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Sepsis PALS April 24, 2017

Sepsis PALS April 24, 2017. Disclosures. No Conflict of Interests or Potential Conflicts of Interests to Declare. Objectives. Review the differences between adult and pediatric septic shock

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Sepsis PALS April 24, 2017

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  1. Sepsis PALS April 24, 2017

  2. Disclosures No Conflict of Interests or Potential Conflicts of Interests to Declare

  3. Objectives Review the differences between adult and pediatric septic shock Identify key elements during the initial management of pediatric sepsis that will improve patient outcomes

  4. Pediatric vs. Adult Sepsis Dehydration Cardiac Dysfunction Sepsis Vasoplegia

  5. Pediatric vs. Adult Sepsis Dehydration Cardiac Dysfunction Sepsis Vasoplegia

  6. Pediatric vs. Adult Sepsis Dehydration Cardiac Dysfunction Sepsis Vasoplegia

  7. Pathophysiology of Pediatric Sepsis Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Pediatrics 1998.

  8. Pathophysiology of Pediatric Sepsis 80% myocardial dysfunction Majority “cold shock” Ceneviva G, Paschall JA, Maffei F, Carcillo JA. Pediatrics 1998.

  9. Goals of Therapy Recognition of sepsis within 5 minutes IV access within 5 minutes Antibiotic delivery within 60 minutes Delivery of 60 mL/kg fluids within 60 minutes Administration of vasoactive substance within 60 minutes 2010 PALS Guidelines: Septic Shock

  10. Recognition of Sepsis Suspected infection suggested by hyper or hypothermia AND: Note: Hypotension is not a required feature

  11. Markers associated with mortality Carcillo JA, et al. Pediatrics 2009.

  12. Goals of Therapy Recognition of sepsis within 5 minutes IV access within 5 minutes Antibiotic delivery within 60 minutes Delivery of 60 mL/kg fluids within 60 minutes Administration of vasoactive substance within 60 minutes 2010 PALS Guidelines: Septic Shock

  13. IV Access IO insertion Rapid and successful insertion Equivalent pharmacokinetics ACCM 2007 Guidelines Peripheral inotropes until central access obtained Recommendation: If rapid IV access is not achieved, IO should be inserted Voight J, Waltzman M, Lottenberg L. Ped Emerg Care 2012. 2007 ACCM Guidelines 2010 PALS Guidelines

  14. Goals of Therapy Recognition of sepsis within 5 minutes IV access within 5 minutes Antibiotic delivery within 60 minutes Delivery of 60 mL/kg fluids within 60 minutes Administration of vasoactive substance within 60 minutes 2010 PALS Guidelines: Septic Shock

  15. Antibiotic Therapy Antibiotic therapy within the first hour: Decreased mortality by 13.5% 7.6% decrease in survival for each hour delayed Antibiotic Choice (no source): Cloxacillin 50 mg/kg IV q6h OR Vancomycin 15 mg/kg IV Cefotaxime 50 mg/kg IV q6h Antibiotic Choice (source):www.childhealthbc.ca Aneja RK, Varughese-Aneja R, Vetterly CG, Carcillo JA. Curr Infect Dis Rep 2011. Gaieski DF, et al. Crit Care Med 2010. Kumar A, et al. Crit Care Med 2006.

  16. Goals of Therapy Recognition of sepsis within 5 minutes IV access within 5 minutes Antibiotic delivery within 60 minutes Delivery of 60 mL/kg fluids within 60 minutes Administration of vasoactive substance within 60 minutes 2010 PALS Guidelines: Septic Shock

  17. IV fluid administration Crystalloid vs. Albumin 3 adult metanalyses published in 2014 Pediatric data weak Albumin may have some advantage Recommendation: Availability should dictate choice of crystalloid or albumin. Jian L, Jian S, Zhang M, Zheng Z, Ma Y. PLoS One 2014. Xu JY, et al. Crit Care 2014. Pater A, Laffan MA, Waheed U, Brett SJ. BMJ 2014. Akech S, Ledermann H, Maitland K. BMJ 2010. Maitland K, et al. Clin Infect Dis 2005 Ford N, Hargreaves S, Shanks L. PLoS One 2012.

