Nursing Education Session

9 yo previously healthy boy chills, belly pain, emesis x 1. brought to ED for chills, belly pain, emesis x 1. Triage assessment: Temp: 38.2 ° C HR: 137 bpm RR: 20 bpm BP: 118/65 Alert, mild distress, but abdomen soft. Triaged as “Urgent” and placed in room Given Tylenol

Patient Course 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A 38.5 Resuscitation not successful HR 137 140 145 RR 20 22 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure

Patient Course 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A 38.5 Resuscitation not successful HR 137 145 140 RR 20 34 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure

Patient Course 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A 38.5 Resuscitation not successful HR 137 145 140 RR 20 34 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure

Patient Course 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A Petechiae present 38.5 Resuscitation not successful HR 137 145 140 RR 20 34 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure

Patient Course 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A Petechiae present 38.5 Resuscitation not successful HR 137 145 140 RR 20 34 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure

Patient Course 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A Petechiae present 38.5 Resuscitation not successful HR 137 145 140 RR 20 34 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure

Goal is to identify patients early 19:57 22:25 23:11 2:00 3:00 3:30 Triage Bedside RN eval. MD eval. Repeat evaluation PICU admit Cardiac arrest Temp 38.2 39.9 Ddx: Viral gastro, UTI, PNA, appy, strep -PO challenge -Rapid strep -U/A Petechiae present 38.5 Resuscitation not successful HR 137 145 140 RR 20 34 30 Vent. BP 118/65 117/60 81/48 75/35 Interventions: IV placed NS bolus x 2 Ceftriaxone Dopamine Intubated for respiratory failure The goal is to identify patients early to prevent this outcome

Goals Define the sepsis disease spectrum SIRS, sepsis, septic shock and severe sepsis Review evidenced based guidelines for the management of severe sepsis/septic shock Use the triage trigger tool Know and be able to perform critical interventions Access, fluids, antibiotics, pressors By the end of this session, you should be able to define the sepsis disease spectrum, understand the EB guidelines for management of severe sepsis/septic shock, be able to use the triage trigger tool, and know and be able to perform critical interventions.

Pediatric Epidemiology Sepsis is a leading cause of illness and death among U.S. children Severe sepsis affects >42,000 children in the U.S. annually Mortality 97% in the 1960’s 60% in the 1980’s 5-10% since 1999 overall mortality (highest in infants and children with chronic medical conditions) 7-9 % of all childhood deaths are due to sepsis Pediatric sepsis accounts for approximately 42,000 cases annually and is the leading cause of illness and death among children in the US, behind asthma, appendicitis, and poisonings. Overall mortality ranges from 5-10%, with increased mortality in children with underlying medical conditions. 7 to 9% of all childhood deaths are due to sepsis—it is more common than death from cancer. Watson Am J Respir Crit Care Med 2003 167:695-701 Kutko Pediatr Crit Care Med 2003; 4:333-337 Carcillo Crit Care Med 2002 30(6):1365-1378

Septic shock is diagnosed clinically from physical exam, vital signs, and history There is no gold standard “test” to confirm sepsis or septic shock. Sepsis and septic shock are diagnosed clinically from physical exam, vital signs and pertinent history (similar to anaphylaxis). Laboratory data and imaging can be supportive. Decreased perfusion decreased oxygen delivery anaerobic metabolism, cell death

Sepsis Disease Spectrum SIRS Sepsis Severe Sepsis Septic Shock Presentation of sepsis reflects a spectrum It is important to realize that the presentation of sepsis is a disease continuum—from SIRS to Sepsis, Severe Sepsis, and finally septic shock. Let’s review some definitions.

Systemic Inflammatory Response Syndrome (SIRS) A clinical response to a nonspecific insult Systemic Inflammatory Response Syndrome

What Can Cause SIRS? Massive tissue injury or ischemia Burns Inflammatory diseases Infection Neoplasms Multiple transfusions Pancreatitis There are many conditions that can cause SIRS

SIRS is Nonspecific Bone RC, Balk RA, Cerra FB, et al. (Jun 1992). "Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine". Chest 101 (6): 1644–55.

