Pedi atri c Septi c Shock

Best Evidence, N ursi ng consi derati ons

Dr . Sami AL Farsi, M DSenior consult ant, PEM

Direct or, Child Healt h Depart ment

Royal Hospit al, Oman

D ISCLOSURE

I do not have any r elevant fi nanci al rel ati onshi p wi th commerci al i nterest to di sclose.

O bjecti ves Def ine sepsis and sept ic shock Recognize ear ly manif est ation of sepsis and septic

shock Dif f erent iat e bet ween t ypes of shockand proposed

m anagement

Review t he curr ent base of evidence f ortime sensitive,goal dir ect ed st epwise management .

Case 1:

1 year old child previously healt hy presented t o ED wit h fever for 2 daysLethargic , HR = 190 , Temp = 38.7 , RR= 40 , BP = 90/40 , Sat = 95% room airCRT 4 sec , week peripheral pulses , cold, mot t led skin

Is he septic / shock ?

NEXT STEPS IN M ANAGM ENT

Case 2

7 years old child ALL on chemot herapy-5 days ago last cycle Fever f or 1 day

Lethargic , Temp: 39.1 HR= 170 RR= 21 Sat= 94% Bounding pulses (centr al and peripheral) , warm skin

CRT= 1 sec Bp= 80/40

septic / shock ??

NEXT STEPS IN MANAGM ENT

Pedia tric Sepsis

75000 children hospit alized each year in t he US f or sever sepsis 4.4% of children’s hospit al admissions 7% of PICU admissions

50% of sever sepsis occurs in infant s 49% of children wit h s ever sepsis have underlying diseases

Respiratory infect ions account for 40% and primary bacteremia 25% M ean LOS 31 days

Pedia tric Sepsis

Sept ic shock mortalit y rates 0-5% in pr eviously healt hy children Sept ic shock mortalit y rates 10% in chronically ill children Already improving mortalit y rates due t o intensive care ( 97% t o

9%)

M ort alit y rates bett er in c hildren (9%) t han in adult 28%

• Updat e f orSurviving SepsisCampaign G uidelines f orM anagement of SevereSepsis and Sept ic Shockincluding t he Pediat r icSubgroup

• Consensus Comm it t eeof68 int ernat ional expert sr epr esent ing 30 int ernat ionalorganizat ions

Dellinger RP, et al: Cr it Car e Med2013

New Co ncepts inSepsis

New def init ions based on a Task Force published in JAM A 2016 – SI RS validit ychallenged Sepsis def ined as a “ lif e-t hreat ening organ dysf unct ioncausedby a

dysregulat ed host due toinf ection” Sept ic shock is a subset of sepsis “in which under lying circulat ory

and cellular/m et abolic abnor malit ies are prof ound enoughtosubst ant ially increase m ort alit y”

From: The Third I nternati onal Consensus Def ini tions for Sepsis and Septi c Shock ( Sepsis- 3)JAM A. 2016;315( 8): 801-810. doi:10.1001/jama. 2016.0287

Sequential [Sepsis-Related] Organ Failure AssessmentScorea

Putting i tTogethe r

A SO FA ≥2 r ef lects mortalit y risk of 10% Pat ient s wit h suspect edinf ection whom ay requir eI CU caremay

be ident if ied by a quick SOFA or qSOFA (RR≥ 21 ; Alt er edM entalSt at us ; hypotension

Sept ic shock have f urt herdysregulat ory dysf unct ion– persist enthypot ension despit e vasopressor agent sandwit h elevated lactat e≥ 2 m m ol/ L – mort alit y> 40%

From: The Third I nternati onal Consensus Def ini tions for Sepsis and Septi c Shock ( Sepsis- 3)JAM A. 2016;315( 8): 801-810. doi:10.1001/jama. 2016.0287

How can any of this be appl iedtochi ldren?

