early goal-directed therapy in pediatric sepsis derek s. wheeler, md, faap, fccp, fccm associate...

Early Goal-Directed Therapy in Pediatric Sepsis

Derek S. Wheeler, MD, FAAP, FCCP, FCCMAssociate Professor of Clinical Pediatrics

University of Cincinnati College of Medicine

Clinical Director, Division of Critical Care MedicineCincinnati 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)

Crit Care Med 2010; 38:367

Surviving Sepsis Campaign

N=15,022

Sepsis Resuscitation (6 H) BundleMeasure Serum Lactate

Administer broad-spectrum antibiotics (<3 h)Early resuscitation to EGDT Targets

Sepsis Management BundleLow-dose corticosteroids

Drotrecogin alfaTight glucose control

Plateau Pressure < 30 cm H2O

Crit Care Med 2006; 34:1589

N=2,731 adults with septic shock

Only 50% of pts received antimicrobial therapy within 6 h of documented hypotension!

Early Antibiotics

“Door to antibiotics” decreased from 143 to 38 minutes

TCH Sepsis ProtocolCruz et al. Pediatrics 2011; 127:e758

Crit Care Med 2006; 34:1589

N=2,731 adults with septic shock

Only 50% of pts received antimicrobial therapy within 6 h of documented hypotension!

Early Antibiotics

“Door to Antibiotics” < 3 hours

Primary Children’s Sepsis ProtocolLarsen et al. Pediatrics 2011; 127:e1585

Arch Dis Child 2001; 85:386

Reduction in mortality from 23% to 2.5%!

Early Resuscitation

Pediatrics 2003; 112:793

Early Resuscitation

Intensive Care Med 2008; 34:1065

Minimize variationEarly Resuscitation

Minimize variationEarly Resuscitation

Intensive Care Med 2008; 34:1065

Minimize variationEarly Resuscitation

28-day Mortality 39.2% versus 11.8%

Intensive Care Med 2008; 34:1065

Minimize variationEarly Resuscitation

No differences in HR, MAP, CVP, ScvO2, or Lactate at Baseline, 6 H, or 72 H

Intensive Care Med 2008; 34:1065

Minimize variationEarly Resuscitation

No differences in TOTAL fluid volume administered at 72 H

Significant differences in amount of fluid volume administered at 6 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

derek.wheeler@cchmc.org

R18 HS020455

The James M. Anderson Center for Health Systems ExcellenceStephen Muething, MDPatrick Brady, MDUma Kotagal, MBBS, MScJanet Jacob, RN, MBA

Children’s Hospital of AkronMary D. Patterson, MD, MEd

Cincinnati Children’s Center for Simulation and ResearchGary Geis, MDJohn Whitt, MDTom LeMaster, RN, MSN, MEd, REMT-P, EMSI

University of Cincinnati College of MedicineAmy Bunger, PhD

University of Michigan Ross School of BusinessKathleen M. Sutcliffe, MSN, PhD

Applied Decision Science, LLCLaura Militello, MA

MacroCognition, LLCGary Klein, PhD

Division of Critical Care MedicineHector R. Wong, MDCarley Riley, MDErika Stalets, MD

Thank You!