8/23/2017. Objectives. Why Is This Topic Important? The Pediatric Sepsis Continuum: Recognition and Treatment

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The Pediatric Sepsis Continuum: Recognition and Treatment Julie Albright Gottfried, DNP, RN, CPNP-PC, CNS 1 Objectives Identify diagnostic criteria for pediatric systemic inflammatory response

1 The Pediatric Sepsis Continuum: Recognition and Treatment Julie Albright Gottfried, DNP, RN, CPNP-PC, CNS 1 Objectives Identify diagnostic criteria for pediatric systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock. List initial management strategies for the pediatric patient in severe sepsis and septic shock. Review current literature findings that describe the incidence and prevalence of pediatric sepsis across inpatient, emergency medicine, and ambulatory settings. Using two case scenarios, identify recognition and management strategies for pediatric patients on the sepsis continuum. 2 Why Is This Topic Important? Pediatric sepsis affects more than 75,000 children in the U.S. annually In-hospital mortality estimates 5-10% Identification of patients at greatest risk of developing severe sepsis and septic shock are a public health priority 3 1

Definitions Systemic Inflammatory Response Syndrome (SIRS) At least 1

Definitions SIRS: Vital signs and lab data 5 Definitions A note about SIRS

from pain, anemia, fluid volume status, respiratory distress, fear No

2 Definitions Systemic Inflammatory Response Syndrome (SIRS) At least 1 diagnostic criteria must be abnormal temp or leukocyte abnormality 4 Definitions SIRS: Vital signs and lab data 5 Definitions A note about SIRS Fever and tachycardia go hand-inhand in children Difficult to differentiate from pain, anemia, fluid volume status, respiratory distress, fear No established criteria to calculate an age-appropriate heart rate in the presence of fever 6 2

Definitions Pediatric sepsis SIRS + known or suspected infection 7 Definitions Systemic inflammatory response Infectious organism or by-products (endotoxins) activate the immune system (neutrophils,

3 Definitions Pediatric sepsis SIRS + known or suspected infection 7 Definitions Systemic inflammatory response Infectious organism or by-products (endotoxins) activate the immune system (neutrophils, monocytes, macrophages) Immune system stimulates release or activation of inflammatory mediators (cytokines) that perpetuate the inflammatory response Cytokines produce vasodilation and damage to endothelium of blood vessels, causing increased capillary permeability Cytokines activate the coagulation cascade and may trigger DIC Specific inflammatory mediators impair cardiac contractility and cause myocardial dysfunction (American Heart Association, 2016) 8 Definitions Pediatric severe sepsis Sepsis with the development of CV dysfunction or ARDS or organ dysfunction in at least 2 systems (renal, hematologic, neurologic, hepatic, respiratory) 9 3

4 10 Definitions Pediatric septic shock Sepsis with CV dysfunction manifesting as alterations in HR (tachycardia or bradycardia) and signs of impaired perfusion 11 Risk Factors Associated with increased mortality Prematurity Congenital heart disease Solid and hematopoietic cancers Immune deficiencies 12 4

Risk Factors: Infants and Children Infants Children Comorbid conditions: Congenital heart disease, chronic lung disease Present with primary bacteremia Comorbid conditions: Cancer and neuromuscular

when SV decreases Hypotension a late and ominous sign 14 More About Hypotension in Kids Age Systolic Blood Pressure (mmhg) Term neonates (0 to 28 days) At least 60 Infants (1 to 12 months) At least

5 Risk Factors: Infants and Children Infants Children Comorbid conditions: Congenital heart disease, chronic lung disease Present with primary bacteremia Comorbid conditions: Cancer and neuromuscular disease Present with respiratory infection and secondary bacteremia 13 Presentation Rely on increased HR to increase CO Cold shock much more common in children as they vasoconstrict to maintain BP when SV decreases Hypotension a late and ominous sign 14 More About Hypotension in Kids Age Systolic Blood Pressure (mmhg) Term neonates (0 to 28 days) At least 60 Infants (1 to 12 months) At least 70 Children 2 to 9 years At least 70 + (2 x age in years) Children 10 years and older At least 90 Recognizing sepsis and initiating definitive treatment before the development of hypotension is key to decreasing mortality associated with pediatric sepsis 15 5

6 Presentation Fussy Sleepy Irritable Lethargic Not feeding well Just not looking right Skin can be pale, cyanotic, mottled, petechiae, purpura Vomiting Diarrhea Chills Respiratory distress Apnea Poor tone Altered mental status Oliguria Shock 16 Differential Diagnoses Cardiopulmonary disease Pneumonia, heart failure, pericarditis, myocarditis, pulmonary embolus Metabolic disorders Adrenal insufficiency, diabetes mellitus, inborn errors of metabolism Gastrointestinal Gastroenteritis, peritonitis, hemorrhage, intussusception, volvulus 17 Differential Diagnoses Hematologic disease Anemia, splenic sequestration, proliferative malignancies Neurologic disorders Spontaneous and traumatic bleeds, intoxication, infant botulism Toxic ingestion Clonidine, beta blockers Anaphylaxis Child abuse/neglect 18 6

Food for Thought Even the most seasoned pediatrician could agree that one of the hardest parts of managing pediatric severe sepsis and septic shock is early recognition (Prusakowski & Chen, 2016, p.

