RCEM Paediatric Sepsis Talk
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Talk given on 29 Sep 2015 at the Royal College of Emergency Medicine annual meeting. Key areas: What are the issues with sepsis in children? How will it apply to the UK Sepsis CQUIN? The Paediatric Sepsis 6 and screening for sepsis in children. Additional notes following main talk.
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RCEM Paediatric Sepsis Talk
- 1. Sepsis in Children Presentation by Jeremy Tong @jez_tong Royal College of Emergency Medicine 2015 29Sep2015
- 10. The most significant recurrent avoidable factor between cases was a failure to recognise severe illness in children. This most often occurred at the point of first contact between the sick (and often febrile) child and healthcare services…
- 11. ! Picture of septic child
- 12. Spotting the Signs of Sepsis
- 16. !
- 17. !!!!!!!!!! !!!!!!!!!! !!!!!!!!!! !!!!!!!!!! !!!!!!!!!! In a large Paediatric ED assessing 50 000 children a year: = 1 per week
- 21. Hospital Length of Stay mon tue wed thu fri sat sun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 27 18 19 20 21 22 23 24 25 26 27 28 29 30 31
- 22. Hospital Length of Stay mon tue wed thu fri sat sun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 27 18 19 20 21 22 23 24 25 26 27 28 29 30 31
- 23. Hospital Length of Stay mon tue wed thu fri sat sun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 27 18 19 20 21 22 23 24 25 26 27 28 29 30 31
- 24. !
- 25. !
- 32. Adherence to PALS Sepsis Guidelines and Hospital Length of Stay Raina Paul, Mark I. Neuman, Michael C. Monuteaux and Elliot Melendez Pediatrics 2012;130;e273; originally published online 2012; DOI: 10.1542/peds.2012-0094.
- 33. Adherence to 5 time-specific goals
- 34. 5 algorithmic time-specific goals 1. Early recognition of Severe Sepsis 2. Vascular access 3. Antibiotic administration 4. Administering IV fluids 5. Vasopressors for fluid refractory shock
- 35. Adherence to 5 algorithmic time-specific goals
- 36. Adherence to 5 algorithmic time-specific goals Hospital LOS 57% reduction ICU LOS 42% reduction
- 37. Adherance to fluid guideline: 37% Adherence to inotrope guidelines: 35% Adherance to all 5-components: 19%
- 40. Paediatric Sepsis 6 Recognition Suspected or proven infection AND at least 2 of: ! Core temperature < 36°C or > 38.5°C ! Inappropriate tachycardia ! Altered mental state ! Reduced peripheral perfusion / prolonged CRT
- 41. Think: could this child have SEPSIS? If in doubt, consult a senior clinician.
- 42. Think could this be sepsis? Experienced Review (History, assess, exam, ?gas) This Identifies at risk group This is “screening” or “test” for sepsis High certainty of Sepsis Treat e.g. with Paed Sepsis 6 Record thinking process High certainty NOT Sepsis Unsure Review again e.g. in 1 hr Suspect / proven infection + 2 criteria
- 43. Paediatric Sepsis 6 1. Give high flow oxygen 2. Obtain IV/ IO access & take blood tests 3. Give IV or IO antibiotics 4. Consider fluid resuscitation 5. Involve senior clinicians / specialists early 6. Consider inotropic support early
- 44. Paediatric Sepsis 6 1. Give high flow oxygen 2. Obtain IV/ IO access & take blood tests 3. Give IV or IO antibiotics 4. Consider fluid resuscitation 5. Involve senior clinicians / specialists early 6. Consider inotropic support early
- 49. CQUIN
- 52. Improving Adherence to PALS Septic Shock Guidelines. Paul R, Melendez E, Stack A, Capraro A, Monuteaux M, Neuman MI. Pediatrics. 2014 May;133(5):e1358–66.
- 54. Bundle adherence pre + post intervention
- 55. Number of cases between each death
- 61. The UK Sepsis Trust Paediatric Group Contributors Adult & Paediatric Intensivists, Adult & Paediatric Emergency phycisians, Adult & Paediatric Anaesthetists, Paediatricians, Neonatologists, Quality Improvement Fellows (alphabetical) Dr Jay Banerjee Dr Linda Clerihew Dr Joe Carcillo Dr Ron Daniels Ms Kirsteen Ellis Dr Minesh Khashu Dr Niranjan ‘Tex’ Kissoon Dr Hilary Klonin Dr Simon Nadel Dr Adrian Plunkett Dr Damian Roland Dr Ranjit Singh Dr Neil Spenceley Dr John Schulga Dr Jeremy Tong The UK Sepsis Trust Paediatric Group is hosted by The UK Sepsis Trust (registered charity no. 1146234) and led by Dr Jeremy Tong
- 64. Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis Weiss SL, Fitzgerald JC, et al. Crit Care Med. 2014 Nov;42(11):2409–17.
