PEDIATRIC SEPTIC SHOCK
COLLABORATIVE
Educational Content
(Sepsis, Septic Shock, & QI Primer)
Goals
• Review the impact of sepsis on patient outcomes
• Define the sepsis disease spectrum
• Review the evidenced based guidelines for the
management of severe sepsis/septic shock
• Outline quality improvement strategies for change
IMPACT OF SEPSIS ON
PATIENT OUTCOMES
Educational Content
Epidemiology
• Over 18 million cases worldwide each year
• The annual incidence in the US of severe
sepsis is approximately 3.0 cases per 1,000
• Sepsis kills approximately 1,400 people
worldwide EVERYDAY
Epidemiology-Pediatric
• Sepsis is a leading cause of illness & death
among U.S. children
• > 42,000 cases annually (4th leading cause behind asthma,
appendicitis, and poisonings)
• 5-10% overall mortality (0-5% healthy children; 10% if
underlying medical conditions)
• 7-9 % of all childhood deaths are due to
sepsis (more common than cancer)
Watson Am J Respir Crit Care Med 2003 167:695-701
Kutko Pediatr Crit Care Med 2003; 4:333-337
Carcillo Crit Care Med 2002 30(6):1365-1378
Conditions Associated with High
Hospital Resource Use
Condition
Mean Cost
Mean LOS
Severe Sepsis
~$40,600
31 days
IRDS
~$35,000
25 days
Spinal cord injury
~$25,000
16 days
Prematurity
~$24,000
22 days
Heart valve disease
~$23,000
9 days
Watson RS et al, Am J Respir CCM 2003
Sepsis Disease Spectrum
Presentation of sepsis reflects a spectrum
SIRS
Sepsis
Severe
Sepsis
Septic
Shock
Definitions
• Systemic Inflammatory Response Syndrome (SIRS): 2
of 4 criteria
• Temp <36 or >38.5
• HR >2 SD above normal for age (or bradycardia if <1
year old*)
• RR > 2 SD above normal for age
• Abnormal WBC or > 10% immature neutrophils
• Sepsis: SIRS with suspected or confirmed infection
• Severe sepsis: Sepsis + organ dysfunction or failure
Goldstein Pediatr Crit Care Med 2005 6(1):2-8
Definitions
• Septic shock= Hypothermia or hyperthermia and signs of
cardiovascular organ dysfunction including
• Altered or decreased mental status (inconsolable irritability,
lack of interaction with parents and inability to be aroused)
• Capillary refill ≥3sec (cold shock) or flash capillary refill (warm
shock)
• Diminished (cold shock) or bounding peripheral pulses (warm
shock)
• Mottled cool extremities (cold shock)
• Decreased urine output <1 mL/kg/hr
• Hypotension
Carcillo Crit Care Med 2002 30(6):1365-1378
2 Major Types of Septic Shock
•Cold Shock
•Warm Shock
•Cold extremities
•Warm extremities
• Capillary refill ≥ 3 sec
•Flash capillary refill
•Myocardial Dysfunction
•Vasomotor Paralysis
•Low CI and high SVRI
•High CI and low SVRI
•Sick heart with significant
vasoconstriction to
maintain perfusion to
organs
•Hyperdynamic heart
with vasodilation
Definitions
• Compensated shock:
• Systolic blood pressure within normal range with
signs and symptoms of inadequate perfusion
• Children more often present in compensated
shock
• Decompensated shock:
• Signs of shock associated with systolic hypotension
Further Definitions
• Fluid-refractory shock:
• Shock despite 60 cc/kg in 1st hour
• Dopamine-resistant shock:
• Shock despite adequate fluid resuscitation and 10
mcg/kg/min
• Catecholamine-resistant shock:
• Shock despite epinephrine or norepinephrine
• Refractory shock:
• Shock despite goal-directed use of inotropic agents,
vasopressors, vasodilators, and maintenance of metabolic
and hormonal homeostasis
Carcillo Crit Care Med 2002 30(6):1365-1378
Sepsis: A Disease Continuum
• Patients with life-threatening infection often present
with fever and excessive, persistent tachycardia
• Tachycardia, tachypnea, and signs of worsening
