12 SSC Pediatric Considerations 06-03-14

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

Slide 2Copyright 2014 SCCM/ESICM

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).


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).



• 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


• 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


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.


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


• 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).


Brierley J. Crit Care Med. 2009;37:666-688


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).

Slide 12


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).


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 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)


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


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).


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%


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


ECMO• We suggest consideration of extracorporeal

membrane oxygenation (ECMO) for refractory pediatric septic shock and/or respiratory failure (Grade 2C).


Extracorporeal Membrane Oxygenation Cannula Size and

Flows

MacLaren G et al. Pediatr Crit Care Med. 2011;12:133-136


Characteristics of Survivors Versus Nonsurvivors to Hospital Discharge

MacLaren G et al. Pediatr Crit Care Med. 2011;12:133-136


Corticosteroids• We recommend timely hydrocortisone

therapy in children with fluid-refractory, catecholamine-resistant shock and proven absolute adrenal insufficiency (Grade 1A).


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).


Outcomes of Restrictive Versus Liberal Transfusion for Anemia in Severe Sepsis

Karam O et al. Pediatr Crit Care Med. 2011;12:512-518


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).


Nguyen TC et al. Crit Care Med. 2008 46(10):2878-2887


Plasma Exchange

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2772176/figure/F1/

Mechanical Ventilation• We suggest providing lung-protective

strategies during mechanical ventilation (Grade 2C).


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).


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).


Neurocognitive Development After Tight Glucose Control or Usual Control

Mesotten D et al. JAMA. 2012;308:1641-1650


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).


Pediatric Considerations• Deep Vein Thrombosis (DVT) Prophylaxis• Stress Ulcer Prophylaxis• Nutrition• SSC Resuscitation and Management

Bundles


DVT Prophylaxis• No graded recommendations were made on

the use of DVT prophylaxis in prepubertal children with severe sepsis.


Stress Ulcer Prophylaxis• No graded recommendations were made on

the use of stress ulcer prophylaxis in prepubertal children with sepsis.


Nutrition• Enteral nutrition should be used in children

who can tolerate it, parenteral feeding in those who cannot (Grade 2C).


Resource-Specific Resuscitation and PICU Management Bundle


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


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


Reduced Mortality with Global Sepsis Initiative Bundle Compliance

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Resuscitation Bundle Management Bundle

Compliant

Non-Compliant

**

http://www.pediatricsepsis.orghttp://www.wfpiccs.org

Global Pediatric Sepsis Initiative

Mortality Odds Ratio with 95% Confidence Intervals


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

http://www.pediatricsepsis.org/

http://www.pediatricsepsis.org/

http://www.wfpiccs.org/

http://www.wfpiccs.org/

12 SSC Pediatric Considerations 06-03-14

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