Pediatric severe sepsis - MSIC
Transcript of Pediatric severe sepsis - MSIC
Jan Hau Lee, MBBS, MRCPCH. MCI
Children’s Intensive Care Unit
KK Women’s and Children's Hospital, Singapore
Pediatric severe sepsis:
What’s new and
controversial in fluid
strategies?
No conflict of interest
Overview
• Is there a controversy? Are there new stuff?
• Fluid resuscitation
• Fluid choice and fluid balance
• Clinical guidelines and quality improvement
• Future directions
Goldstein et al. Pediatr Crit Care Med 2005
• 20 ml/kg bolus of NS or 5% albumin vs. maintenance therapy
• 3141 children with clinical evidence of impaired perfusion
• Risk of mortality was significantly higher in patients receiving
bolus therapy (RR: 1.45; 95% CI 1.13 – 1.86)
Davis et al. Crit Care Med 2017
SSC 2012 SSC 2016 WHO 2016
Who gets fluid? Fluid resuscitation
recommended for
normotensive and
hypotensive children in
hypovolaemic shock
In children where
euvolemia
needs to be restored
Children with all 3 signs of
shock:
1) Cold extremities
2) capillary refill time > 3 s
3) weak and fast pulse
How much? Up to 20 ml/kg for
crystalloids (or albumin
equivalent) over 5 – 10
mins
No specific fluid or
volume
recommendations
10 – 20 ml/kg crystalloid
over 30 – 60 mins
Maximum? Up to 40 – 60 ml/kg for
initial resuscitation
No recommendations Further infusion of 10
ml/kg over 30 mins
for persistent shock.
Cessation? Hepatomegaly and/or
rales as signs of
hypervolemia
No recommendations Signs of fluid overload,
cardiac failure or
neurological deterioration
What do other guidelines say?
Glassford et al. Anaesth Intensive Care 2017
FBT: Fluid Bolus Therapy
Glassford et al. Anaesth Intensive Care 2017
Where Does Fluid Go?
Glassford et al. Anaesth Intensive Care 2017
• Single center RCT (N=96)
• 20ml/kg given in 15 – 20 mins vs 5 – 10 mins
• Primary outcome: Need for mechanical
ventilation and/or increase in OI of 5 points at 2
time points: 6 and 24 hours
• 6 hours: 36 vs. 57%. RR: 0.62; 95% CI: 0.39–0.99
• 24 hours: 43 vs. 68%. RR 0.63; 95% CI: 0.42–0.93
Sankar et al. Pediatric Critical Care Medicine 2017
Sankar et al. Pediatric Critical Care Medicine 2017
So how do you currently give
fluid bolus at your institution?
Would you change your practice
after the FEAST trial and recent
WHO guidelines?
Overview
• Is there a controversy? Are there new stuff?
• Fluid resuscitation
• Fluid choice and fluid balance
• Clinical guidelines and quality improvement
• Future directions
Fluid Choices in Pediatric Severe Sepsis
• Fluid resuscitation is the cornerstone of hemodynamic resuscitation
• Many studies on crystalloids vs. colloids
–0.9%NS
–Albumin
–Semi-synthetic colloids (e.g. gelafundin)
• There is growing interest in chloride load in 0.9%NS and hence in the use of balanced solutions in fluid resuscitation
–Hartmann’s/ Ringer’s Lactate
–Plasmalyte
Type of Fluids
Long and Duke. Journal of Paediatrics and Child Health 2015
• Hyperchloremic acidosis – Worsen capillary leak
• Hyperchloremia – Renal dysfunction, AKI and need for CRRT
– Associated with mortality in critically ill adults
Cl-
154
111
98
N/S
LR/Hartmann’s
Plasmalyte
• Matched retrospective cohort study
• Administrative database
• Examined all patients that received LR or NS as
fluid resuscitation during first 3 days
• Primary outcome: 30-day mortality
• Secondary outcomes: AKI, LOS
Weiss et al. Journal of Pediatrics 2017
• 30-day mortality
(LR vs. NS): 7.2% vs. 7.9%
• No difference in AKI
• Median hospital LOS was longer in any LR group [15.5 (6, 22) vs. 13.1 (4, 20)]
Weiss et al. Journal of Pediatrics 2017
• Observational cohort study
• Administrative database
• Examined all patients that received balanced and unbalanced solutions as fluid resuscitation during first 3 days
• Primary outcome: In-hospital mortality
• Secondary outcomes: AKI, LOS, vasoactive infusion days
Emrath et al. Critical Care Medicine 2017
• Propensity score matching
• Matched for hospital, year, age, gender, septic shock, organ
dysfunction, and various comorbidities
