Clinical Leads Presentation Paediatric Sepsis 5 2013
description
Transcript of Clinical Leads Presentation Paediatric Sepsis 5 2013
Paediatric Sepsis “The Paediatric Toolkit unpacked”
Author: Paul Hunstead Project Officer Paediatric Sepsis
Acknowledgements:
CEC “Sepsis Kills” Program
Our Objectives
• A brief look at what is septic shock
• What’s in the toolkit
• Recognition of sepsis
• Responding to sepsis
• Resuscitation
• Case studies
Paediatric Sepsis
• Many paediatric sepsis related deaths are
preventable
• One of the leading causes of death in
children
• Mortality rates are as high as 10%
The Call to Action
Clinical Focus Report from the CEC 2009
Review of incidents from IIMS and Root Cause Analyses
Recurring theme regarding Sepsis
Failure to recognise Sepsis
Delayed or inappropriate initial management
Need for improvement in sepsis management across the state
-Sepsis kills campaign launched May 2011
Stanford Hospital 2010
Infection
+
Sepsis continuum
What’s in the paediatric sepsis
toolkit?
Paediatric Resources
Paediatric Pathway
Sepsis Neonatal FIRST DOSE Empirical IV Antibiotic Guideline
Sepsis paediatric FIRST DOSE Empirical IV Antibiotic Guideline
Neonatal and Paediatric Blood Culture Sampling Guideline
Paediatric reference card
HETI e-learning sepsis program
Linkages with other Paediatric
Resources
Between the flags
Standard Paediatric Observation
Charts (SPOC) • Paediatric Clinical
Practice Guidelines
Recognition of a Sick Baby or
Child in the ED
Bacterial Meningitis and Fever
Adults vs. Kids
Kids are not little adults
The evidence for management of sepsis in paediatric patients
is limited and not comprehensive (mostly adult)
Limited data however suggests
-Rapid antibiotic therapy
-Early aggressive fluid resuscitation improves survival
-supportive measures including respiratory and hemodynamic
management
Paediatric Recommendations
Surviving Sepsis Campaign 2012
Fluids should be infused as 20ml/kg 0.9% NaCl boluses over no
more than 10 mins
Rapid administration of antibiotic therapy
BP not a reliable target in paediatrics but treatment should be
titrated to clinical signs of adequate cardiac output
Heart rate in normal range
Improved Capillary refill time
Improved LOC
UO 1ml/kg/hr
Early intubation recommended
Pitfalls…….
• Difficult diagnosis to make
• We under appreciate the mortality
• Do not see sepsis as time critical
Paediatric Pathway Pilot
• 10 pilot sites across NSW
• 60 patients activated the pathway
• 38 not septic & 21 septic
• Did we miss anyone?
• Provides 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)
Aims of the Paediatric
Sepsis Pathway
Case Study
• 17 month female
• Previously fit and
well
• No meds, NKDA,
Imm UTD
• Family all have
mild coryzal
symptoms
Metropolitan Hospital At triage (17:30)
• Alert and playful
• Temp 39, Hr 172, RR 40
• Good central perfusion
• Pale and mottled peripherally
?
?
18:45 Seen by RMO
• Given panadol with resolution of fever
• HR never less than 170 since triage
Blood results 19:57
• WCC 3.0, N 3, PLT 455,Hb 100
• UEC / LFT/ Ca/ Mg/ Po4 NAD
• VBG pH 7.15, BE -10, Bicarb 10, lact 5, CO2 25
• BSL 6
• Urine NAD
Progress
• URTI focus for fever identified
• 2 small vomits in waiting room
• No further reviews documented
• 20:00 triage RN noticed non blanching rash
(petechaie)
• NETS contacted advised O2, AB’s and Fluid
bolus
• 21:20 AB’s and 10ml/kg 0.9% NaCl
22:30 NETS arrive
A Maintained, no oxygen
B RR 60, marked increased resp effort
C HR 178,CR >5 secs
D alert, interacting with mum
• IVC insitu
• IV cefotaxime administered
• 10ml / kg fluid bolus, no maintenance
Progress
Rapid deterioration
• AVPU
• Increasing respiratory distress
• HR >200, normal ECG
• Only femoral pulse palpable
ABG pH 7.0, BE -20, Lactate 8, pCO2 50, pO2 80
Case 2
Triaged 18:40
• 8 week old female
• Presented with poor
feeding
• Felt warm last night
• Alert, HR 146, CR=2sec,
sl mottled peripherally
• RR 66, Temp 37.5
Cat 3 -Seen by Dr 19:36
•Obs 19:48
•RN noticed baby more diff to rouse
•Dr who was taking the history informed
•HR 171, RR 68, T 38.6, CR =3sec, BP 86/60, Sao2 95% RA
•Bloods, LP and In Out catheter
•Lrg Leuk and blood on urine dipstick, BSL 3.6
•Remains tachycardic with poor perfusion
•10ml/kg Nacl bolus @ 20:26
Obs 20:40
•Drowsy,
•HR 196,
•CR= 3 sec, mottled
•RR 66 with mod tug/mild IC Rec,
• T 35.8°c
• Spo2 94% RA
At 20:59 apnoea
•Diff to rouse
•CR=3sec, HR 204
•RR 76 with mod tug and mod recession
•SpO2 92% with oxygen via hudson mask
At 21:19 2nd 10ml/kg 0.9% NaCl
bolus given
21:00-21:30 Results:
• Urine MCS orgs with > 100WC, WCC 25.7,
•VBG 7.2, CO2 35, BiCarb 10, Lactate 5, BE -10
•21:39 AB’s commenced •CICU consult requested
Recognition – Can’t we just do
a blood test?
• Blood Culture
• Lactate
• CRP
• Pro-calcitionin (PCT)
• All have a place and should never be ignored
when ‘positive’ but sensitivity and specificity
remain issues
• Dozens of new markers in the “pipeline” – all
flawed so far…..
What is the evidence
for urgent delivery of
first dose antibiotics
and aggressive fluid
resuscitation?
Antibiotics
• For each hour of delay to administration of antibiotics there was a
7.6% increased risk of mortality (in grown ups)
Kumar Crit Care Med 2006
Fluid, Fluid and more Fluid
• Early aggressive fluid resuscitation improves
survival
• 20mL/kg of 0.9% NaCl -repeat until clinical
improvement (consider colloid if available beyond
40mL/kg)
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
“For every hour a child remains in
shock their mortality rate doubles”
91 children retrieved to Pittsburgh
1993-2001 for
“septic shock”
Key messages
• SEPSIS KILLS
• TIME IS LIFE
Recognise Resuscitate Refer