7 Food for Thought Even the most seasoned pediatrician could agree that one of the hardest parts of managing pediatric severe sepsis and septic shock is early recognition (Prusakowski & Chen, 2016, p. 131) 19 Key Takeaway Classic presentations of pyrexia, vasodilatation, and tachycardia are often seen with benign viral syndromes; however, when combined with signs of poor perfusion, sepsis should be considered (Prusakowski & Chen, 2016, p. 131) 20 Evaluation Source identification Cultures Laboratory studies Imaging as appropriate Inflammatory markers less studied and supported than in adult sepsis Emerging evidence supports the use of procalcitonin over c-reactive protein for diagnosing serious bacterial infections (Gomez et al., 2013; Lopez et al., 2003) 21 7

Septic Shock Primary goals in the initial management of septic shock: Restoration of hemodynamic stability Support of organ function Identification and control of infection Management Increase tissue

8 Septic Shock Primary goals in the initial management of septic shock: Restoration of hemodynamic stability Support of organ function Identification and control of infection Management Increase tissue oxygen delivery by optimizing cardiac output and arterial oxygen content while minimizing oxygen consumption (American Heart Association, 2016) 22 Initial Stabilization: Within One Hour Monitor and support ABCs Order/establish vascular access Order/obtain blood cultures, chemistries, CBC with diff and platelets Order/administer fluid bolus(es) 20 ml/kg Order/administer antipyretics if needed Order/administer antibiotics 23 What to Choose for Antibiotic Coverage? Age Organism Regimen 0-1 month Group B strep E coli Listeria Viral (e.g., herpes simplex) Coag-negative staph---nosocomial Gram negative bacteria (e.g., pseudomonas, enterobacter) 1-3 months Neonatal pathogens (see above) Haemophilus influenzae type B Neisseria meningitidis Strep pneumoniae 3 months-12 years H. influenzae type B N. meningitidis S. pneumoniae 13 years and older N. meningitidis S. pneumoniae Amp + gent -OR- Amp + cefotaxime Amp + cefotaxime/ceftriaxone Ceftriaxone + vancomycin Ceftriaxone + vancomycin (Ohler, 2012) 24 8

9 What Else Can Help Identify Children at Risk? 25 Epidemiology of Sepsis 2016 article by Novosad and colleagues appeared in Morbidity and Mortality Weekly Report CDC partnered with NYSDOH to perform medical chart reviews to describe clinical characteristics of pediatric patients diagnosed with sepsis 26 Epidemiology of Sepsis: Novosad et al. (2016) Inclusion criteria 4 acute care hospitals in NYS participated Pediatric patients <18 yo admitted 10/1/2012 9/30/2013 Diagnosed with severe sepsis or septic shock Methods Timing of first sepsis documentation used as proxy for sepsis onset Classified as community-associated/onset if documentation of sepsis occurred at time of admission or within 3 days of admission as long as there were no health care factors present Classified as healthcare-associated if documentation occurred within 3 days of admission with health care factors present, or 4 days post-admission 27 9

10 Epidemiology of Sepsis: Novosad et al. (2016) Results 79 pediatric cases reviewed 31 infants aged <1 year (39%) 48 children aged 1-17 years (61%) At least one comorbidity present for 62 patients (78%) Among infants: congenital heart disease most common (23%) Among children: cognitive deficits or cerebral palsy (38%) 45 patients (57%) were community-associated sepsis cases without known healthcare factors (such as recent IV antibiotic administration) 28 Epidemiology of Sepsis: Novosad et al. (2016) Most Common Sites of Infection Type of Infection <1 Year of Age (n = 31) 1-17 Years of Age (n = 48) Respiratory tract 9 (29%) 14 (29%) Gastrointestinal 8 (26%) 11 (23%) Bloodstream 8 (26%) 6 (13%) Source unknown 6 (19%) 8 (17%) 29 Causes of Death in Pediatric Patients Diagnosed with Severe Sepsis/Septic Shock 2017 article appeared in Pediatric Critical Care Medicine Children s Hospital of Philadelphia and Nationwide Children s Hospital conducted a retrospective analysis of pediatric patients treated for severe sepsis/septic shock to determine causes of death (Weiss et al., 2017) 30 10

