WelcomeThe Pediatric Guidelines from the

Surviving Sepsis Campaign: Considerations for Care

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Stephen L. Davidow, MBA-HCM, APR

Manager, Quality Implementation ProgramsSociety of Critical Care MedicineMount Prospect, IL

Today’s webcast is funded by a generous grant from the Gordon and Betty Moore Foundation

WelcomeThe 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 MassachusettsEmanuel 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 HospitalStony Brook, NY

SCCM SSC Representative, 2002-2009Past 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 Goal O2 sat > 70%

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

% Additional Inotrope or Vasodilator

Control

Intervention

P value

7.8%

31.4%

0.01

24.4%

27.4%

0.92

31.4%

58.8%

0.05

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

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 Goal O2 sat > 70%

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, intra-abdominal hypertension, or endocrine emergencies in patients with refractory shock Grade 1C

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.

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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.

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 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 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 GuidelinesECMO

We suggest consideration of ECMO for refractory pediatric septic shock and / or respiratory failure (Grade 2C).

SSC 2012 GuidelinesCorticosteroids

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 GuidelinesBlood 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)

©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Published by Lippincott Williams & Wilkins, Inc.

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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 forLow ScVO2 shock we recommend the liberal strategy when ScVO2 is < 70%.

SSC 2012 GuidelinesBlood 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 GuidelinesMechanical Ventilation

We suggest providing lung-protective strategies during mechanical ventilation (Grade 2 C).

SSC 2012 GuidelinesSedation/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 GuidelinesGlycemic 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 inoutcome fours years later in thecomposite of neurological disabilityand survival between the Tight Glycemic control and Usual Glycemic control study in the LeuvenPICU. There was an improved score in one measure of cognition in the TightGlycemic control group even though episodes of hypoglycemia had been more prevalent in the PICU for this treatment arm

SSC 2012 GuidelinesDiuretics 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 GuidelinesDVT prophylaxis

No graded recommendations on the use of DVT prophylaxis in pre-pubertal children with severe sepsis.

SSC 2012 GuidelinesStress Ulcer Prophylaxis

No recommendations on the use of stress ulcer prophylaxis in pre-pubertal children with sepsis

SSC 2012 GuidelinesNutrition

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 PediatricsInfrequently elevated in childrenMay be useful if elevated

Questions?