Welcome The Pediatric Guidelines from the Surviving Sepsis Campaign: Considerations for Care Audience Participation Your Participation Open your control panel • • Join audio: Choose “Mic & Speakers” to use computer VoIP Choose “Telephone” and dial using the information provided Submit questions and comments via the Questions panel Note: Today’s presentation is being recorded and will be provided within 45 days. Audience Participation Your Participation • Please continue to submit your text questions and comments using the Questions Panel or • Click Raise Hand button to be unmuted for verbal questions. Stephen L. Davidow, MBA-HCM, APR Manager, Quality Implementation Programs Society of Critical Care Medicine Mount Prospect, IL Today’s webcast is funded by a generous grant from the Gordon and Betty Moore Foundation Welcome The Pediatric Guidelines from the Surviving Sepsis Campaign: Considerations for Care Save the Date! The Next Surviving Sepsis Campaign Webcast October 15, 2013, 1 pm CT Topic: The Surviving Sepsis Campaign as a Model for Mentoring Faculty: Ryan O’Gowan, MBA, PA-C, FCCM, St. Vincent Hospital Marie Mullen, MD, University of Massachusetts Emanuel P. Rivers, MD, MPH, Henry Ford Health System Margaret M. Parker, MD, FCCM Professor of Pediatrics, Anesthesia, and Medicine Stony Brook University Director, Pediatric Intensive Care Unit Long Island Children’s Hospital Stony Brook, NY SCCM SSC Representative, 2002-2009 Past President, SCCM Potential Conflicts of Interest No direct or indirect potential financial conflict of interest as to any material presented in this presentation. “Time Zero” • Time Zero = time of presentation – ED, Medical Floors, ICU • Both adult bundles time based • Most important time based elements: – Antibiotic timing – Resuscitation timing (EGDT) Implications for Time Zero • New York State DOH – Mandated reporting of sepsis outcomes – Adherence to “evidence-based” protocols • NQF sepsis measures – Recently approved • Fear of being “dinged” for patients who did not meet criteria on triage in ED – Public reporting – Pay for Performance Evaluating Severe Sepsis • Q1: Signs of SIRS – Adjusted for pediatric age-specific populations. • Q2: Suspected infection - clinical judgment to determine if there is a new potential site of infection. • Q3: Organ dysfunction – often discovered by an abnormal serum lactate value Pediatric Considerations • • • • Initial resuscitation Antibiotics and source control Fluid resuscitation Inotropes/vasopressors/ vasodilators • ECMO • Corticosteroids SSC 2012 Guidelines Initial Resuscitation We suggest starting with face mask oxygen or if needed and available, high flow nasal cannula oxygen or nasopharyngeal CPAP for respiratory distress and hypoxemia. For improved circulation, peripheral intravenous access or intraosseus access can be used for fluid resuscitation and inotrope infusion when a central line is not available. If mechanical ventilation is required then cardio-vascular stability during intubation is more likely after these are achieved. Grade 2C SSC 2012 Guidelines Initial Resuscitation We suggest that the therapeutic end points of resuscitation of septic shock be capillary refill of <2 secs, normal blood pressure for age, normal pulses with no differential between peripheral and central pulses, warm extremities, urine output >1 mL·kg-1·hr-1, and normal mental status in the first hour and SCV O2 > 70% and CI between 3.3 and 6.0 L/min/m2 thereafter. Grade 2C A Comparison of ACCM-PALS Guidelines to Standard Care on Outcome from Pediatric Septic Shock A Randomized Control Trial (de Oliveira et al Intens Care Med 2010) Goal normal perfusion Central line to RA/SVC or RA/IVC No continuous O2 sat monitoring (n = 51) 102 Septic Shock Patients Fluid resuscitated Goal O2 sat > 70% Central line to RA/SVC or RA/IVC Continuous O2 sat monitoring (n = 51) De Oliveira et al Intens Care Med 2010 De Oliveira et al Intens Care Med 2010 Before 0-6 h 6-72 h Total Crystalloid Control Intervention P value 49 +/- 33 47 +/- 26 0.89 11 +/- 14 32 +/- 23 < 0.0001 19 +/- 25 15 +/- 21 0.53 79 +/- 47 94 +/- 40 0.10 RBC Control Intervention P value 0.9 +/- 3.7 0.6 +/- 3.1 0.86 2.1 +/- 5.1 7.2 +/- 8.5 0.0053 5.6 +/- 7.1 4.4 +/- 8.0 0.26 8.6 +/- 7.91 12.1 +/- 11.2 0.14 N % RBC Control Intervention P value 5.9 3.9 1.0 15.7 45.1% 0.0023 43.1 31.4 0.31 58.8 68.6 0.41 7.8% 31.4% 0.01 24.4% 27.4% 0.92 31.4% 58.8% 0.05 15.7 45.1% 0.0023 