Unclear at t his t im east hese guidelines do not addresspediat ricpat ient s

Biomar kers such aslact ate cont inuest o playa role andhasim plicat ions on survival

Sepsi s

Sepsi s D i sease Spectrum

SI RS Sepsis Sever e Sepsis

Sept ic Shock

Tem p inst abilit y >38.5° C or <36.5°CHR >2SD (HR if <1year )RR >2SD Abnorm al WBC or >10% immat ur e neut rophil

Goldst ein Pediat rCrit Care Med2005 6( 1) :2-8

Alt er ed m ental status CRT ≥3sec or f lash capillary refill Diminished or bounding peripher al pulses M ott led cool extremit ies Decr eased urine out put <1 mL/kg/hrHypot ension

Temperature

Fever def ined as ≥38°C

≥38. 5 C has im proved specif icit y Core t emperat ure is consider ed gold st andar d

Rect al, bladder , oral

Pediat r Cr it Care Med2005; 6: 2-8

Pedi atri c Age Group D efi ni ti ons

Newbor n Neonat e

I nf ant Toddler

School age child Adolescent and young adult

0 days t o 1 wk 1 wk t o 1 mo

1 m o t o 1 yr 2 - 5 yr s

6 - 12 yr s 13 t o 18 yr s

Pediat r Cr it Care Med2005; 6: 2-8

SI RS : Age- speci f i c vi t al si gns andl aboratory vari abl es

Syst oli c BPmm Hg

WBCX103/ mm3

Respir atory Rate ( breat h/mi n)

Bradycardia( Beat s/ min)

Tachycardia( Beat s/ min)

Age gr oup

< 65> 34> 50< 100> 180Newbor n< 75> 19. 5 or < 5 > 40< 100> 180Neonat e< 100> 17. 5 or < 5 > 34< 90> 180I nf ant<94 > 15. 5 or < 6 > 22NA > 140Toddler< 105> 13. 5 or < 4.5 > 18NA> 130Child< 117> 11 or < 4. 5 > 14NA> 110Adolescent

Pediat r Cr it Care Med2005; 6: 2-8

Septi c Shock

Sept ic shock = Sepsis and cardiovascul ar organ dysf uncti on– There is no r equir ement f or hypot ension as t here is in t he

adult populat ion

– Tachycar dia ( m ay be absent if hypot herm ic)wit h signs of decreased per fusion)

– Decreased per ipheral pulses, alt ered alert ness, capillary r ef ill >2 seconds, mot tled or cool extr emit ies, or decr eased urine out put

Col d or Warm Shock

Decreased per f usion m anif ested by alt ered/ decreased mental st at us

Capillary r ef ill >2 secs ( cold shock) or flash capillary r efill

( warm shock) Diminished ( cold shock) or bounding ( warm shock) per ipheral

pulses

M ot t led cool ext r emit ies (cold shock), or decr eased urine out put 1 mL/ kg/h

Col d Shock

Implementation of Sepsis Protoco l

Short er t ime to fir st intravenous f luid Short er t ime to ant ibiotics administ rat ion Reduced t ime t o vasoactive infusion

Decreased m ort alit y Reduced lengt h of hospit al and PICU st ay

Reduced number of children wit h organ dysf unct ion

Implementation of Sepsis Protoco l

Early use of pract ice consistent wit h 2002 guidelines improved outcom e in newborn and children (mortalit y rates 8% vs38% ) .

Every hour delay wit hout rest orat ion of normal BP f or age and CRT less t han 3 sec – associated wit h a t wo f old increase in adjusted mort alit y odd ratio

Han et all, pediat rics 2003; 112: 793 –799

Improv ing Adherence to PAL S Septic Shock Guide l ines O bjecti ve: improveadherence t o national guidelines for children wit h

septic s hock in a pediat ric emergency depart ment wit h poor guideline adherence

Methods: Prospective cohort study of children presenting t o a t er tiary care pediat r ic emer gency department wit h septic shock

Qualit y improvement (QI) interventions, were used t o improve adherence t o a 5-component sepsis bundle, including timely (1) recognit ion of sept ic shock, (2) vascular access, (3) administrat ion of intravenous (IV) f luid, (4) antibiotics, and (5) vasoact ive agents

Paul et all, Pediat rics 2014;133:e1–e9

Improv ing Adherence to PAL S Septic Shock Guide l inesResul ts:

242 patients were included: 126 pat ients before the intervention and 116 patients dur ing t he QI intervent ion

Achieved 100% adherence for all metr ics

Reduct ion in hospit al mort alit y from 4. 0% to 1.7%.

