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1Welcome The Pediatric Guidelines from the Surviving Sepsis Campaign: Considerations for Care
2Audience Participation Open your control panelJoin audio:Choose “Mic & Speakers” to use computer VoIPChoose “Telephone” and dial using the information providedSubmit questions and comments via theQuestions panelNote: Today’s presentation is being recorded and will be provided within 45 days.Your Participation
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4Stephen L. Davidow, MBA-HCM, APR Manager, Quality Implementation ProgramsSociety of Critical Care MedicineMount Prospect, ILToday’s webcast is funded by a generous grantfrom the Gordon and Betty Moore Foundation
5Welcome The Pediatric Guidelines from the Surviving Sepsis Campaign: Considerations for Care
6Save the Date! The Next Surviving Sepsis Campaign Webcast October 15, 2013, 1 pm CTTopic: The Surviving Sepsis Campaignas a Model for MentoringFaculty:Ryan O’Gowan, MBA, PA-C, FCCM, St. Vincent HospitalMarie Mullen, MD, University of MassachusettsEmanuel P. Rivers, MD, MPH, Henry Ford Health System
7Margaret M. Parker, MD, FCCM Professor of Pediatrics, Anesthesia, and Medicine Stony Brook UniversityDirector, Pediatric Intensive Care Unit Long Island Children’s HospitalStony Brook, NYSCCM SSC Representative,Past President, SCCM
8Potential Conflicts of Interest No direct or indirect potential financial conflict of interest as to any material presented in this presentation.
9“Time Zero” Time Zero = time of presentation ED, Medical Floors, ICU Both adult bundles time basedMost important time based elements:Antibiotic timingResuscitation timing (EGDT)
10Implications for Time Zero New York State DOHMandated reporting of sepsis outcomesAdherence to “evidence-based” protocolsNQF sepsis measuresRecently approvedFear of being “dinged” for patients who did not meet criteria on triage in EDPublic reportingPay for Performance
11Evaluating 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
12Pediatric Considerations Initial resuscitationAntibiotics and source controlFluid resuscitationInotropes/vasopressors/ vasodilatorsECMOCorticosteroids12
13SSC 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 2CThe initial resuscitation section is new in the 2012 guidelines. It represents no new data but a simpler reorganization of the 2007 recommendations
14SSC 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 2CThis section represents a reorganization of the 2007 guildiens
15A 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)102 Septic ShockPatientsCentral line toRA/SVC or RA/IVCNo continuousO2 sat monitoring(n = 51)Fluid resuscitatedContinuousGoal normal perfusionGoal O2 sat > 70%De Oliveira and colleagues performed a randomized trial demonstrating that use of ACCM-PALS guidelines directed to ScVO2 > 70% reduced mortality compared to use of ACCM –PALS guidelines directed only to capillary refill and blood pressure
18Before0-6 h6-72 hTotalCrystalloidControlInterventionP value49 +/- 3347 +/- 260.8911 +/- 1432 +/- 23<19 +/- 2515 +/- 210.5379 +/- 4794 +/- 400.10RBC0.9 +/- 3.70.6 +/- 3.10.862.1 +/- 5.17.2 +/- 8.50.00535.6 +/- 7.14.4 +/- 8.00.268.6 +/- 7.9112.1 +/- 11.20.14N % RBC5.93.91.015.745.1%0.0023188.8.131.5258.868.60.41% Additional Inotrope or Vasodilator7.8%31.4%0.0124.4%27.4%0.9258.8%0.05When resuscitation was directed to ScVO2 saturation in the PICU, patients received more fluid resuscitation, more blood transfusions, more inotropes, and more vasodilators in order to increase cardiac output and oxygen delivery
19Reduced Mortality with ACCM-PALS Guidelines compared to Standard Care for Pediatric Septic Shock - A Randomized Control Trial (de Oliveira Intens Care Med 2010)102 Septic ShockPatients28 day Mortality39.2%20/51P =11.8%6/51Goal normal perfusionGoal O2 sat > 70%ScVO2 directed therapies resulted in a three fold reduction in mortality with a Number Needed to Treat of < 3 patients
20de Oliveira et al Intens Care Med 2010 Fig. 3 Kaplan–Meier estimates of mortality (28 days)ScVO2 directed therapy improved outcome only in patients with low ScVO2de Oliveira et al Intens Care Med 2010
21SSC 2012 Guidelines Initial Resuscitation We recommend following ACCM-PALS guidelines for the management of Septic Shock Grade 1CWe recommend reversal of unrecognized pneumothorax, pericardial tamponade, intra-abdominal hypertension, or endocrine emergencies in patients with refractory shock Grade 1CThes erecomemndtaion are unchanged
23SSC 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 1DThese recommendations do not differ from 2008
24SSC 2012 Guidelines Antibiotics and source control We suggest clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension Grade 2DWe recommend early and aggressive source control Grade 1DClostridium difficile should be treated with enteral antibiotics if tolerated. Vancomycin is preferred for severe disease Grade 1AThese recommendations are added since 2008 in keeping with more detailed adult recommendations
25SSC 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 non-hypotensive children with severe hemolytic anemia (severe malarial anemia, or sickle cell anemia crises) blood transfusion is considered superior to crystalloid or colloid bolusing Grade 2CWe have re-emphasized the need to consider fluid overload and severe anemia as relative contraindications to fluid boluses. Fluid boluses are for hypovolemia. Inotropes are for poor cardiac function despite euvolemia. Blood is for severe anemia.