43.1 31.4 0.31 58.8 68.6 0.41 % Additional Inotrope or Vasodilator Control Intervention P value N % RBC Control Intervention P value 5.9 3.9 1.0 Reduced Mortality with ACCM-PALS Guidelines compared to Standard Care for Pediatric Septic Shock - A Randomized Control Trial (de Oliveira Intens Care Med 2010) Goal normal perfusion 102 Septic Shock Patients 28 day Mortality 39.2% 20/51 Goal O2 sat > 70% 28 day Mortality P = 0.0027 11.8% 6/51 Fig. 3 Kaplan–Meier estimates of mortality (28 days) de Oliveira et al Intens Care Med 2010 SSC 2012 Guidelines Initial Resuscitation • We recommend following ACCM-PALS guidelines for the management of Septic Shock Grade 1C • We recommend reversal of unrecognized pneumothorax, pericardial tamponade, intraabdominal hypertension, or endocrine emergencies in patients with refractory shock Grade 1C Figure 2 Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Dellinger, R; Levy, Mitchell; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; MD, PhD; Opal, Steven; Sevransky, Jonathan; Sprung, Charles; Douglas, Ivor; Jaeschke, Roman; Osborn, Tiffany; MD, MPH; Nunnally, Mark; Townsend, Sean; Reinhart, Konrad; Kleinpell, Ruth; PhD, RN-CS; Angus, Derek; MD, MPH; Deutschman, Clifford; MD, MS; Machado, Flavia; MD, PhD; Rubenfeld, Gordon; Webb, Steven; MB BS, PhD; Beale, Richard; Vincent, Jean-Louis; MD, PhD; Moreno, Rui; MD, PhD Critical Care Medicine. 41(2):580-637, February 2013. DOI: 10.1097/CCM.0b013e31827e83af Figure 2 . Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children. Reproduced from Brierley J, Carcillo J, Choong K, et al: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-688. © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc. 2 SSC 2012 Guidelines Antibiotics and source control • We recommend that empiric antibiotics be administered within 1 hr of the identification of sepsis. Although cultures are preferred they are not always possible. Antibiotics should not be delayed while awaiting attainment of cultures. The empiric drug choice should be changed as epidemic and endemic ecologies dictate (eg H1N1, MRSA, chloroquine resistant malaria) Grade 1D SSC 2012 Guidelines Antibiotics and source control • We suggest clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension Grade 2D • We recommend early and aggressive source control Grade 1D • Clostridium difficile should be treated with enteral antibiotics if tolerated. Vancomycin is preferred for severe disease Grade 1A SSC 2012 Guidelines Fluid resuscitation In the industrialized world with access to inotropes, and mechanical ventilation, initial resuscitation of hypovolemic shock begins with infusion of isotonic crystalloids or albumin with boluses of up to 20 mL/kg (or albumin equivalent) over 5–10 min titrated to reversing hypotension, increasing urine output, and attaining normal capillary refill, peripheral pulses and level of consciousness without inducing hepatomegaly or rales. If hepatomegaly or rales exist then inotropic support should be implemented, not fluid resuscitation. In nonhypotensive children with severe hemolytic anemia (severe malarial anemia, or sickle cell anemia crises) blood transfusion is considered superior to crystalloid or colloid bolusing. Grade 2C Can I Give Too Much Fluid? You most certainly can give too much or too little! • Check for Hepatomegaly • Check for Rales • Evaluate MAP – CVP • Give diuretics • Use Dialysis CRRT if unsuccessful • You can definitely do harm if you do not attend to this! • Some children need zero mLs / kg of fluid because they are not hypovolemic, while others need up to 60 mL/kg or more of fluid during resuscitation to treat hypovolemia. • Severe anemia patients need blood not fluids. Fluids will worsen anemic shock (Hgb < 6 g/dL). NY Protocols • Department of Health requiring hospitals to have protocols for early detection and management of sepsis, including pediatric protocols • Data will be reported to the State starting January, 2014 • Current Pediatric measures under consideration: – Within 1 hour: establish IV access, administer fluid bolus, draw blood cultures, administer antibiotics SSC 2012 Guidelines Inotropes/Vasopressors/Vasodilators • Begin peripheral inotropic support until central venous access can be attained in children who are not responsive to fluid resuscitation Grade 2C • Patients with low cardiac output and elevated systemic vascular resistance states with normal blood pressure be