12 ssc pediatric considerations 06-03-14
TRANSCRIPT
SSC 2012 Guidelines Pediatric Considerations
Copyright 2014 SCCM/ESICM
The Pediatric Sub-Group of the Surviving Sepsis Campaign Update
J. Carcillo
• Initial resuscitation
• Antibiotics and source control
• Fluid resuscitation
• Inotropes/vasopressors/vasodilators
• ECMO• Corticosteroids
• Activated Protein C
• Blood Products and Therapies
• Mechanical Ventilation
• Sedation/Analgesia/ Drug Toxicities
• Glycemic Control• Diuretics and
Renal Replacement Therapy
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Initial Resuscitation• We suggest starting with face mask oxygen
or, if needed and available, high flow nasal cannula oxygen or nasopharyngeal continuous positive airway pressure for respiratory distress and hypoxemia. For improved circulation, peripheral intravenous access or intraosseous access can be used for fluid resuscitation and inotrope infusion when a central line is not available. If mechanical ventilation is required then cardiovascular stability during intubation is more likely after these are achieved (Grade 2C).
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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 ScvO2 >70% and cardiac index between 3.3 and 6.0 L/min/m2 thereafter (Grade 2C).
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• Cruz AT, Perry AM, Williams EA, Graf JM, Wuestner ER, Patel B. Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. Pediatrics. 2011;127:e758-66.
Pediatric Screening Assessment Tool
Statistical Process Control Charts of Time to First Bolus for Children Identified at Triage
Cruz A T et al. Pediatrics. 2011;127:e758-e766
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• Time to first
bolus
• Time to third
bolus
• Time to
antibiotics
• Reduced
mechanical
ventilation– 3.2% to 2.0%
• Reduced
vasoactive agents– 16% to 10.1%
• Reduced mortality– 4% to 2.5%
Five Time Points Evaluated for Adherence from 2006 PALS Algorithm
Paul R et al. Pediatrics. 2012;130:e273-e280
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Adherence to Five Algorithm Time Points and Median Time to Intervention
Paul R et al. Pediatrics. 2012;130:e273-e280
• Adherence associated with 57% reduction in PICU and hospital LOS• Error bars represent IQRs for median times.
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Statistical Process Control Charts and Predefined Goals for ED Septic Shock
Project
Larsen GY et al. Pediatrics. 2011;127:e1585-e1592©2011 by American Academy of Pediatrics
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• Increase in protocol compliance 60% to 80%
• LOS decreased 181 h to 141 h
• Mortality 7.1% to 6.1%• Mortality if received 20
mL/kg in first hour and antibiotics within 3 hours reduced mortality
8.4% to 3.5%
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).
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Brierley J. Crit Care Med. 2009;37:666-688
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American College of Critical Care Medicine-Pediatric Advanced Life Support Hemodynamic
Support Algorithm
Antibiotics and Source Control• We recommend that empiric antibiotics be
administered within 1 hour 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 [e.g., H1N1, methicillin-resistant staphylococci, chloroquine resistant malaria, etc.] (Grade 1D).
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Copyright 2014 SCCM/ESICM
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).
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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)
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Can I Give Too Much Fluid?
You certainly can give too much or too little!• Check for hepatomegaly• Check for rales• Evaluate mean arterial pressure – central venous pressure• Evaluate stroke volume or systolic blood pressure
variation• Give diuretics• Use dialysis continuous renal replacement therapy if
unsuccessful• Some children need 0 mL/kg of fluid because they are not
hypovolemic, while others need up to >60 mL/kg during resuscitation to treat hypovolemia
• Severe anemia patients need blood, not fluids; fluids will worsen anemic shock (hemoglobin <6 g/dL)
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Fluid Boluses Increased Mortality Compared to Maintenance IVF and Blood Transfusion in
FEAST Trial
Maitland K et al. N Engl J Med. 2011;364:2483-2495
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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 should be given vasodilator therapies in addition to inotropes (Grade 2C).
