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Welcome
The Pediatric Guidelines from the
Surviving Sepsis Campaign:
Considerations for Care
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Stephen L. Davidow, MBA-HCM, APR
Manager, Quality Implementation Programs
Society of Critical Care Medicine
Mount Prospect, IL
Today’s webcast is funded by a generous grant
from the Gordon and Betty Moore Foundation
Welcome
The Pediatric Guidelines from the
Surviving Sepsis Campaign:
Considerations for Care
Save the Date!
The Next Surviving Sepsis Campaign Webcast
October 15, 2013, 1 pm CT
Topic: The Surviving Sepsis Campaign
as a Model for Mentoring
Faculty:
Ryan O’Gowan, MBA, PA-C, FCCM, St. Vincent Hospital
Marie Mullen, MD, University of Massachusetts
Emanuel P. Rivers, MD, MPH, Henry Ford Health System
Margaret M. Parker, MD, FCCM
Professor of Pediatrics, Anesthesia, and
Medicine
Stony Brook University
Director, Pediatric Intensive Care Unit
Long Island Children’s Hospital
Stony Brook, NY
SCCM SSC Representative, 2002-2009
Past President, SCCM
Potential Conflicts of Interest
No direct or indirect potential financial conflict
of interest as to any material presented in this
presentation.
“Time Zero”
• Time Zero = time of presentation
– ED, Medical Floors, ICU
• Both adult bundles time based
• Most important time based elements:
– Antibiotic timing
– Resuscitation timing (EGDT)
Implications for Time Zero
• New York State DOH
– Mandated reporting of sepsis outcomes
– Adherence to “evidence-based” protocols
• NQF sepsis measures
– Recently approved
• Fear of being “dinged” for patients who did not meet criteria
on triage in ED
– Public reporting
– Pay for Performance
Evaluating 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
Pediatric Considerations
•
•
•
•
Initial resuscitation
Antibiotics and source control
Fluid resuscitation
Inotropes/vasopressors/
vasodilators
• ECMO
• Corticosteroids
SSC 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 2C
SSC 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 2C
A 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)
Goal normal perfusion
Central line to
RA/SVC or RA/IVC
No continuous
O2 sat monitoring
(n = 51)
102 Septic Shock
Patients
Fluid resuscitated
Goal O2 sat > 70%
Central line to
RA/SVC or RA/IVC
Continuous
O2 sat monitoring
(n = 51)
De Oliveira et al Intens Care Med 2010
De Oliveira et al Intens Care Med 2010
Before
0-6 h
6-72 h
Total
Crystalloid
Control
Intervention
P value
49 +/- 33
47 +/- 26
0.89
11 +/- 14
32 +/- 23
< 0.0001
19 +/- 25
15 +/- 21
0.53
79 +/- 47
94 +/- 40
0.10
RBC
Control
Intervention
P value
0.9 +/- 3.7
0.6 +/- 3.1
0.86
2.1 +/- 5.1
7.2 +/- 8.5
0.0053
5.6 +/- 7.1
4.4 +/- 8.0
0.26
8.6 +/- 7.91
12.1 +/- 11.2
0.14
N % RBC
Control
Intervention
P value
5.9
3.9
1.0
15.7
45.1%
0.0023
43.1
31.4
0.31
58.8
68.6
0.41
7.8%
31.4%
0.01
24.4%
27.4%
0.92
31.4%
58.8%
0.05
15.7
45.1%
0.0023
43.1
31.4
0.31
58.8
68.6
0.41
% Additional Inotrope
or Vasodilator
Control
Intervention
P value
N % RBC
Control
Intervention
P value
5.9
3.9
1.0
Reduced Mortality with ACCM-PALS Guidelines compared to Standard
Care for Pediatric Septic Shock
- A Randomized Control Trial
(de Oliveira Intens Care Med 2010)
Goal normal perfusion
102 Septic Shock
Patients
28 day Mortality
39.2%
20/51
Goal O2 sat > 70%
28 day Mortality
P = 0.0027
11.8%
6/51
Fig. 3 Kaplan–Meier estimates of mortality (28 days)
de Oliveira et al Intens Care Med 2010
SSC 2012 Guidelines
Initial Resuscitation
• We recommend following ACCM-PALS guidelines for
the management of Septic Shock
Grade 1C
• We recommend reversal of unrecognized
pneumothorax, pericardial tamponade, intraabdominal hypertension, or endocrine emergencies
in patients with refractory shock
Grade 1C
Figure 2
Surviving Sepsis Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock: 2012.
Dellinger, R; Levy, Mitchell; Rhodes, Andrew; Annane,
Djillali; Gerlach, Herwig; MD, PhD; Opal, Steven;
Sevransky, Jonathan; Sprung, Charles; Douglas, Ivor;
Jaeschke, Roman; Osborn, Tiffany; MD, MPH; Nunnally,
Mark; Townsend, Sean; Reinhart, Konrad; Kleinpell, Ruth;
PhD, RN-CS; Angus, Derek; MD, MPH; Deutschman,
Clifford; MD, MS; Machado, Flavia; MD, PhD; Rubenfeld,
Gordon; Webb, Steven; MB BS, PhD; Beale, Richard;
Vincent, Jean-Louis; MD, PhD; Moreno, Rui; MD, PhD
Critical Care Medicine. 41(2):580-637, February 2013.