Pediatric SIRS Criteria Modified SIRS Criteria: must have 2 of 4 criteria, 1 must be temperature or leukocyte abnormality Temperature (core)* <36 °C or >38.5 °C Tachycardia: HR >2 SD above normal for age or bradycardia if <1 year old* Respiratory: Mean RR > 2 SD above normal for age or mechanical ventilation required for an acute process* Elevated or depressed WBC for age (unrelated to chemotherapy induced leukopenia) or >10% immature neutrophils Temperature: recommended a core temperature measured via rectal, bladder, oral or central catheter probe Tachycardia: defined as a mean heart rate >2 SD above normal for age in the absence of external stimulus, chronic drugs, or painful stimuli; or otherwise unexplained persistent elevation over a 0.5- to 4-hr time period OR for children <1 yr old: bradycardia, defined as a mean heart rate <10th percentile for age in the absence of external vagal stimulus, beta-blocker drugs, or congenital heart disease; or otherwise unexplained persistent depression over a 0.5-hr time period. Respiratory: mechanical ventilation unrelated to underlying neuromuscular disease or the receipt of general anesthesia Goldstein Pediatr Crit Care Med 2005 6(1):2-8

Pediatric Sepsis Defined Sepsis: SIRS in the presence of or as a result of suspected or proven infection Infection: A suspected or proven infection caused by any pathogen OR a clinical syndrome associated with a high probability of infection Proven= by positive culture, tissue stain, or polymerase chain reaction test. “Evidence of infection includes positive findings on clinical exam, imaging, or laboratory tests (e.g. white blood cells in a normally sterile body fluid, perforated viscus, chest radiograph consistent with pneumonia, petechial or purpuric rash, or purpura fulminans).” Goldstein Pediatr Crit Care Med 2005 6(1):2-8

Pediatric Definitions Severe Sepsis: Sepsis + 1 of the following: cardiovascular organ dysfunction OR acute respiratory distress syndrome OR two or more other organ dysfunctions* Septic shock: Sepsis & cardiovascular organ dysfunction* From Brierley Table 2. (American College of Critical Care Medicine hemodynamic definitions of shock) Cold or warm shock Decreased perfusion manifested by altered decreased mental status, capillary refill > 2 secs (cold shock) or flash capillary refill (warm shock), diminished (cold shock) or bounding (warm shock) peripheral pulses, mottled cool extremities (cold shock), or decreased urine output 1 mL/kg/h Goldstein Definitions: Table 4. Organ dysfunction criteria Cardiovascular dysfunction Despite administration of isotonic intravenous fluid bolus 40 mL/kg in 1 hr ● Decrease in BP (hypotension) 5th percentile for age or systolic BP 2 SD below normal for age OR ● Need for vasoactive drug to maintain BP in normal range (dopamine 5 g/kg/min or dobutamine, epinephrine, or norepinephrine at any dose) ● Two of the following Unexplained metabolic acidosis: base deficit 5.0 mEq/L Increased arterial lactate 2 times upper limit of normal Oliguria: urine output 0.5 mL/kg/hr Prolonged capillary refill: 5 secs Core to peripheral temperature gap 3°C Respiratory ● PaO2/FIO2 300 in absence of cyanotic heart disease or preexisting lung disease ● PaCO2 65 torr or 20 mm Hg over baseline PaCO2 ● Proven needc or 50% FIO2 to maintain saturation 92% ● Need for nonelective invasive or noninvasive mechanical ventilationd Neurologic ● Glasgow Coma Score 11 (57) ● Acute change in mental status with a decrease in Glasgow Coma Score 3 points from abnormal baseline Hematologic ● Platelet count 80,000/mm3 or a decline of 50% in platelet count from highest value recorded over the past 3 days (for chronic hematology/oncology patients) ● International normalized ratio 2 Renal ● Serum creatinine 2 times upper limit of normal for age or 2-fold increase in baseline creatinine Hepatic ● Total bilirubin 4 mg/dL (not applicable for newborn) ● ALT 2 times upper limit of normal for age a See Table 2; b acute respiratory distress syndrome must include a PaO2/FIO2 ratio 200 mm Hg, bilateral infiltrates, acute onset, and no evidence of left heart failure (Refs. 58 and 59). Acute lung injury is defined identically except the PaO2/FIO2 ratio must be 300 mm Hg; cproven need assumes oxygen requirement was tested by decreasing flow with subsequent increase in flow if required; din postoperative patients, this requirement can be met if the patient has developed an acute inflammatory or infectious process in the lungs that prevents him or her from being extubated. Brierley Crit Care Med 2009 37(2):666-688 Goldstein Pediatr Crit Care Med 2005 6(1):2-8 Dellinger Crit Care Med 2013 41(2):580-637