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Outcomes Comparison of ACCM-PALS Guidelines to Standard Care in Pediatric Septic
Shock102 Septic Shock
Patients
Central line toRA/SVC or RA/IVC
No continuousO2 sat monitoring
(n = 51)
Fluid resuscitated Central line to
RA/SVC or RA/IVCContinuous
O2 sat monitoring(n = 51)
Goal normal perfusion Goal O2 sat > 70%
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de Oliveira CF et al. Intensive Care Med. 2008;34:1065–1075
• Kaplan–Meier estimates of 28-day mortality
de Oliveira CF et al. Intensive Care Med. 2008;34:1065–1075
ScvO2-Directed Therapy Improved Outcome
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ECMO• We suggest consideration of extracorporeal
membrane oxygenation (ECMO) for refractory pediatric septic shock and/or respiratory failure (Grade 2C).
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Extracorporeal Membrane Oxygenation Cannula Size and
Flows
MacLaren G et al. Pediatr Crit Care Med. 2011;12:133-136
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Characteristics of Survivors Versus Nonsurvivors to Hospital Discharge
MacLaren G et al. Pediatr Crit Care Med. 2011;12:133-136
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Corticosteroids• We recommend timely hydrocortisone
therapy in children with fluid-refractory, catecholamine-resistant shock and proven absolute adrenal insufficiency (Grade 1A).
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Blood Products and Therapies• Similar hemoglobin targets are
recommended 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).
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Outcomes of Restrictive Versus Liberal Transfusion for Anemia in Severe Sepsis
Karam O et al. Pediatr Crit Care Med. 2011;12:512-518
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Blood Products and Therapies• We suggest similar platelet transfusion
targets in children as in adults (Grade 2C).• We suggest the use of 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).
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Nguyen TC et al. Crit Care Med. 2008 46(10):2878-2887
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Plasma Exchange
Mechanical Ventilation• We suggest providing lung-protective
strategies during mechanical ventilation (Grade 2C).
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Sedation/Analgesia/Drug Toxicities• We recommend use of sedation with a
sedation goal in critically ill mechanically ventilated patients with sepsis (Grade 1D).
• We recommend monitoring drug toxicity because drug metabolism is reduced in severe sepsis, putting children at greater risk of adverse drug-related events (Grade 1C).
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Glycemic Control• We suggest controlling 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).
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Neurocognitive Development After Tight Glucose Control or Usual Control
Mesotten D et al. JAMA. 2012;308:1641-1650
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Diuretics and Renal Replacement• We suggest the use of diuretics to reverse
fluid overload when shock has resolved and, if unsuccessful, then continuous venovenous hemofiltration or intermittent dialysis to prevent >10% total body weight fluid overload (Grade 2C).
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Pediatric Considerations• Deep Vein Thrombosis (DVT) Prophylaxis• Stress Ulcer Prophylaxis• Nutrition• SSC Resuscitation and Management
Bundles
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DVT Prophylaxis• No graded recommendations were made on
the use of DVT prophylaxis in prepubertal children with severe sepsis.
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Stress Ulcer Prophylaxis• No graded recommendations were made on
the use of stress ulcer prophylaxis in prepubertal children with sepsis.
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Nutrition• Enteral nutrition should be used in children
who can tolerate it, parenteral feeding in those who cannot (Grade 2C).
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Resource-Specific Resuscitation and PICU Management Bundle
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Global Sepsis Initiative Administrative and Clinical Care Bundles for Resuscitation and
ICU Management
Kissoon N et al. Pediatr Crit Care Med. 2011;12:494-503
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Kissoon N et al. Pediatr Crit Care Med. 2011;12:494-503
Global Sepsis Initiative Administrative and Clinical Care Bundles for Resuscitation and
ICU Management
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Reduced Mortality with Global Sepsis Initiative Bundle Compliance
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Resuscitation Bundle Management Bundle
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http://www.pediatricsepsis.orghttp://www.wfpiccs.org
Global Pediatric Sepsis Initiative
Mortality Odds Ratio with 95% Confidence Intervals
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Resuscitation Bundle: odds ratio, 0.369; 95% CI, 0188-0.724; P <0.0004ICU Management Bundle: odds ratio, 0.277; 95% CI, 0.096-0.80; P <0.0