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