given vasodilator therapies in addition to inotropes Grade 2C SSC 2012 Guidelines ECMO We suggest consideration of ECMO for refractory pediatric septic shock and / or respiratory failure (Grade 2C). SSC 2012 Guidelines Corticosteroids We recommend timely hydrocortisone therapy in children with fluid refractory, catecholamine resistant shock and suspected or proven absolute adrenal insufficiency (Grade 2 C). Pediatric Considerations • Activated Protein C (no longer available) • Blood Products and Therapies • Mechanical Ventilation • Sedation/Analgesia/Drug Toxicities • Glycemic Control • Diuretics and Renal Replacement Therapy SSC 2012 Guidelines Blood Products and Therapies Similar hemoglobin targets in children as in adults. During resuscitation of low superior vena cava oxygen saturation shock (< 70%), hemoglobin levels of 10 g/dL are targeted. After stabilization and recovery from shock and hypoxemia then a lower target > 7.0 g/ dL can be considered reasonable. (Grade 1B) Table 4. Red blood cell transfusion thresholds in pediatric patients with sepsis *. Karam, Oliver; Tucci, Marisa; MD, BSc; Ducruet, Thierry; Hume, Heather; Lacroix, Jacques; Gauvin, France; MD, MSc Pediatric Critical Care Medicine. 12(5):512-518, September 2011. DOI: 10.1097/PCC.0b013e3181fe344b Table 4. Outcome measures Although there were no significant differences in outcomes in children with sepsis in the Conservative (transfuse for Hgb < 7 g/dL) vs Liberal (transfuse for Hgb < 9.5 g/dL) arms the mortality rate was 10% in the Conservative group and 3% in the Liberal group (p = 0.08). In light of the de Oliveira study findings of improved outcomes with transfusions given for Low ScVO2 shock we recommend the liberal strategy when ScVO2 is < 70%. ©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Published by Lippincott Williams & Wilkins, Inc. 2 SSC 2012 Guidelines Blood Products and Therapies Similar platelet transfusion targets in children as in adults (Grade 2C) Use plasma therapies in children to correct sepsis induced thrombotic purpura disorders including progressive Disseminated Intravascular Coagulation, Secondary Thrombotic Microangiopathy, and Thrombotic Thrombocytopenic Purpura (Grade 2C) SSC 2012 Guidelines Mechanical Ventilation We suggest providing lung-protective strategies during mechanical ventilation (Grade 2 C). SSC 2012 Guidelines Sedation/Analgesia/Drug Toxicities We recommend use of sedation with a sedation goal in critically ill mechanically ventilated patients with sepsis (Grade 1D). Monitor drug toxicity because drug metabolism is reduced in severe sepsis putting children at greater risk of adverse drug related events (Grade 2C) SSC 2012 Guidelines Glycemic Control Control hyperglycemia using a similar target as in adults < 180 mg/dL. Glucose infusion should accompany insulin therapy in newborns and children because some hyperglycemic children make no insulin whereas others are insulin resistant (Grade 2C). From: Neurocognitive Development of Children 4 Years After Critical Illness and Treatment With Tight Glucose Control: A Randomized Controlled Trial JAMA. 2012;308(16):1641-1650. doi:10.1001/jama.2012.12424 There were no differences in outcome fours years later in the composite of neurological disability and survival between the Tight Glycemic control and Usual Glycemic control study in the Leuven PICU. There was an improved score in one measure of cognition in the Tight Glycemic control group even though episodes of hypoglycemia had been more prevalent in the PICU for this treatment arm SSC 2012 Guidelines Diuretics and Renal Replacement Use diuretics to reverse fluid overload, and if unsuccessful then continuous veno-venous hemofiltration (CVVH) or intermittent dialysis to prevent > 10% total body weight fluid overload (Grade 2C). Pediatric Considerations • DVT prophylaxis • Stress Ulcer Prophylaxis • Nutrition SSC 2012 Guidelines DVT prophylaxis No graded recommendations on the use of DVT prophylaxis in pre-pubertal children with severe sepsis. SSC 2012 Guidelines Stress Ulcer Prophylaxis No recommendations on the use of stress ulcer prophylaxis in pre-pubertal children with sepsis SSC 2012 Guidelines Nutrition Enteral nutrition given to children who can be fed enterally, and parenteral feeding in those who cannot (Grade 2 C) What about Lactate? Not included in 2012 Guidelines for Pediatrics Infrequently elevated in children May be useful if elevated Questions?