11 Causes of Death in Pediatric Patients Diagnosed with Severe Sepsis/Septic Shock Inclusion criteria Patients who died 1/1/ /31/2013 <18 years old Diagnosed with severe sepsis or septic shock Treated in ED or PICU Died before hospital discharge Methods Timing of death calculated as # of calendar days from hospital admission (those who dies on the day of admission assigned 1 day) (Weiss et al., 2017) 31 Causes of Death in Pediatric Patients Diagnosed with Severe Sepsis/Septic Shock Results 79 pediatric cases reviewed 52 deaths (66%) were directly attributed to the acute sepsis event (Weiss et al., 2017) 32 Causes of Death in Pediatric Patients Diagnosed with Severe Sepsis/Septic Shock Days Since Sepsis Recognition Category Days 0-1 Days 2-3 Days 4-7 >7 Days Total, n (%) Refractory shock (34) MODS (27) Neurologic injury Respiratory failure Other due to sepsis Not due to sepsis (19) (9) (5) (6) (Weiss et al., 2017) 33 11

12 Future Considerations 34 What s the Latest from the AAP? Still trying to determine when to watch and wait in febrile infants New guideline coming out this year stratifying infants into 7-28 days, days, days diagnostic groups Include role for inflammatory markers Allow for a kinder, more gentler approach Should not be used as a substitute for clinical judgment 35 What s the Latest from the AAP? Project REVISE (Reducing Excessive Variability in Infant Sepsis Evaluation) National AAP QI collaborative with 133 participating hospitals Project Aim Provide multi-disciplinary teams with quality improvement education and tools specific to management of children with fever to increase compliance with the evidence-based research and thereby decrease overuse of non-evidence-based therapies and tests

Project REVISE 37 On the National Front: Sepsis Alliance Sepsis Alliance is a charitable organization run by a team of dedicated laypeople and healthcare professionals who share a strong commitment

13 Project REVISE 37 On the National Front: Sepsis Alliance Sepsis Alliance is a charitable organization run by a team of dedicated laypeople and healthcare professionals who share a strong commitment to battling sepsis. The organization was founded in 2007, by Dr. Carl Flatley, whose daughter Erin died of sepsis when she was 23 years old. Sepsis Alliance was created to raise sepsis awareness among both the general public and healthcare professionals. 38 On the National Front: Children s Hospital Association Represents 220 children s hospitals Improving Pediatric Sepsis Outcomes (IPSO) aims to reduce sepsis mortality by 75 percent and reduce hospital-onset severe sepsis by 75 percent. IPSO is addressing all stages of sepsis across the care continuum, including the emergency department, intensive care, general care, hematology/oncology and bone marrow transplant units initially, and NICU, pre-hospital, and ambulatory settings in subsequent phases

Video Case Studies 40 Questions? Thank you very much for your time! I can be reached at julie.gottfried@rochesterregional.org 41 References American Heart Association. (2016).

Diagnostic value of procalcitronin in well-appearing young febrile infants. Pediatrics, 130, 815-822. doi: 10.1542/peds.2011-3575 Lopez, A. F., Cubells, C. L., Garcia, J. J., Pou, J. F., and the Spanish Society of Pediatric Emergencies.

14 Video Case Studies 40 Questions? Thank you very much for your time! I can be reached at julie.gottfried@rochesterregional.org 41 References American Heart Association. (2016). Pediatric Advanced Life Support: Provider manual. Unites States: American Heart Association. Gomez, B., Bressan, S., Mintegi, S., Da Dalt, L., Blazquez, D., Olaciregui, I., Ruano, A. (2012). Diagnostic value of procalcitronin in well-appearing young febrile infants. Pediatrics, 130, doi: /peds Lopez, A. F., Cubells, C. L., Garcia, J. J., Pou, J. F., and the Spanish Society of Pediatric Emergencies. (2003). Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: Results of a multicenter study and utility of a rapid qualitative test for this marker. The Pediatric Infectious Disease Journal, 22, doi: /01.inf Novosad, S. A., Sapiano, M. R., Grigg, C., Lake, J., Robyn, M., Dumyati, G., Epstein, L. (2016). Vital signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention. Morbidity and Mortality Weekly Report, 65, doi: /mmwr.mm6533e

15 References Ohler, K. H. (2012). Pediatrics. In ACCP Updates in Therapeutics 2012: The Pharmacotherapy Preparatory Review and Recertification Course. Prusakowski, M. K., & Chen, A. P. (2016). Pediatric sepsis. Emergency Medicine Clinics of North America, 35, doi: /j.emc Weiss, S. L., Balamuth, F., Hensley, J., Fitzgerald, J. C., Bush, J., Nadkarni, V. M., Muszynski, J. (2017). The epidemiology of hospital death following pediatric severe sepsis: When, why, and how children with sepsis die. Pediatric Critical Care Medicine [Epub ahead of print]. doi: /pcc

Staging Sepsis for the Emergency Department: Physician

Staging Sepsis for the Emergency Department: Physician Sepsis Continuum 1 Sepsis Continuum SIRS = 2 or more clinical criteria, resulting in Systemic Inflammatory Response Syndrome Sepsis = SIRS + proven/suspected