perfusion precede hypotension
• Hypotension is a late, ominous sign in pediatrics
• Often followed by cardiopulmonary collapse
• Stopping progression to hypotension (decompensated
shock) via early aggressive interventions improves
outcomes
THE EVIDENCE
Educational Content
p < .001
Each hour of delay
associated with 50%
increased odds of
mortality
p < .001
Han et al., Pediatrics 112: 2003
Adult Mortality Reduced by 15% with
Early Goal Directed Therapy
For every 6
adults with
septic shock
who are treated
effectively, 1
death is
prevented
Rivers et al., NEJM 2001
Early Rapid Fluid Resuscitation in Pediatric Septic
Shock is Associated with Improved Outcomes
Time-sensitive
% Mortality
Fluid-sensitive
Oliveira et al, Ped Emergency Care 24:2008
Every hour delay in receiving effective antibiotics is associated with a
7.6% decrease in survival in
adults with septic shock
Kumar et al, Crit Care Med 34: 2006
EVIDENCED BASED
GUIDELINES
Educational Content
Pediatric Septic Shock Guidelines
• Early aggressive fluid resuscitation (up to 60 cc/kg in the first 15
minutes)
• Proportionally larger quantities of fluid in children
• Initial volume resuscitation commonly requires 40-60 cc/kg but
can be as much as 200 cc/kg in the 1st hour
• Reassess between boluses for signs of volume overload—
hepatomegaly, rales, gallops
• Vasoactive agents for fluid refractory shock
• Can be given through peripheral IV until central access is obtained
• Initiate dopamine for fluid-refractory shock
• Initiate norepinephrine (warm shock) or epinephrine (cold shock) for
fluid-dopamine-refractory shock
• Remember short half life therefore rapid titrations are needed
• Hydrocortisone for adrenal insufficiency
• Identify need for invasive cardiovascular monitoring for fluid-refractory
shock
Carcillo Crit Care Med 2002 30(6):1365-1378
Pediatric Septic Shock Guideline
• Therapeutic goals include:
• Capillary refill time ≤ 2 seconds
• Normal pulses with no differential between peripheral
and central pulses
• Warm extremities
• Urine output > 1 cc/kg/hr
• Normal mental status
• Normal blood pressure for age
ACCM Guidelines:
60 cc/kg in 15 minutes
PALS Guidelines:
60 cc/kg in 60 minutes
The PSSC
Clinical
Pathway
TRIAGE TRIGGER TOOL
High Risk
Conditions
Vital Signs
Signs of
Perfusion
TRIAGE TRIGGER TOOL
Identify as at risk for sepsis if:
1. Hypotension or
2. Meets 3/8 criteria or
3. Meets 2/8 criteria if high-risk
Intubation and Septic Shock
• Low threshold for ET intubation even without primary
respiratory failure
• Up to 40% of cardiac output may be devoted to work of breathing;
this can be unloaded
• Atropine, ketamine preferred agents for sedation
• Caution with etomidate
PEDIATRIC SEPTIC SHOCK
COLLABORATIVE
Educational Content
(Quality Improvement Primer)
QI BASICS
• Create a mission statement
• Identify specific aims
• Identify measures
• Gather key stakeholders
• Needs assessment
• Rapid cycle change
Plan-Do-Study-Act
EXAMPLE OF QI INITIATIVE
Quality Improvement Primer
Mission Statement
• To improve the care of children with severe sepsis
and septic shock in a pediatric emergency medicine
department
Background
PALS (2006)
Recognize altered mental status and poor perfusion
5 min
Establish vascular access and begin resuscitation
5 min
1st hour
1st hour: Push repeated 20 mL/kg IVF up to 3
60 min
 Administer antibiotics STAT
yes
Fluid responsive (i.e. normalization
of BP and/or perfusion)?
Consider ICU
monitoring
60 min
no
Begin vasoactive drug therapy and titrate
to correct hypotension / poor perfusion
Modified from Pediatric Advanced Life Support Manual. American Heart Association.
2006.