Paul et all, Pediat rics 2014;133:e1–e9

Improv ing Adherence to PAL S Septic Shock Guide l ines

Paul et all, Pediatr ics 2014;133:e1–e9

Improv ing Adherence to PAL S Septic Shock Guide l ines

Paul et all, Pediat rics 2014;133:e1–e9

P lan

Do

Stu d y

Act

Process f ocused QI methodology

Reduced mort alit y 4.8% t o 1.7%

Care bundles simplif y & st reamline t he pr ocess t hus

speeding it up

Pedi atri c sepsi s

Early

R e co gn itio n Flu id An timicrob ial

Copyright©2017 by the Society of Crit ical Care Medicine andWolt er sKluwer Healt h, Inc. All rights reserved.

31

BUNDLES

Pedi atri c sepsi s

Extra

Resus citation

Recognition

Recogni ti on bundl e

Screen patient f or septic s hock using an inst it ution t r igger t ool ( High r isk patients, Vit al signs and

physical examination)

Clinician assessment wit hin 15 minut es f or any pat ient who sc reens posit ive in t he t r igger t ool

Init iate resuscit at ion bundle wit hin 15 m inut es f or any patients ident if ied by t he t r igger t ool whom t he

assess ing clinician confirm suspicion of septic s hock

Assessment

H i gh Ri sk Popul ati on

M alignancy

Asplenia (I ncluding SCD)

Bone M arr ow Transplant

Centr al or Indwelling line/cat heter

Solid organ t ransplant Immunodef iciency / Immunosuppress ion /

Immunocompromise

Age- speci f i c vi t al si gns

Syst oli c BPmmHgRespir atory Rate ( breat h/mi n)

Bradycardia( Beat s/ min)

Tachycardia( Beat s/ min)

Age gr oup

< 60> 50< 100> 180Newbor n< 60> 40< 100> 180Neonat e< 70> 34< 90> 180I nf ant< 70 + age in yr x 2 > 22NA > 140Toddler< 70 + age in yr x 2> 18NA> 130Child<90> 14NA> 110Adolescent

Exam abnormal i ti es

Non- specific War m shock Cold shock

Bounding Decr eased or weak Pulses

< 1 sec≥ 3 secCapillar y Ref ill

Pet echiae/purpur aFlushedM ot t led,cool Skin

Decr eased/ Lethar gyI r r it abilit y /confusion/ inappropr iate cr y , poor int er act ivnesswith par ent s, obt unded

M ent al status

I dentif y as meeting sepsis / septic shock if :

1- Hypot ension or2- Meet 3/8 crit eria or 3- Meet 2/8 crit eria in

high r isk

Pat ient s pres ent t o ED wit h concern f or inf ect ion and / or tem perat ure abnor malit y

Exc lude f r om shock triage t ool, cont inue r outine

t r iage proc ess

Continue ass ess ment at t r iage

• Obt ain f ull set of vit al signs• Focus ed hist ory and PE • I s t he pt . high r isk ? Tem p - - - - --- -- -- -Hypot ension - - -- -- -- -- --Tachyc ar dia - -- -- -- -- -Tachypnea - - -- -- --- -- --CRT - - - - - -- -- -- -- -Ment al st at us - - -- --- -- -- -- --Pulse qualit y - - - - -- -- -- -- --Skin - - - - - - -- --- -- -- -

No

Yes

Elect ronic M edical Record

Weight esti mati on

Consi stent wei ght esti mati on tool

An accurat e weight , whether obtained wit h a scale locked t o read only in kil ograms or a lengt h‐based

resuscit at ion t ape, is t he f oundation of ef f icient and accurat e dosing f or f luid resuscit at ion and medicat ion administ rat ion f or t he pediat r ic patient wit h s hock

sym ptom s

Moni tori ng

- Dynamic cardiopulmonary monit oring f acilit ates

t rending of vit al signs

O xygen admi ni strati on- Begin wit h a high‐ f low f ace mask t o improve

oxygenation is needed

Temperature control

Fir st mi nutes

Pat ient placed on 100%oxygen I V access obtained and 20 mL/ kg bolus initiat ed–

consider t wo lines Blood sugar Tem p

Blood sent f orlaborat ories, cult ures andlact at e Ant ibiot ics begun –

Vascul ar access

Resusci tati on Bundl e

Att ain I V/IO access wit hin 5 m inut es

appropriate f luid resuscit at ion begun wit hin 30 m inut es

Init iat ion of broad s pectr um empir ic antibiotics wit hin

60 m inut es Begin peripheral or centr al inotr ope infusion t herapy

f or f luid – ref ract ory shock wit hin 60 m inut es.

