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