rcem paediatric sepsis talk

Sepsis in ChildrenPresentation by Jeremy Tong @jez_tongRoyal College of Emergency Medicine 2015

29 Sep 2015

Scope of the Problem

The most significant recurrent avoidable factor between cases was a failure to recognise severe illness in children. This most often occurred at the point of first contact between the sick (and often febrile) child and healthcare services…

! Picture of septic child

Spotting the Signs of Sepsis

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In a large Paediatric ED assessing 50 000 children a year:

= 1 per week

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Half are Newborn

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Mortality 6 – 12%

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Hospital Length of Stay

mon tue wed thu fri sat sun

1 2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 27 18 19 20 21

22 23 24 25 26 27 28

29 30 31

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ACCM-PALS 2002 (2007)

Adherence to PALS Sepsis Guidelines and Hospital Length of Stay Raina Paul, Mark I. Neuman, Michael C. Monuteaux and Elliot Melendez Pediatrics 2012;130;e273; originally published online 2012;DOI: 10.1542/peds.2012-0094.

Adherence to 5 time-specific goals

5 algorithmic time-specific goals

1. Early recognition of Severe Sepsis

2. Vascular access

3. Antibiotic administration

4. Administering IV fluids

5. Vasopressors for fluid refractory shock

Adherence to 5 algorithmic time-specific goals

Adherence to 5 algorithmic time-specific goals Hospital LOS 57% reduction ICU LOS 42% reduction

Adherance to fluid guideline: 37% Adherence to inotrope guidelines: 35% Adherance to all 5-components: 19%

Paediatric Sepsis 6

Paediatric Sepsis 6Recognition

Suspected or proven infection AND at least 2 of:

! Core temperature < 36°C or > 38.5°C

! Inappropriate tachycardia

! Altered mental state

! Reduced peripheral perfusion / prolonged CRT

Think: could this child have SEPSIS? If in doubt, consult a senior clinician.

Think could this be sepsis?

Experienced Review

(History, assess, exam, ?gas)

This Identifies at risk group

This is “screening” or “test” for sepsis

High certainty of Sepsis

Treat e.g. with

Paed Sepsis 6

Record thinking process

High certainty NOT SepsisUnsure

Review again e.g. in 1 hr

Suspect / proven infection+ 2 criteria

Paediatric Sepsis 6

1. Give high flow oxygen

2. Obtain IV/ IO access & take blood tests

3. Give IV or IO antibiotics

4. Consider fluid resuscitation

5. Involve senior clinicians / specialists early

6. Consider inotropic support early

Exponential Growth

“SPOT%IT%TREAT%IT%BEAT%IT”

Terence Canning

Improving Adherence to PALS Septic Shock Guidelines.Paul R, Melendez E, Stack A, Capraro A, Monuteaux M, Neuman MI. Pediatrics. 2014 May;133(5):e1358–66.

Bundle adherence pre + post intervention

Number of cases between each death

The UK Sepsis Trust Paediatric Group Contributors

Adult & Paediatric Intensivists, Adult & Paediatric Emergency phycisians, Adult & Paediatric Anaesthetists, Paediatricians, Neonatologists, Quality Improvement Fellows (alphabetical)

Dr Jay BanerjeeDr Linda ClerihewDr Joe CarcilloDr Ron DanielsMs Kirsteen EllisDr Minesh KhashuDr Niranjan ‘Tex’ KissoonDr Hilary Klonin

Dr Simon NadelDr Adrian PlunkettDr Damian RolandDr Ranjit SinghDr Neil SpenceleyDr John SchulgaDr Jeremy Tong

The UK Sepsis Trust Paediatric Group is hosted by The UK Sepsis Trust (registered charity no. 1146234) and led by Dr Jeremy Tong

Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis Weiss SL, Fitzgerald JC, et al. Crit Care Med. 2014 Nov;42(11):2409–17.

Time from recognition to initial antimicrobial administration

OR = 4.84

[Clinical research of timing of application of antibiotics in septic shock of pediatric patients]Chinese Critical Care Medicine. 2013 Apr;25(4):207-10. doi: 10.3760/cma.j.issn.2095-4352.2013.04.007.

Chinese'Critical'Care'Medicine'(��)

Antibiotic timing in pediatric septic shock

Antibiotics within 1 hour n = 40Antibiotics 1 – 6 hours n = 40

Lactate lower 8.65 vs 11.75 mmol/L P <0.01CRP lower 66.25 vs 91.77 mg/L P <0.01 PCT lower 0.67 vs 1.16 µg/L P <0.01

Time to shock reversal: 6.80 vs 12.80 hours P <0.05

Fluid Resuscitation of Hypovolemic Shock: Acute Medicine's Great Triumph for Children. Carcillo, J. A. & Tasker, R. C. Intensive Care Med 32, 958–961 (2006).