- 65. Time from recognition to initial antimicrobial administration OR = 4.84
- 66. [Clinical research of timing of application of antibiotics in septic shock of pediatric patients] Chinese Critical Care Medicine. 2013 Apr;25(4):207-10. doi: 10.3760/cma.j.issn.2095-4352.2013.04.007. Chinese'Critical'Care'Medicine' ( )
- 67. Antibiotic timing in pediatric septic shock Antibiotics within 1 hour n = 40 Antibiotics 1 – 6 hours n = 40 Lactate lower 8.65 vs 11.75 mmol/L P <0.01 CRP lower 66.25 vs 91.77 mg/L P <0.01 PCT lower 0.67 vs 1.16 µg/L P <0.01 Time to shock reversal: 6.80 vs 12.80 hours P <0.05
- 68. Fluid Resuscitation of Hypovolemic Shock: Acute Medicine's Great Triumph for Children. Carcillo, J. A. & Tasker, R. C. Intensive Care Med 32, 958–961 (2006).
- 69. Single-center ‘best’ mortality rates (%) from septic shock
- 70. Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome Yong Y. Han, Joseph A. Carcillo, Michelle A. Dragotta, Debra M. Bills, R. Scott Watson, Mark E. Westerman and Richard A. Orr. Pediatrics 2003;112;793 DOI:10.1542/peds.112.4.793.
- 71. Reversal of Shock before PICU: Capillary refill < 2 secs with normal BP
- 72. Resuscitative efforts by community hospital physicians
- 73. Shock reversal Survival OR = 9.49 Resus consistent with ACCM-PALS Survival OR = 6.81
- 74. Every additional hr of persistent shock OR = 2.29 Every additional hr delay in ACCM-PALS OR = 1.53
- 75. Implementation of Goal- Directed Therapy for Children With Suspected Sepsis in the Emergency Department Andrea T. Cruz, Andrew M. Perry, Eric A. Williams, Jeanine M. Graf, Elizabeth R. Wuestner and Binita Patel Pediatrics; originally published online February 21, 2011; DOI: 10.1542/peds.2010-2895.
- 76. Implementation of goal-directed therapy for children with suspected sepsis in the ED
- 77. Intubated in ED 3.2% vs 20% Inotropes in ED 10.1% vs 16% Death during admission 1.9% vs 4%
- 78. Emergency management of children with severe sepsis in the United Kingdom: the results of the Paediatric Intensive Care Society sepsis audit. Inwald, D. P., Tasker, R. C., Peters, M. J., Nadel, S. on behalf of the Paediatric Intensive Care Society Study Group (PICS-SG). Archives of Disease in Childhood 94, 348–353 (2009).
- 79. UK PICU Sepsis Audit ACCM-PALS guideline … was not followed in 62% of shocked children OR for death … if shock present at PICU admission = 3.8 (95% CI 1.4 to 10.2, p = 0.008)
- 83. Types of Shock Tachycardia Warm Bounding pulses Pink/Flushed Flash CRT Altered Mental State Reduced Urine Output Tachycardia Cool Warm Difficult pulses Pale/Mottled Prolonged CRT Altered Mental State Reduced Urine Output
- 86. What processes are in place to spot the sick child?
- 87. Is there available equipment to help spot the sick child?
- 88. Access to specialist advice?
- 89. Process for handover of care?
- 94. Epidemiology
- 95. Trends in the Epidemiology of Pediatric Severe Sepsis Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Pediatr Crit Care Med. 2013 Jul 26.
- 96. Prevalence: 0.89 per 1000 population
- 97. Characteristics: Age 3.8 yrs (median <1) Newborn sepsis increasing
- 98. Characteristics: LoS 31.5 days (median 16) Mortality 8.9%
- 99. Characteristics of Pediatric Severe Sepsis Cohort:
- 100. Mortality related to pediatric severe sepsis:
- 101. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Crit Care Med. 2001 Jul;29(7):1303–10.
- 102. National age-specific incidence and mortality rates for all cases of severe sepsis by gender, excluding those with HIV disease.
- 103. National age-specific average and total hospital costs for severe sepsis. Expressed as 1995 USD
- 104. Epidemiology of Severe Sepsis and Septic Shock Arturo Artero, Rafael Zaragoza and José Miguel Nogueira
- 105. Prevalence around the world:
- 106. Annual incidence of severe sepsis by age in the pediatric population of the United States
- 107. Quality of life of 164 patients with sepsis or trauma after 2 yrs following ICU (adults)
- 109. Severe Sepsis in Children US 0.56 - 0.89 cases per 1000 per year UK ≈ 1000 PICU admissions per year
- 110. Severe Sepsis in Children Mortality rate ~ 10% >10% of deaths in under 4 yr PICU mortality up to 20%
- 111. Risk Factors in Children < 1 year VLBW / Prematurity Underlying diseases Immunocompromised
- 112. What is Sepsis?
- 113. International sepsis consensus definitions for pediatric sepsis Goldstein et al Ped Critic Care Med 2005, Vol 6, no 1
- 114. What is Sepsis? Severe SepsisSepsisSIRS
- 115. At least 2 of: • Temperature high or low • Heart rate high • Breathing rate high • WCC high or low What is Sepsis? Severe SepsisSepsisSIRS
- 116. SIRS + Suspected / Proven Infection What is Sepsis? Severe SepsisSepsisSIRS
- 117. Sepsis + Organ dysfunction • Cardiovascular or • Respiratory or • 2 or more other organs What is Sepsis? Severe SepsisSepsisSIRS
- 118. Sepsis + Organ dysfunction • Cardiovascular or • Respiratory or • 2 or more other organs What is Sepsis? Severe SepsisSepsisSIRS