26Can I Give Too Much Fluid? You most certainly can give too much or too little!Check for HepatomegalyCheck for RalesEvaluate MAP – CVPGive diureticsUse Dialysis CRRT if unsuccessfulYou 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).
27NY ProtocolsDepartment of Health requiring hospitals to have protocols for early detection and management of sepsis, including pediatric protocolsData will be reported to the State starting January, 2014Current Pediatric measures under consideration:Within 1 hour: establish IV access, administer fluid bolus, draw blood cultures, administer antibiotics
28SSC 2012 Guidelines Inotropes/Vasopressors/Vasodilators Begin peripheral inotropic support until central venous access can be attained in childrenwho are not responsive to fluid resuscitation Grade 2CPatients with low cardiac output and elevated systemic vascular resistance states with normal blood pressure be given vasodilator therapies in addition to inotropes Grade 2CWe re-emphasize the need to start inotropes in euvolemic shock, and vaosdilators in non-hypotensive inotrope resistant euvolemic shock.
29SSC 2012 Guidelines ECMOWe suggest consideration of ECMO for refractory pediatric septic shock and / orrespiratory failure (Grade 2C).These guidelines have not changed since Outcomes for sepsis related refractory respiratory or cardiovascular failure are the same as non-sepsis related refractory respiratory or cardiovascular failure with ECMO use. New data suggests that central (chest) cannulation for septic shock can be more effective than peripheral (neck or groin) cannulation in children.
30SSC 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).These guidelines have not changed since Mortality from adrenal shock occurs in the first 8 hours in patients with catecholamine refractory shock. Hydrocortisone is indicated both for infection related and non-infection related Addisonian shock.
31Pediatric Considerations Activated Protein C (no longer available)Blood Products and TherapiesMechanical VentilationSedation/Analgesia/Drug ToxicitiesGlycemic ControlDiuretics and Renal Replacement Therapy31
32SSC 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)These recommendations do not vary from 2008 but new studies support this recommendation
34SSC 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)There is no pediatric literature to suggest using different platelet thresholds. Plasma exchange is used in adults and children with infection related thrombotic microangiopathies.
35SSC 2012 Guidelines Mechanical Ventilation We suggest providing lung-protective strategies during mechanical ventilation (Grade 2 C).No new recommendations since Lung protection is used in children with ARDS
36SSC 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)Drug toxicities are common in children with sepsis
37SSC 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).This is not a new recommendation since 2008.
38There were no differences in outcome fours years later in the From: Neurocognitive Development of Children 4 Years After Critical Illness and Treatment With Tight Glucose Control: A Randomized Controlled TrialJAMA. 2012;308(16): doi: /jamaThere were no differences inoutcome fours years later in thecomposite of neurological disabilityand survival between theTight Glycemic control and UsualGlycemic control study in the LeuvenPICU. There was an improved score inone measure of cognition in the TightGlycemic control group even thoughepisodes of hypoglycemia had beenmore prevalent in the PICU for thistreatment armVlasselaers and colleagues performed a randomized study in a general PICU with 70% CICU patients that showed increased 28 day survival with strict glycemic control and the expense of increased hypoglycemia. In this follow-up of the study 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.Two additional predominantly CICU population studies not related to sepsis also showed no effect of tight glycemic control on survival.
39SSC 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).This is not a new recommendation since Once appropriate fluid resuscitation is performed in the first hour then careful monitoring of fluid balance is required. If the kidney has been ischemic for a sufficient period of time then diuretics are required to maintain fluid balance and prevent subsequent fluid overload. If unsuccessful then extracorporeal renal support is recommended.