Early Goal-Directed Therapy in Pediatric Sepsis
Derek S. Wheeler, MD, FAAP, FCCP, FCCM
Associate Professor of Clinical Pediatrics
University of Cincinnati College of Medicine
Clinical Director, Division of Critical Care Medicine
Cincinnati Children’s Hospital Medical Center
The James M. Anderson Center for Health Systems Excellence
Co-Director, The Center for Acute Care Nephrology
Early Goal-directed Therapy
Early Goal-directed Therapy
Protocolized Care for Early Septic Shock (ProCESS)
NCT00510835 (expected study completion August 2013)
Surviving Sepsis Campaign
Sepsis Resuscitation (6 H) Bundle
Measure Serum Lactate
Administer broad-spectrum antibiotics (<3 h)
Early resuscitation to EGDT Targets
Sepsis Management Bundle
Low-dose corticosteroids
Drotrecogin alfa
Tight glucose control
Plateau Pressure < 30 cm H2O
N=15,022
Crit Care Med 2010; 38:367
Early Antibiotics
“Door to antibiotics” decreased
from 143 to 38 minutes
N=2,731 adults with septic shock
TCH Sepsis Protocol
Only 50% of pts received antimicrobial therapy
within 6 h of documented hypotension!
Cruz et al. Pediatrics 2011; 127:e758
Crit Care Med 2006; 34:1589
Early Antibiotics
“Door to Antibiotics” < 3 hours
N=2,731 adults with septic shock
Primary Children’s Sepsis Protocol
Larsen et al. Pediatrics 2011; 127:e1585
Only 50% of pts received antimicrobial therapy
within 6 h of documented hypotension!
Crit Care Med 2006; 34:1589
Early Resuscitation
Reduction in mortality from 23% to 2.5%!
Arch Dis Child 2001; 85:386
Early Resuscitation
Pediatrics 2003; 112:793
Early Resuscitation
Minimize variation
Intensive Care Med 2008; 34:1065
Early Resuscitation
Minimize variation
Intensive Care Med 2008; 34:1065
Early Resuscitation
Minimize variation
28-day Mortality 39.2% versus 11.8%
Intensive Care Med 2008; 34:1065
Early Resuscitation
Minimize variation
No differences in HR, MAP, CVP,
ScvO2, or Lactate at Baseline, 6 H, or 72 H
Intensive Care Med 2008; 34:1065
Early Resuscitation
Minimize variation
Significant differences in amount of
fluid volume administered at 6 H
No differences in TOTAL fluid volume
administered at 72 H
Early administration of inotropes
Intensive Care Med 2008; 34:1065
Final Thoughts
1. Protocolized care to minimize
practice variations.
2. Early recognition = Early
Treatment
3. Better therapeutic endpoints
are on the horizon
Thank You!
Division of Critical Care Medicine
Hector R. Wong, MD
Carley Riley, MD
Erika Stalets, MD
The James M. Anderson Center for Health Systems Excellence
Stephen Muething, MD
Patrick Brady, MD
Uma Kotagal, MBBS, MSc
Janet Jacob, RN, MBA
Cincinnati Children’s Center for Simulation and Research
Gary Geis, MD
John Whitt, MD
Tom LeMaster, RN, MSN, MEd, REMT-P, EMSI
University of Cincinnati College of Medicine
Amy Bunger, PhD
Children’s Hospital of Akron
Mary D. Patterson, MD, MEd
University of Michigan Ross School of Business
Kathleen M. Sutcliffe, MSN, PhD
R18 HS020455
Applied Decision Science, LLC
Laura Militello, MA
MacroCognition, LLC
Gary Klein, PhD
derek.wheeler@cchmc.org