Single-center ‘best’ mortality rates (%) from septic shock

Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved OutcomeYong Y. Han, Joseph A. Carcillo, Michelle A. Dragotta, Debra M. Bills, R. Scott Watson, Mark E. Westerman and Richard A. Orr. Pediatrics 2003;112;793 DOI:10.1542/peds.112.4.793.

Reversal of Shock before PICU:Capillary refill < 2 secs with normal BP

Resuscitative efforts by community hospital physicians

Shock reversal Survival OR = 9.49

Resus consistent with ACCM-PALS Survival OR = 6.81

Every additional hr of persistent shock OR = 2.29

Every additional hr delay in ACCM-PALS OR = 1.53

Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency DepartmentAndrea T. Cruz, Andrew M. Perry, Eric A. Williams, Jeanine M. Graf, Elizabeth R. Wuestner and Binita Patel Pediatrics; originally published online February 21, 2011; DOI: 10.1542/peds.2010-2895.

Implementation of goal-directed therapy for children with suspected sepsis in the ED

Intubated in ED 3.2% vs 20%Inotropes in ED 10.1% vs 16%Death during admission 1.9% vs 4%

Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit.Inwald, D. P., Tasker, R. C., Peters, M. J., Nadel, S. on behalf of the Paediatric Intensive Care Society Study Group (PICS-SG). Archives of Disease in Childhood 94, 348–353 (2009).

UK PICU Sepsis Audit

ACCM-PALS guideline … was not followed in 62% of shocked children

OR for death… if shock present at PICU admission = 3.8

(95% CI 1.4 to 10.2, p = 0.008)

Shock in Children

Types of Shock

TachycardiaWarmBounding pulsesPink/FlushedFlash CRTAltered Mental StateReduced Urine Output

TachycardiaCool WarmDifficult pulsesPale/Mottled Prolonged CRT Altered Mental StateReduced Urine Output

Deterioration in children

What processes are in place to spot the sick child?

Is there available equipment to help spot the sick child?

Access to specialist advice?

Process for handover of care?

Email: [email protected]: @jez_tong

Sepsistrust.org

spottingthesickchild.com

Epidemiology

Trends in the Epidemiology of Pediatric Severe SepsisHartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Pediatr Crit Care Med. 2013 Jul 26.

Prevalence:0.89 per 1000 population

Characteristics:Age 3.8 yrs (median <1)Newborn sepsis increasing

Characteristics:LoS 31.5 days (median 16)Mortality 8.9%

Characteristics of Pediatric Severe Sepsis Cohort:

Mortality related to pediatric severe sepsis:

Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care.Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Crit Care Med. 2001 Jul;29(7):1303–10.

National age-specific incidence and mortality rates for all cases of severe sepsis by gender, excluding those with HIV disease.

National age-specific average and total hospital costs for severe sepsis. Expressed as 1995 USD

Epidemiology of Severe Sepsis and Septic Shock

Arturo Artero, Rafael Zaragoza and Jose Miguel Nogueira

Prevalence around the world:

Annual incidence of severe sepsis by age in the pediatric population of the United States

Quality of life of 164 patients with sepsis or trauma after 2 yrsfollowing ICU (adults)

Severe Sepsis in Children

US 0.56 - 0.89 cases per 1000 per year

UK ≈ 1000 PICU admissions per year

Severe Sepsis in Children

Mortality rate ~ 10%

>10% of deaths in under 4 yr

PICU mortality up to 20%

Risk Factors in Children

< 1 year

VLBW / Prematurity

Underlying diseases

Immunocompromised

What is Sepsis?

International sepsis consensus definitions for pediatric sepsisGoldstein et al Ped Critic Care Med 2005, Vol 6, no 1

What is Sepsis?

Severe SepsisSepsisSIRS

At least 2 of:

• Temperature high or low

• Heart rate high

• Breathing rate high

• WCC high or low

What is Sepsis?


SIRS +

Suspected / Proven

Infection

What is Sepsis?


Sepsis + Organ dysfunction

• Cardiovascular or

• Respiratory or

• 2 or more other organs

What is Sepsis?


ACCM-PALS 2002 (2007)

Recognise

AirwayAccess

20'ml/kg20'ml/kg20'ml/kg

…glucosecalcium

Antibiotics

Central'line

Inotropes

Arterial'line

0'min5'min

15'min

60'min

Norm'BPCold'ShockLow'CO

VasodilatorMilrinoneFluids

Low'BPCold'ShockLow'CO

FluidsAdrenaline

Low'BPWarm'Shock

FluidsNorAd

vasopressin

rcem paediatric sepsis talk

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