initial antibiotic, both because it has some broad coverage as well as the speed, which usually you can get that from the pharmacy and into the patient, which is really an important factor.

One thing that we neglected to mention a little bit when we were talking about fluids, we’re moving away a little bit from using normal saline to using lactated ringers. And so there’s an effect of chloride can have on perpetuate metabolic acidosis. And so there’s been some studies that suggest better outcomes in patients when you do your initial fluid resuscitation with lactated ringers, which most facilities will have lactate ringers on hand.

If they don’t, give normal saline. I don’t want people to think, I don’t have lactated ringers at my hospital or at my urgent care, and so I shouldn’t give normal saline. Definitely a good alternative as a second line option.

Dr. Courtney Herring: It’s either/or at this point, right?

Dr. Gabi Hester: Yes, exactly.

Dr. Courtney Herring: And you’re right, there’s some low power studies obviously looking more in adults as expected around lactated ringers versus normal saline. The hyperchloremia is a big part of the perpetual acidosis. The pH itself of lactated ringers is closer to neutral blood sera. So there’s a lot of those hypotheticals. I agree, and you’re right, especially in the United States, we carry a lot of lactated ringers because it is utilized heavily in adult medicine as well.

So I do think it’s an easy grab in your emergency department. So considering that when you’re maybe building that algorithm, which is definitely another great topic of how do you ensure consistency of care. And you’re a great proponent of this. You’ve obviously been a huge gift to guidelines at Children’s and have promoted quality and evidence-based medicine, which we all adore and I’m grateful for as a physician.

But at the same time, you also have implemented how to identify that in translational medicine, how to look at that with the resources we have. And then an example of that is an electronic medical record. So can you briefly just speak on your experience of building a sepsis tool?

Dr. Gabi Hester: When you think about a sepsis screening tool, you have to remember it’s a screening tool. So you’re never going to have high specificity, right? That’s not the goal of a screening test. And I think what brings some frustration for some people and myself as well, you get a page that says your patient has a fever and a fast heart rate, and they meet criteria for the sepsis trigger. And often you’re like, yeah, I know. Thanks.

I have a friend, Dr. Jenny Workman, led the sepsis initiatives at the University of Utah Primary Children’s Hospital out in Salt Lake City, and they saw a huge reduction in mortality after implementing these electronic tools for screening for sepsis. And when I asked her what’s the magic sauce? Why is it working so well at your hospital? First of all, there’s buy-in from everybody, and it’s really a multidisciplinary tool, really owned by nurses, to be honest.

A lot of engagement and leadership there of recognizing that this helps them get a clear message to the providers when they’re trying to reach out and has some structure around the next step of the process. And the other thing she talks about is it’s really just a reminder to, A, talk about sepsis, and B, to get together to talk about a plan and to reevaluate the patient.

So the huddle is super important. It gets everybody at the bedside to say, “Yep. No. We’re good. This patient looks okay. We’re going to continue with the plan.” I’m going to go about my day to, oh, something has changed in the last hour, because we know sepsis can act quickly. And so what are we going to do differently? How do we implement the plan? And that can be challenging in a busy day with a busy workload in a complex system.

So I definitely recognize that there are challenges with the tool. In places that maybe don’t have a focus on pediatric care, if you’re embedded more in a adult focused system, implementing a tool may have different challenges with the inputs coming in from the electronic medical record may be different. It may not involve more pediatric focused vital sign ranges and things like that.

So really important to factor in the specific setting you’re in. The way I think about it in my community hospital is a little bit less on the specifics of you need to know this lab value and this heart rate range and everything like that. For some of the providers who might not see a lot of kids, I think my message would be, if you feel like something is not right, call me. A lot of hospitalists in community hospitals, one of their main roles is in consultation in the emergency department.

And so I don’t think there would be a community hospitalist out there who would not go to the bedside to look to see if the kid is okay or not. And so that’s a big part of what we do is go down to the emergency room, do an evaluation of the patient with that extra pediatric experience and knowledge that we have and say, “This is an appropriate response to the pneumonia that you’ve identified or your infection,” or whatever it might be, because you have a fever, you get a fast heart rate with some of those things.

Versus I get there and the behavior isn’t appropriate for that child’s age and development, or the parent has a concern that there haven’t been wet diapers in 18 hours. So for me, the focus is on really emphasizing my availability and my excitement to come and see a patient as opposed to really detailed teaching and education about every specific potential disease that’s out there.

Dr. Courtney Herring: And as we’ve talked about, fluid resuscitation as well as antibiotics being the two main components that are highlighted in that efficiency to care and intervention. I just want to say with a call-out to the Phoenix criteria that we chatted about earlier, disability and death, the potential outcomes, but really painting an allegory, capturing revival and rebirth that we should be expecting for our future designs of taking care of children with sepsis.

Revival meaning pediatric-centric considerations and defining sepsis, and also rebirth of pediatric sepsis awareness and efforts for equitable management across healthcare settings. For today, that’s the end of our time together for this episode of Evidence Based Charm. Thank you for listening in. Gabi, I just want to say thank you for being here, sharing space.

Dr. Gabi Hester: Oh, Courtney, this has been so fun. I wish we had endless hours to talk about sepsis.

Dr. Courtney Herring: For everyone listening, one, thanks for being here with us. Two is that we are just scraping the surface literally on sepsis.

Dr. Gabi Hester: We didn’t even get the time to talk about neonatal population.

Dr. Courtney Herring: Absolutely.

Dr. Gabi Hester: As you briefly mentioned, it’s own separate bag. We didn’t talk about the immunocompromised populations. We didn’t even get to touch on disparities in sepsis.

Dr. Courtney Herring: Which are huge.

Dr. Gabi Hester: Incidents and outcomes, which are huge and need to be thought about really carefully. So I’ll just have to come back.

Dr. Courtney Herring: I know. We need probably a sepsis part two. I always enjoy speaking to you about anything clinical, and I look forward to sharing space with you soon.

Dr. Gabi Hester: Anytime, friend.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.