  18. IV fluid administration ACCM 2007 Target 60mL/kg within first 15 minutes PALS 2010//2015 Target 60mL/kg within first 1 hour Goal of fluid resuscitation Restoring normal mental status, restoring threshold HRs, CRT < 3 secs, palpable peripheral pulses, normal blood pressure Carcillo JA, Davis AL, Zaritsky A. JAMA 1991. Wills BA, et al. NEJM 2005.

  19. IV fluid administration Methods for rapid fluid administration Rapid Infuser Pressure Bag Push-Pull Technique

  20. IV Fluid Administration Long E, Duke T. J Pediatr Child Health 2016.

  21. IV fluid administration 20mL/kg IV fluid bolus After each bolus, assess for hepatomegaly, rales, gallop Impaired perfusion + no signs of fluid overload Impaired perfusion + signs of fluid overload Hold fluids, start inotropic agent Bolus to target of 60mL/kg fluids in first hour

  22. Goals of Therapy Recognition of sepsis within 5 minutes IV access within 5 minutes Antibiotic delivery within 60 minutes Delivery of 60 mL/kg fluids within 60 minutes Administration of vasoactive substance within 60 minutes 2010 PALS Guidelines: Septic Shock

  23. Vasoactive Agents Early inotropes improves mortality, and can be run peripherally Traditionally dopamine was initial agent New Recommendations (initial agent): Peripherally Epinephrine (0.05 to 0.3 mcg/kg/min) Centrally Epinephrine (cold shock) or norepinephrine (warm shock) Ninis N, et al. BMJ 2005. ACCM 2007 El-wither N, Cornell T, Kissoon N, Shanley TP. Open Inflamm J 2011. www.childhealthbc.ca

  24. Airway and Breathing High-flow oxygen Intubate patients with: Substantially increased work of breathing Hypoventilation Altered LOC or obtundation Consider intubation in: Patients with persistent or worsening shock >40 mL/kg ACCM 2007. Booy R, et al. Arch Dis Child 2001.

  25. Airway and Breathing Intubation Medications: Atropine 0.02mg/kg (0.1 to 1mg) Ketamine 1 to 2 mg/kg Avoid Etomidate* IV fluids and vasoactive agents before and during intubation Tarquinio KM, et al. Pediatr Crit Care Med 2015. ACCM 2007 PALS 2010 Gu WJ, Wang F, Tang L, Liu JC. Chest 2015.

  26. Glucose and Calcium Glucose demands increase in sepsis High risk of hypoglycemia Ionized calcium frequently low in sepsis Treat if iCa < 1.10mmol/L Recommendations: Run IV D10NS at maintenance Correct hypocalcemia

  27. Steroids Paucity of literature in pediatric patients Trend to benefit to steroids in pediatric sepsis Recommendations: Steroids should be given in patients with purpura fulminans, previous steroid therapies for chronic illness, hypothalamic/pituitary or adrenal abnormalities (including CAH) Dose: 1 – 2 mg/kg (insufficiency) to 50 mg/kg (shock reversal) Baseline cortisol level prior to administration Menon K, McNally D, Choong K, Sampson M. Pediatr Crit Care Med 2013. ACCM 2007

  28. Future Directions Fluid-Sparing Strategies FEAST Trial SQUEEZE Trial Albumin vs. Crystalloid Epinephrine vs. Dopamine 2 studies suggesting benefit with epinephrine Maitland K, et al. NEJM 2011. Ford N, Hargreaves S, Shanks L. PLoS One 2012. Ventura AMC, et al. CCMJ 2015. Ramaswamy KN, et al. PCCM 2016.

  29. Summary Recognize Sepsis! www.childhealthbc.ca Airway/Breathing Atropine + Ketamine Avoid Etomidate Fluids and vasoactive agents Circulation Early IO insertion Rapid fluid delivery 60mL/kg in first hour IF no fluid overload Epinephrine 1st line agent

  30. Summary Antibiotics Deliver in 1st hour: Cefotaxime + Cloxacillin/Vancomycin Glucose and Calcium Run D10NS at maintenance + normalize ionized calcium Steroids Patients with absolute adrenal insufficiency Call for help early!

  31. Thank You Questions?

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