Sepsis Guidelines for Children

PICU CICM day May 17FM

Severe Sepsis Guidelines:

• Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016

• Dellinger et al: Crit Care Med. 2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af

• The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3): JAMA. 2016;315(8):801-810.

• Rhodes et al: Crit Care Med. 2017. www.ccmjournal.org

Severe Sepsis Campaign• Evidence-based recommendations for acute

management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

• Two 'bundles':

– resuscitation bundle : first 6 hours

– management bundle : first 24 hours

• New guidelines in 2016: ‘nuanced’

Definitions• Severe sepsis:

sepsis + organ dysfunction or tissue hypoperfusion

– hypotension + oliguria (SBP< 65 children, < 55 infants)

– hypoxaemia and altered mental state (3 points)

– perfusion abnormalities (lactate >4)

• Septic shock:hypotension despite adequate fluid resuscitation

• SIRS: systemic response to infection +

inadequate organ perfusion

“Sepsis 3”ESICM/ SCCM

• Definitions outdated: – excessive focus on inflammation

– misleading model of sepsis as continuum through severe sepsis to shock

– lack specificity, sensitivity SIRS criteria.

– the term severe sepsis redundant.

• Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

qSOFA (Quick SOFA) Criteria

• Respiratory rate ≥22/min

• Altered mentation

• Systolic blood pressure ≤100 mm Hg

Date of download: 6/7/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287

Sequential [Sepsis-Related] Organ Failure Assessment Scorea

Table Title:

Surviving Sepsis Campaign Responds to Sepsis 3March 1, 2016

qSOFA• does not define sepsis

• tool for identifying patients at higher risk death or prolonged ICU stay

• New definitions do not change primary focus of early identification and treatment

Guidelines: Continue as previously recommended :

– Step 1: Screening and Management of Infection: culture, abx, lab tests

– Step 2: Screening for Organ Dysfunction: Same criteria AND qSOFA

– Step 3: Management of Initial Hypotension: if hypotension or lactate > 4, give 30 ml/kg crystalloid

• www.survivingsepsis.org/.../SSC-Statements-Sepsis-Definitions-3-2016.pdf

What about paeds?

• “The task force focused on adult patients yet recognizes the need to develop similar updated definitions for pediatric populations and the use of clinical criteria that take into account their age-dependent variation in normal physiologic ranges and in pathophysiologic responses.”

Initial Resuscitation

• 2016 guidelines:

– Sepsis and septic shock are emergencies, commence resuscitation immediately

– Fluids, and frequent reassessment

– Normalise lactate

First hour:

Fluid Resuscitation

• Aggressive fluid resuscitation • May require large volumes

– 20 ml/kg crystalloid over 5-10 mins (cf 30 ml/kg adults)

– No difference mortality crystalloid vs colloid

• Titrate to output: HR, UO, CR and LOC– BP unreliable but once hypotensive, collapse imminent

• Early intraosseous if difficult

Use crystalloids/saline Use albuminAvoid starches

Diagnosis

• Obtain cultures: peripheral/ central if doing so results in no delay in treatment with antibiotics

• 2 sets: anaerobic and aerobic• Broad spectrum antibiotics within one hour

<3 /12: cefotaxime/ amoxycillin,

>3 /12: cefotaxime / gentamicin

• Identify source rapidly – Imaging– Debridement– Remove iv access if infected

• Review daily, stop if non infectious

First 6 hours: Mechanical Ventilation

• May require early intubation• Use of mask O2, CPAP, high flow• Lung protective strategies

– TV 6ml/kg– Use PEEP– PIP<30cm H20– Permissive hypercarbia– ProningUse Recruitment manoeuvres, spontaneous breathing,weaning protocols, Don’t use HFOV, B-2 agonists

Fluids:

• Resuscitation: may need >100 ml/kg: – 10-20ml/kg: isotonic: saline– >30 ml/kg: colloid, consider inotropes– >60 ml/kg : blood/ platelets/ FFP

• Maintenance: 4:2:1 rule: – isotonic fluids, 80% if intubated– feed within 24 hours.

REF: https://www.starship.org.nz/for-health-professionals/starship-clinical-

guidelines/i/intravenous-fluids-effective-until-0700-14-june-2016/

First hour:Blood products

• No recommendations

• Optimal Hb not known, similar outcomes if Hb>7g/dL cf 9.5g/dL.

• Aim 7-9 g/dl

• IVIG:

– Suggested

– Reduce mortality in neonates

Suggest against IVIG in adults

Vasopressors/Inotropes

• Noradrenaline/adrenaline

– Now noradrenaline then vasopressin/adrenaline

• Dobutamine/Milrinone : low CO/high SVR

• Calcium: <6 mths

• Vasopressin: low SVR

• Hydrocortisone 1 mg/kg 6hTitrate to end point reflecting perfusion

and reduce or discontinue in face of worsening

hypotension or arrhythmias

First 6 hours: Glucose and sedation

• Recommend sedation protocols • morphine, chloral, diazepam

• not propofol, dexametatomidine, etomidate

• No glucose control recommendations

– (cf adults, glc<180mg/dL, monitor 1-2h)

– Risk of hypoglycaemia, need intake of 4-6mg/kg/min or 10% dextrose saline

– Only use insulin if strict monitoring

First 6 hours:Steroids

• Hydrocortisone (50 mg/m2/24h); 1 mg/kg 6h

• Catecholamine resistant /adrenal insufficiency

• Severe septic shock and purpura

• Random cortisol <18g/dL (496 nmol/L)

• Random use associated with increased mortality (OR 1.9)

Suggest against hydrocortisone if

adequate fluid resuscitation and

vasopressors restore stability. If

not achievable, suggest iv

hydrocortisone

? Application of other recommendations(NB: adult guidelines)

• Avoid bicarbonate if pH>7.15

• CRRT for sepsis and AKI for fluid management – not for high creatinine or oliguria alone

• LMW heparin and mechanical thromboprophylaxis

• Stress ulcer prophylaxis only if risk GI bleeding

• Enteral feeding, prokinetics,jejunal tubes (avoid TPN)

• Avoid selenium, arginine, glutamine, ?carnitine

• Discuss goals of care with families, < 72 hours in ICU

ECMO for Septic Shock

• VA ECMO with high flows to reverse MOF

• Survival with ECMO: – 73% for newborns, 39% for older children, highest VV ECMO

– 41% with respiratory failure survive to discharge

– 74% with refractory septic shock survival using VA

– 2004-2012 increasing use ECMO with improved survival

Sepsis Guidelines: Recommend ECMO in children with refractory septic shock or with refractory respiratory failure associated with sepsis (2C)

Extracorporeal therapies in pediatric severe sepsis: Crit Care. 2015; 19: 397.

Questions?