rcem paediatric sepsis talk
TRANSCRIPT
Sepsis in ChildrenPresentation by Jeremy Tong @jez_tongRoyal College of Emergency Medicine 2015
29 Sep 2015
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…
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In a large Paediatric ED assessing 50 000 children a year:
= 1 per week
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Hospital Length of Stay
mon tue wed thu fri sat sun
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8 9 10 11 12 13 14
15 16 27 18 19 20 21
22 23 24 25 26 27 28
29 30 31
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
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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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.
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
Adherance to fluid guideline: 37% Adherence to inotrope guidelines: 35% Adherance to all 5-components: 19%
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 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
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
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.
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.
[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).
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.
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.
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)
Types of Shock
TachycardiaWarmBounding pulsesPink/FlushedFlash CRTAltered Mental StateReduced Urine Output
TachycardiaCool WarmDifficult pulsesPale/Mottled Prolonged CRT Altered Mental StateReduced Urine Output
Trends in the Epidemiology of Pediatric Severe SepsisHartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Pediatr Crit Care Med. 2013 Jul 26.
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.
Epidemiology of Severe Sepsis and Septic Shock
Arturo Artero, Rafael Zaragoza and Jose Miguel Nogueira
Severe Sepsis in Children
Mortality rate ~ 10%
>10% of deaths in under 4 yr
PICU mortality up to 20%
International sepsis consensus definitions for pediatric sepsisGoldstein et al Ped Critic Care Med 2005, Vol 6, no 1
At least 2 of:
• Temperature high or low
• Heart rate high
• Breathing rate high
• WCC high or low
What is Sepsis?
Severe SepsisSepsisSIRS
Sepsis + Organ dysfunction
• Cardiovascular or
• Respiratory or
• 2 or more other organs
What is Sepsis?
Severe SepsisSepsisSIRS
Sepsis + Organ dysfunction
• Cardiovascular or
• Respiratory or
• 2 or more other organs
What is Sepsis?
Severe SepsisSepsisSIRS