3/14/2017. Pediatric Sepsis: From Goal Directed Therapy to Protocolized Care. Objectives. Developmental Response to Sepsis

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1 Pediatric Sepsis: From Goal Directed Therapy to Protocolized Care March 20, 2017 Reid WD Farris, MS MD Objectives Review the evolution & current state of the pediatric septic shock treatment guidelines Review published outcomes in pediatrics associated with sepsis guideline adherence Introduce novel methods of patient risk stratification aimed at targeting resuscitation & therapeutic approaches for pediatric sepsis Developmental Response to Sepsis Children are not little adults. Except, when the evidence is thin and we don t really have anything else to go on Pediatric septic shock clinical phenotype Associated with severe hypovolemia Low cardiac output more frequent than high (when evaluated) Hemodynamic state often quite dynamic over the first 48hrs Oxygen consumption dependent on delivery 1

2 Crit Care Med 2002 No change in emphasis No change in therapeutic endpoints Circulation Fluid Overload Glycemic control Crit Care Med 2009 Integration Emphasis Initial Resuscitation Antibiotics & Source Control Blood Products Glycemic Control Fluid Overload Nutrition Crit Care Med

3 Crit Care Med 2012 Crit Care Med 2012 From Guidelines to Outcomes Han et al. Adherence to current ACCM/PALS sepsis guidelines in referring centers prior to transport team arrival Pediatrics

4 Arikan et al. Pre & Post implementation of a septic shock pathway in a pediatric ED J Pediatr 2015 Balamuth et al. Pediatr Crit Care Med 2016 Workman et al. Pediatr Crit Care Med

5 Oliveira et al. Fig. 3 Kaplan Meier estimates of mortality (28 days) Intensive Care Med 2008 Oliveira et al. Table4 Treatments administered Fluids Hours after study entry Resuscitation fluids (ml/kg) 0 6 Crystalloid Control group 5 (0 20) 10 (0 28) 80 (45 100) Intervention group 28 (20 40) 0 (0 20) 90 (65 114) c c c p-value < Colloid Control group 0 (0 0) 0 (0 15) 0 (0 15) Intervention group 0 (0 0) 0 (0 0) 0 (0 15) p-value 0.73 c 0.15 c 0.18 c Red-cell transfusion (% of patients) Control group Intervention group a a a p-value C di l t Intensive Care Med 2008 Risk Stratification Pediatric sepsis biomarker risk model (PERSEVERE) Stratification of patients with use of clinical data and blood samples early in ICU course Gene expression profiling utilized to classify subjects Am J Respir Crit Care Med

6 Risk Stratification Systemic inflammatory markers Serial measurement of CRP & Ferritin Pediatr Crit Care Med 2016 Pediatric Sepsis References Carcillo, J. A., Davis, A. L. & Zaritsky, A. Role of early fluid resuscitation in pediatric septic shock. JAMA 266, (1991). Carcillo, J. A., Fields, A. I. & Members, A. C. of C. C. M. T. F. C. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 30, (2002). Brierley, J. et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. (2009). Dellinger, R. P. et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: Crit Care Med 41, (2013). Han, Y. Y. et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 112, (2003). Akcan Arikan, A. et al. Resuscitation Bundle in Pediatric Shock Decreases Acute Kidney Injury and Improves Outcomes. J. Pediatr. 167, e1 (2015). Balamuth, F. et al. Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis. Pediatr. Crit. Care Med. J. Soc. Crit. Care Med. World Fed. Pediatr. Intensive Crit. Care Soc. 17, (2016). Workman, J. K. et al. Treatment of Pediatric Septic Shock With the Surviving Sepsis Campaign Guidelines and PICU Patient Outcomes. Pediatr. Crit. Care Med. J. Soc. Crit. Care Med. World Fed. Pediatr. Intensive Crit. Care Soc. 17, e451 e458 (2016). Oliveira, C. F. de et al. ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Med 34, (2008). Wong, H. R. et al. Developing a Clinically Feasible Personalized Medicine Approach to Pediatric Septic Shock. Am. J. Respir. Crit. Care Med. 191, (2014). Wong, H. R. et al. The pediatric sepsis biomarker risk model. Crit. Care Lond. Engl. 16, R174 (2012). Carcillo, J. A. et al. A Systemic Inflammation Mortality Risk Assessment Contingency Table for Severe Sepsis. Pediatr. Crit. Care Med. J. Soc. Crit. Care Med. World Fed. Pediatr. Intensive Crit. Care Soc. 18, (2016). 6

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