60 min
Needs Assessment
100
90
80
70
60
% Adherence 50
40
30
20
10
0
Recognition
in 5 min
Vascular Access
in 5 min
60ml/kg
in 60 min
Antibiotics
in 60 min
PALS Intervention
Inotropes
in 60 min
Needs Assessment
Fluid
adherence
n= 29
(mean # days)
Fluid
non-adherence
n= 98
(mean # days)
% decrease
P value
Hospital
LOS
8.0
11.2
57%
0.039
ICU LOS
5.5
7.2
42%
0.024
Total algorithm
adherence
n= 15
(mean # days)
Total algorithm
non-adherence
n= 112
(mean # days)
% decrease
P value
Hospital
LOS
6.8
10.9
57%
0.009
ICU LOS
5.5
6.8
59%
0.035
Aim Statement
• Increase adherence to the Pediatric
Advanced Life Support Guidelines
• for severe sepsis and septic shock in the Children’s Hospital
Boston Emergency department
• from 19% overall adherence to the 5 component bundle to >
90% adherence
• within one year
Secondary Aims
• COMPONENTS OF THE BUNDLE:
• Improve recognition: > 90 % of patients are recognized within 5
minutes of meeting definition of SS
• Improve attainment of vascular access: (peripheral, intraosseous or
central): >90% of patients have access within 5 minutes of meeting
definition of SS
• Improve delivery of fluid: > 90% of patients have 60 ml/kg of isotonic
fluid delivered within 60 minutes of meeting definition of SS
• Improve delivery of antibiotics: >90% of patients have antibiotics
delivered within 60 minutes of meeting definition of SS
• Improve delivery of vasoactive agents: > 90% of patients have a
vasoactive agent begun at 60 minutes of meeting definition of SS
Measures
• Outcome Measures
• Mortality
• Length of stay in ICU, hospital
• Days on vasoactive agents
• Multiorgan dysfunction syndrome
• Process Measures
• Adherence to recognition, vascular access, IV fluid,
antibiotic and vasoactive agents
• Balancing Measures
• ED length of stay
• Increased respiratory support due to pulmonary edema
Team Members
Middle Management
Frontline workers
Physicians
Nursing
Respiratory
Nursing assistants
Pharmacists
Research
Assistants
Pharmacy Head
Statistical Support
Computer Support
Upper Level
Management
Physician
Leadership
Nursing Leadership
Hospital Leadership
Equipment
MD’s are too busy with
patient to put in orders
Waiting for IV team
Don’t know how to
use pressure bag
Holding for other
procedures
CA’s cannot be
reached
Need labels to sent labs
CA’s usually get labels but
are busy holding for IV
Can’t find
pressure bag
Wrong
fluid
device
used
People
CA phones numbers not
uniformly posted, some
don’t have phones
Hesitance to use
IO
People don’t know
pharmacy number
No IV access
Access tenuous
Pharmacists difficult
to get a hold of
Don’t know to use
pressure bag
Too many
patients
Too busy
to
recognize
septic
patients
No pocket cards for
bedside reference
Poor knowledge of
protocol
Not enough
MDS
No visible
algorithms
No trigger
system
Environment
60ml/kg
within 60
minutes
MD’s don’t know
who the nurses are
No educational
sessions
No
accountability/feedback
Many trainees to
educate, many
adult trainees
Poor RN/MD
communication
Many trainees
Methods
Needs Assessment: Pareto
35
100%
90%
30
80%
25
70%
60%
20
Frequency
Percent
50%
15
40%
30%
10
20%
5
10%
0
0%
Inotropes in 60 60ml/kg in 60 min Vascular Access
min
in 5 min
Antibiotics in 60
min
Recognition in 5
min
Cumulative
Percentage
Change Hypotheses
• Educational sessions MDs
October 6
• Educational sessions RNs
• Didactics
• Net learning
• Skills Day (pressure bags)
• Computer Orderset
September 21, October 2
Ongoing
October 12
September 26
• Visible algorithm
• Posters
October 16
• Pocket cards
October 27
• Clock
October 19
• Bedside Survey
October 10
SEVERE SEPSIS AND SEPTIC
SHOCK PROTOCOL
WITHIN
RECOGNIZE
altered mental status / poor perfusion
0:05 min
VASCULAR ACCESS
IV FLUIDS
60 mL/kg
pressure bag if >10kg
WITHIN
1:00 hr
ANTIBIOTICS
no
AT
1:00 hr
Fluid Responsive
(normalization of BP
and/or perfusion)?
VASOACTIVE DRUG
titrate quickly to correct
hypotension / poor
perfusion
Modified from Pediatric Advanced Life Support Manual. American Heart Association.
yes
Admission
for
monitoring
ED Septic Shock Orderset
Personal Feedback
Hi,
This email is to let you know that your patient AT
(24 year old Asperger's, panhypopit, vomiting
and diarrhea) met the criteria for septic shock.
He had fever, tachycardia (SIRS) and
hypotension.
You met the recognition in 5 minute goal!
You met the IV access in 5 minute goal!
You met the 60cc/kg in 60 minute goal for IVFs!
You met the antibiotics in 60 minute goal!
You met the pressor initiation at 60 minute goal!
MEASURE: Run Chart
MEASURE: SPC Chart
Upper Control Limit
Lower Control Limit
Example SPC chart
Total Bundle Adherence Pre and Post Intervention
100%
90%
80%
INTERVENTION
70%
60%
Percent
Adherence
50%
Mean Adherence
Institutional Adherence
40%
Lower Control Limit
Upper Control Limit
30%
20%
10%
0%
Month
The Improvement Guide: 1996
Sepsis and Septic Shock
• Early, timely goal directed therapy improves patient
outcomes and mortality
• A systematic approach is necessary for a successful
quality improvement project