Management

Resuscit at ion:

A- AirwayB- BreathingC- Cir culat ion - cryst alloidsD- Dext rose, Drugs = antibiotics, inotrops S-St eroids

Fluid Resusci tati on

Rapid f luid boluses of 20 ml/kg ( push or rapid infusion device )

Observe f or signs of f luid overload ( Hepat omegaly, increase work of breat hing, rales)

Repeat f luid boluses up t o 40-60 ml /kg in f ir st hour if

no signs of f luid overload Goal t o at t ain normal perf usion and BP

Cor rect Hypoglycem ia ( D10%)

Early Rapi d Flui d Resusci tati on i n Pedi atri c Septi c Shock i s Associ ated wi th Improved O utcomes

Oliveir a et al, Ped Emergency Car e24:2008

Tim e- sens it iveFluid- sens it ive

% M

ort

alit

y

• M ort alit y is f luid- sensit ive, where m ort alit y wit h decr eased amount of f luids given• M ort alit y is t im e sensit ive, where m ort alit y wit h delays to f luid administ rat ion

Ini ti al Resusci tati on

O xygen by f ace m ask or if needed – high f low nasalcannula oxygen, or nasal CPAP f or r espir at ory dist r ess

and hypoxem ia

I f r equir e int ubat ion - cardiovascular inst abilit y is lesslikely af t er appropr iat e cardiovascular r esuscit at ion( give f luids f ir st if possible(

Anti bi oti cs

G ive ant ibiot ics wit hin 1 hour * of ident if icat ion of sever e sepsis

Blood cult ures should be drawn f ir st if at all possible

– DO NO T DELAY adm inist r at ion of ant ibiot ics f orCT/LP

Anti mi crobi al therapy

Weiss et al. Delayed ant imicrobial t herapy increases mortalit y and organ dysfunction dur at ion in pediat ric sepsis. Crit Car e Med. 2014; 42(11): 2409–17.

Laboratori es

Elect r olyt es, calcium, r enal and liver f unct ion t est s

G lucose, lact at e Consider adding ket ones and amm onia

CBC and blood cult ure, I NR Cat h UA and cult ure

Consider t ox scr een CXR

ABCs: Fir st H our of Resusci tati on

Goal M aint ain or r est ore:

Air wayOxyg enat ionVentilat ion

Cir culat ionHear t r at e

M onit or

Pulse oxymet erContinuous ECGBlood Pr ess ureTempera t ure Ur ine output

Glucose

I onized calcium

End point :Norm al PulseCRT < 2 sec

War m extr emit iesNorm al urine output Norm al ment al stat usNorm al BP f or age Norm al G lucose

Normal I onized Calcium

Flui d Refractory Shock

• Can begin wit h dopam ine t hroughper ipheral I V• I nt ubat ion m aybe perf or med here (RSI(• Child r equir ing invasive m onit oring andcentr al line should be

int ubat ed

Inotropes-Vasopressors-Vas odilators

• Cold shock – begindopam ine – if r esist ant– cent r al epinephr ine

– Consider vasodilat or• War m shock – cent r al

nor epinephr ine

Mechani cal Venti l ati on

• I ndicat ions:– Decreased Conscious level– Need t o est ablish invasive hem odynamic m onitoring– Should be consider ed in any pat ient whois not r apidly

st abilized wit h fluid r esuscit ation and per ipherallyadm inist ered inot r opes

– Evidence of r espir at ory f ailure– Co M oribid condit ion

H ydrocort i sone

• G ive if child at r isk foradr enal insuff iciencyoradr enal pit uit ary axis f ailure

– Purpura f ulm inans– Congenit al adr enal hyperplasia– Pr ior r ecent steroidexposure, hypot halamic/pit uit ar yabnormalit y(

AND• Remains in shock despit e epinephr ine ornor epinephr ine inf usion

• St r ess dose 1- 2 mg/ kg/ day[ may requir eup to 50 mg/ kg/day

N ow what?

Stabi l i zati on bundl e

Use mult imodal monit oring t o optim ize f luid , horm onal and cardiovascular t herapies t o at t ain

hemodynamic goals.