DOI: 10.1097/CCM.0b013e31827e83af
Figure 2 . Algorithm for time sensitive, goal-directed
stepwise management of hemodynamic support in
infants and children. Reproduced from Brierley J, Carcillo
J, Choong K, et al: Clinical practice parameters for
hemodynamic support of pediatric and neonatal septic
shock: 2007 update from the American College of Critical
Care Medicine. Crit Care Med 2009; 37:666-688.
© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams
& Wilkins, Inc.
2
SSC 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 1D
SSC 2012 Guidelines
Antibiotics and source control
• We suggest clindamycin and anti-toxin therapies for
toxic shock syndromes with refractory hypotension
Grade 2D
• We recommend early and aggressive source control
Grade 1D
• Clostridium difficile should be treated with enteral
antibiotics if tolerated. Vancomycin is preferred for
severe disease
Grade 1A
SSC 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 nonhypotensive children with severe hemolytic anemia (severe malarial anemia, or
sickle cell anemia crises) blood transfusion is considered superior to crystalloid or
colloid bolusing.
Grade 2C
Can I Give Too Much Fluid?
You most certainly can give too much or too little!
• Check for Hepatomegaly
• Check for Rales
• Evaluate MAP – CVP
• Give diuretics
• Use Dialysis CRRT if unsuccessful
• You 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).
NY Protocols
• Department of Health requiring hospitals to have
protocols for early detection and management of
sepsis, including pediatric protocols
• Data will be reported to the State starting January,
2014
• Current Pediatric measures under consideration:
– Within 1 hour: establish IV access, administer fluid bolus,
draw blood cultures, administer antibiotics
SSC 2012 Guidelines
Inotropes/Vasopressors/Vasodilators
• Begin peripheral inotropic support until central
venous access can be attained in children
who are not responsive to fluid resuscitation
Grade 2C
• Patients with low cardiac output and elevated
systemic vascular resistance states with normal blood
pressure be given vasodilator therapies in addition to
inotropes
Grade 2C
SSC 2012 Guidelines
ECMO
We suggest consideration of ECMO for
refractory pediatric septic shock and / or
respiratory failure (Grade 2C).
SSC 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).
Pediatric Considerations
• Activated Protein C (no longer
available)
• Blood Products and Therapies
• Mechanical Ventilation
• Sedation/Analgesia/Drug Toxicities
• Glycemic Control
• Diuretics and Renal Replacement
Therapy
SSC 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)
Table 4.
Red blood cell transfusion thresholds in pediatric
patients with sepsis *.
Karam, Oliver; Tucci, Marisa; MD, BSc; Ducruet, Thierry;
Hume, Heather; Lacroix, Jacques; Gauvin, France; MD,
MSc
Pediatric Critical Care Medicine. 12(5):512-518,
September 2011.
DOI: 10.1097/PCC.0b013e3181fe344b
Table 4. Outcome measures
Although there were no significant differences in outcomes in children with sepsis in the
Conservative (transfuse for Hgb < 7 g/dL) vs Liberal (transfuse for Hgb < 9.5 g/dL) arms the
mortality rate was 10% in the Conservative group and 3% in the Liberal group (p = 0.08).
In light of the de Oliveira study findings of improved outcomes with transfusions given for
Low ScVO2 shock we recommend the liberal strategy when ScVO2 is < 70%.
©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care
Societies. Published by Lippincott Williams & Wilkins, Inc.
2
SSC 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)
SSC 2012 Guidelines
Mechanical Ventilation
We suggest providing lung-protective
strategies during mechanical ventilation
(Grade 2 C).
SSC 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)
SSC 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).
From: Neurocognitive Development of Children 4 Years After Critical Illness and Treatment With Tight Glucose
Control: A Randomized Controlled Trial
JAMA. 2012;308(16):1641-1650. doi:10.1001/jama.2012.12424
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
SSC 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).
Pediatric Considerations
• DVT prophylaxis
• Stress Ulcer Prophylaxis
• Nutrition
SSC 2012 Guidelines
DVT prophylaxis
No graded recommendations on the use of DVT
prophylaxis in pre-pubertal
children with severe sepsis.
SSC 2012 Guidelines
Stress Ulcer Prophylaxis
No recommendations on the use of stress
ulcer prophylaxis in pre-pubertal children
with sepsis
SSC 2012 Guidelines
Nutrition
Enteral nutrition given to children who can
be fed enterally, and parenteral feeding in
those who cannot (Grade 2 C)
What about Lactate?
Not included in 2012 Guidelines for
Pediatrics
Infrequently elevated in children
May be useful if elevated
Questions?