Slide 1

SEPSIS KILLS program Paediatric Inpatients Slide 2 Learning Objectives Recognise that sepsis is a medical emergency Identify the risk factors, signs and symptoms Outline the escalation of the septic patient Define the initial A-G management actions Discuss the requirements for 48 hour sepsis management including referral Apply the pathway to a case study Slide 3 Paediatric Sepsis Many paediatric sepsis related deaths are preventable Sepsis is one of the leading causes of death in children Mortality rates are as high as 10% Slide 4 Sepsis continuum Systemic Inflammatory Response Syndrome Infection Sepsis Severe Sepsis Septic Shock Increasing Mortality Slide 5 Sepsis recognition & management ..is there a problem in your facility? Slide 6 Sepsis program linkages with other paediatric resources Slide 7 Surviving Sepsis Campaign Infuse 20ml/kg 0.9% sodium chloride bolus over no more than 10 minutes Rapid administration of antibiotic therapy BP is not a reliable target. Treatment should be titrated to clinical signs of adequate cardiac output -Heart rate in normal range -Improved capillary refill time -Improved LOC -Urine output 1ml/kg/hr Early intubation recommended Slide 8 Pitfalls. Sepsis is a difficult diagnosis to make Often under appreciate the mortality Do not see sepsis as time critical Slide 9 Sepsis is a medical emergency You can make a difference for patients in this hospital Slide 10 Provide clear guidelines regarding sepsis notification escalation and initial management Early involvement of senior clinicians in diagnosis and management of sepsis Prompt administration of resuscitation fluids Prompt administration of antibiotics (goal is within one hour of recognition) Timely referral, clinical supervision and escalation Sepsis Pathway aims to: Slide 11 Slide 12 Slide 13 Slide 14 Slide 15 Slide 16 Slide 17 Slide 18 Case Study Slide 19 20:0922:00 7 year old girl Admitted via the Emergency Department with 3 day history of flu-like symptoms Preliminary diagnosis of asthma 7 year old girl Admitted via the Emergency Department with 3 day history of flu-like symptoms Preliminary diagnosis of asthma Transferred to the ward Slide 20 Bloods VBG: pH 7.31; BE -5.3mmol/L Lactate 3.4mmol/L; CO 2 48mmHg Bloods VBG: pH 7.31; BE -5.3mmol/L Lactate 3.4mmol/L; CO 2 48mmHg RA A FD 21 Slide 21 22:0023:1000:42 C/O tummy pain Reviewed by RMO Given analgesia + ventolin 2/24 Oral antibiotics ordered C/O tummy pain Reviewed by RMO Given analgesia + ventolin 2/24 Oral antibiotics ordered Arrive on ward Observations stable Arrive on ward Observations stable Slide 22 Sepsis pathway activated with obs in Yellow Zone and deterioration despite treatment RARA RA 21 22 2340 Slide 23 22:0000:4201:3001:46 SPO2 drop to 91% with NP O2 3 rd review by RMO Ordered IV antibiotics SPO2 drop to 91% with NP O2 3 rd review by RMO Ordered IV antibiotics 2 nd Clinical Review Obs in Yellow Zone and looks tired 2 nd Clinical Review Obs in Yellow Zone and looks tired Bloods 01:46 Repeat VBG pH 7. 35; CO 2 52mmHg; BE -7.1mmol/L; Lactate 5.6mmol/L; Bloods 01:46 Repeat VBG pH 7. 35; CO 2 52mmHg; BE -7.1mmol/L; Lactate 5.6mmol/L; Slide 24 21 22 2340130 RARA RA6LH 21 22 2340130 Slide 25 01:3002:1002:2002:40 Refusing to keep Hudson mask on SPO 2 91% with NP oxygen Becomes irritable Refusing to keep Hudson mask on SPO 2 91% with NP oxygen Becomes irritable IVAB administered Bloods 02:30 Repeat VBG pH 7.19 CO2 57mmHg; BE -7.1mmol, Lactate 6.3mmol/L Bloods 02:30 Repeat VBG pH 7.19 CO2 57mmHg; BE -7.1mmol, Lactate 6.3mmol/L Now grunting as Hudson mask held on by RN Administered ventolin nebuliser and IV hydrocortisone Now grunting as Hudson mask held on by RN Administered ventolin nebuliser and IV hydrocortisone Slide 26 03:0504:1004:26 Reviewed by paediatrician Requested repeat CXR Contacts NETS requesting transfer to tertiary hospital Reviewed by paediatrician Requested repeat CXR Contacts NETS requesting transfer to tertiary hospital Nil improvement Paediatrician contacted Nil improvement Paediatrician contacted 10ml/kg 0.9% sodium chloride bolus and IV ceftriaxone and fluclox Slide 27 21 22 2340130 03 RARA RA6L 6L Slide 28 04:2605:0006:00 Asystole CPR 07:20 2 nd arrest Significant deterioration Difficulty keeping SPO 2 >88% (NRB) Significant deterioration Difficulty keeping SPO 2 >88% (NRB) Rapid Response call made Decision to intubate Rapid Response call made Decision to intubate NETS arrive Adrenaline infusion commenced Arrested while transferring on to equipment NETS arrive Adrenaline infusion commenced Arrested while transferring on to equipment Slide 29 Aystole CPR 07:20 2 nd arrest Post mortem Slide 30 Slide 31 Slide 32 Slide 33 What is the evidence for urgent delivery of first dose antibiotics and aggressive fluid resuscitation? Slide 34 Antibiotics For each hour of delay to administration of antibiotics, after the onset of hypotension, there is a 7.6% increase in mortality (in adults) Kumar Crit Care Med 2006 Slide 35 Oliveira et al Time-and fluid- sensitive resuscitation for haemodynamic support of children in septic shock. Pediatr Emerg Care 2008 Time - and Fluid - Sensitive Resuscitation for Hemodynamic Support of Children in Septic Shock Slide 36 For every hour a child remains in shock their mortality rate doubles 91 children retrieved to Pittsburgh 1993-2001 for septic shock Slide 37 Points to remember Senior clinician review is crucial Beware of a lactate over 2mmol/L Not all children with sepsis will be febrile Persistent tachycardia is often consistent with sepsis For every hour a child remains in shock their mortality rate doubles Sepsis is an emergency Rapid antibiotic therapy and early aggressive fluid resuscitation improves survival Slide 38 SEPSIS KILLS TIME IS LIFE Recognise Resuscitate Refer