Confirm administ rat ion of appropriate antim icr obial t herapy and source contr ol

Aggress ive Infection SourceControl

• Debr idem ent– Necrot izing pneum onia

– Necrot izing f asciit is– G angrenous m yonecrosis– Em pyem a

– Abscesses• Perf orat ed viscus – r epair and per it oneal

washout• Remove inf ect ed devices

Performance Bundl e

M easure adherence t o Trigger, r esuscit at ion, and st abilizat ion bundles

Perf orm root cause analysis t o ident if y barr iers to

adherence

Provide an act ion plan t o address ident if ied bar r iers

Case 1:

1 year old child previously healt hy presented t o ED wit h fever for 2 days. Lethargic , HR = 190 , Temp = 38.7 , RR= 40 , BP = 90/40 , Sat = 95% room airCRT 4 sec , week peripheral pulses , cold mottled

Is he septic / shock ?

Case 1

I dentif y as meeting sepsis / septic shock if :1- Hypot ension or

2- Meet 3/8 crit eria or 3- Meet 2/8 crit eria in

high r isk

• Obt ain f ull set of vit al signs• Focus ed hist ory and PE • I s t he pt . high r isk ? Tem p - - - - --- -- -- -Hypot ension - - -- -- -- -- -Tachyc ar dia - -- -- -- -- -Tachypnea - - -- -- --- -- --CRT - - - - - -- -- -- -- -M ent al st at us - - -- --- -- -Pulse qualit y - - - - -- -- -- -Skin - - - - - - -- --- -- -- -

Age- speci f i c vi t al si gns

Syst oli c BPmmHgRespir atory Rate ( breat h/mi n)

Bradycardia( Beat s/ min)

Tachycardia( Beat s/ min)

Age gr oup

< 60> 50< 100> 180Newbor n< 60> 40< 100> 180Neonat e< 70> 34< 90> 180I nf ant< 70 + age in yr x 2 > 22NA > 140Toddler< 70 + age in yr x 2> 18NA> 130Child<90> 14NA> 110Adolescent

Case 1 acti on

M onit ored bed

Assessm ent by M D

Init iate resuscit at ion bundle

Case 2

7 years old child ALL on chemot herapy-5 days ago last cycle Fever f or 1 day

Lethargic , Temp: 39.1 HR= 170 RR= 21 Sat= 94% Bounding pulses (centr al and peripheral) , warm skin

CRT= 1 sec Bp= 80/40

septic / shock ??

Age- speci f i c vi t al si gns

Syst oli c BPmmHgRespir atory Rate ( breat h/mi n)

Bradycardia( Beat s/ min)

Tachycardia( Beat s/ min)

Age gr oup

< 60> 50< 100> 180Newbor n< 60> 40< 100> 180Neonat e< 70> 34< 90> 180I nf ant< 70 + age in yr x 2 > 22NA > 140Toddler< 70 + age in yr x 2> 18NA> 130Child<90> 14NA> 110Adolescent

Case 2

I dentif y as meeting sepsis / septic shock if :1- Hypot ension or

2- Meet 3/8 crit eria or 3- Meet 2/8 crit eria in

high r isk

• Obt ain f ull set of vit al signs• Focus ed hist ory and PE • I s t he pt . high r isk ? Tem p - - - - --- -- -- -Hypot ension - - -- -- -- --Tachyc ar dia - -- -- -- -- -Tachypnea - - -- -- --- -- --CRT - - - - - -- -- -- -- -M ent al st at us - - -- --- --Pulse qualit y - - - - -- -- -- -Skin - - - - - - -- --- -- -- -

Case 2

Next steps

Take H ome Messages

Recognit i on –esufo DEslocotor profcitpeskcohscanim prove compliancewit h guidelines and improve outcomeTimer

Early appropr iat e f luid resuscitat ion( vascular access) Early empir ic ant ibiot ics wit hin 1 hour M oni t or HR, RR, Temp, BP, Spo2, glucose Early use of inot rope Early init iat ion of t r ansf erof cr it ical children

M aint ain or r estore air way, oxygenat ion and vent ilat ion

Take H ome Messages

• Therapeut i c endpoint s:– Capillary r ef ill <2 secs– Norm al pulses wit h no dif ferent ial between thequalit y

of per ipheral and centr alpulses– War m ext r em it ies– Ur ine out put >1 mL/ kg/ h– Norm al m ent al st at us– Norm al blood pressure f orage– Norm al glucose concent rat ion– Norm al ionized calcium concentr ation

Separati on Sl i de