Emrath et al. Critical Care Medicine 2017
Propensity-Matched Outcomes 24-hour Fluid Groups
72-hour Fluid Groups
Emrath et al. Critical Care Medicine 2017
Fluid Balance
• Fluid Accumulation Fluid Overload Organ Dysfunction
• Fluid overload at time of CRRT was associated with mortality and morbidities
• Limited but growing studies in children examining the impact of fluid balance on clinical outcomes
Foland et al. Critical Care Medicine 2004
Sutherland et al. Am J Kidney Dis 2010
Abulebda et al. Critical Care Medicine 2013
Abulebda et al. Critical Care Medicine 2013
• Matched case-control study
• Single-center study over 7 month period
• Cases: Children with fluid accumulation > 10%
of admission weight
• Controls: Without these early fluid accumulation
• Primary outcome: PICU mortality
Bhaskar et al. Intensive Care Medicine 2015
Bhaskar et al. Intensive Care Medicine 2015
Bhaskar et al. Intensive Care Medicine 2015
Characteristics Survivors (N=48) Non-survivors (N=23) P-value
Age, years 10.6 (4.9, 13.5) 8.0 (2.4, 12.6) 0.175
Male gender, n (%) 23 (48) 10 (43) 0.802
PIM 2 2.3 (1.1, 5.2) 4.7 (3.7, 14.3) 0.010
Source, n (%)
Respiratory 20 (42) 8 (35) 0.615
Central nervous system 3 (6.3) 4 (17.4) 0.203
Gastrointestinal 6 (13) 7 (30) 0.100
Bacteremia 2 (4) 2 (9) 0.591
Comorbidities, n (%) 21 (44) 18 (78) 0.010
Mechanical ventilation 18 (38) 22 (96) <0.001
Inotropes, n (%) 39 (81) 23 (100) 0.027
Cumulative balance*,
(x10ml/kg)
2.1 (-0.9, 9.8) 15.6 (5.5, 42.1) <0.001
Multi-organ dysfunction 28 (58) 23 (100) <0.001
Cardiovascular 37 (77) 23 (100) 0.013
Neurological 14 (29) 19 (83) <0.001
Hematological 17 (35) 10 (43) 0.604
Renal 12 (25) 8 (35) 0.411
Hepatic 16 (33) 12 (52) 0.194
Ho S et al.
Abstract at
PAS 2017
Fluid Balance per 10ml/kg Over First 5
Days of Severe Sepsis
Ho S et al. Abstract at PAS 2017
After adjusting for severity of illness,
organ failures and comorbidities,
each 10ml/kg positive fluid balance
increases mortality risk by 0.2%
Secondary Outcomes
Outcomes β coefficient 95% Confidence Interval p value
VFD
Cumulative fluid balance -0.20 -0.25, -0.14 <0.001
IFD
Cumulative fluid balance -0.20 -0.24, -0.15 <0.001
InoFD
Cumulative fluid balance -0.16 -0.22, -0.11 0.007
Adjusted for weight, PIM-2 score, PELOD score, comorbidities, multiorgan dysfunction VFD- 28-day ventilator-free day IFD- 28-day intensive care-free day InoFD- 28-day inotrope free day
Ho S et al. Abstract at PAS 2017
Overview
• Is there a controversy? Are there new stuff?
• Fluid resuscitation
• Fluid choice and fluid balance
• Clinical guidelines and quality improvement
• Future directions
Davis et al. Crit Care Med 2017
Nonadherence with timely fluid administration was
associated with both a longer ICU and hospital stay
Paul et al. Pediatrics 2012
Paul et al. Pediatrics 2014
Quality Improvement in Severe Sepsis
• Understand local barriers
• Adapt and individualize intervention
• Multidisciplinary approach
• Some strategies to consider: - Recognize abnormal vital signs of sepsis
- Delay in securing vascular access
Melendez et al. Curr Opin Pediatr 2015
Future Directions
• Pressing need for an updated pediatric severe sepsis and septic shock definition
• Increasing studies on balanced solutions and attention to fluid balance after the resuscitative phase
• Quality improvement and standardization of management of severe sepsis is important in improving overall outcomes
Kissoon. Critical Care 2017
“The optimal approach to fluid administration in both high and low income countries
is not yet settled, with no rigorous study conducted in high income countries. The
FEAST trial, the largest and most rigorous attempt to address approaches to fluid
administration was done in low and middle income settings in Africa.”
“What is still unclear is how much fluid should be infused and
how fast to replenish intravascular volume deficits in children
with shock and complex co-morbidities. We need to
challenge our present dogma regarding approaches to
fluid resuscitation.”
Thank You [email protected]