Signs of Cardiovascular Dysfunction in Pediatric Septic Shock Altered or decreased mental status Inconsolable irritability, lack of interaction with parents and inability to be aroused, etc. Abnormal capillary refill Delayed > 2 seconds Flash capillary refill Abnormal Pulses Diminished pulses, differential between peripheral and central Bounding peripheral pulses Mottled cool extremities Decreased urine output <1 mL/kg/hr Hypotension Septic shock is defined as condition associated with hypothermia or hyperthermia, along with signs of cardiovascular organ dysfunction. Associated signs and symptoms include altered mental status, delayed capillary refill or flash refill, diminished or bounding peripheral pulses, mottled extremities, and decreased urine output. Carcillo Crit Care Med 2002 30(6):1365-1378 Brierley Crit Care Med 2009 37(2):666-688

Pediatric Definitions xxx00.#####.ppt 6/16/2018 Pediatric Definitions Compensated septic shock: Sepsis and signs/symptoms of inadequate perfusion with systolic blood pressure within normal range for age Most common presentation of septic shock in children Decompensated shock: Sepsis and signs/ symptoms of inadequate perfusion associated with systolic hypotension 2010 PALS Definitions (Circulation. 2010;122:S876-S908 page 3): Shock results from inadequate blood flow and oxygen delivery to meet tissue metabolic demands. Compensatory mechanisms include tachycardia and increased systemic vascular resistance (vasoconstriction) in an effort to maintain cardiac output and perfusion pressure respectively. Decompensation occurs when compensatory mechanisms fail and results in hypotensive shock.

Goal is to recognize and treat early in continuum. SIRS Sepsis Severe Sepsis Septic Shock Goal is to recognize and treat early in continuum. .

In order to help recognize patients as early as possible, this triage tool was developed. This tool is designed to be used in triage. We are going to go through some cases to practice using this. (MODIFY TO INCLUDE HOW IT WILL BE USED AT YOUR SITE)

9 yo with ALL brought by ambulance Appearance: difficult to arouse Temp: 40°C HR: 155 bpm Resp: 32 bpm BP: 70/32 Perfusion: thready

This child is in decompensated septic shock. Transfer immediately to resuscitation and notify MD. For this patient, we didn’t really need to use the triage tool – the patient is critically ill so needs to be moved to the resuscitation bay and the team needs to be notified immediately.

15 mo previously healthy girl Temp: 39.2 ° C HR: 195 bpm Resp: 38 bpm BP: 85/50 Mental status: alert, fussy Does she meet triage trigger tool criteria? This next patient is brought in by her Mom by car to the ED for fever for 2 days. On triage assessment she has the following VS: (see slide). Does she meet triage trigger tool criteria?

Let’s look at the trigger tool in more detail Let’s look at the trigger tool in more detail. To trigger the tool, the patient needs to have 3 or more of the 8 clinical criteria. Or, if it is a high-risk patient they need to meet 2 or more of the 8 clinical criteria.

Table 1. High Risk Conditions Malignancy Asplenia (including SCD) Bone marrow transplant Central or indwelling line/catheter Solid organ transplant Severe MR/CP Immunodeficiency, immunocompromise, or immunosuppression Does she have a high risk condition? No.

Let’s compare her VS to the VS for the 1-2 year olds Let’s compare her VS to the VS for the 1-2 year olds. Her HR of 195 is abnormal and temperature is abnormal. The remaining VS do not meet criteria.

Does she have any of these alterations in her exam? No.

15 mo previously healthy girl Temp: 39.2 ° C HR: 195 bpm Resp: 38 bpm BP: 85/50 Mental status: alert, fussy This patient does not meet clinical criteria. This patient does not meet criteria. She only has 2 of the clinical criteria (temperature and heart rate). She can be triaged as usual.

2 yo boy with sickle cell disease General: alert, but tired appearing Temp: 38.9° C HR: 150 bpm Resp: 45 bpm BP: 88/55 Does he meet trigger tool criteria? This is a 2 year old boy with sickle cell disease coming in with fever for 1 day and URI symptoms. Here is his initial triage assessment. Does he meet trigger criteria?

To trigger the tool, the patient needs to have 3 or more of the 8 clinical criteria. Or, if it is a high-risk patient they need to meet 2 or more of the 8 clinical criteria.

Table 1. High Risk Conditions Malignancy Asplenia (including SCD) Bone marrow transplant Central or indwelling line/catheter Solid organ transplant Severe MR/CP Immunodeficiency, immunocompromise, or immunosuppression He has sickle cell which is a high risk condition. Therefore, he only needs to meet 2 other criteria.

His heart rate, respiratory rate, and temperature all meet criteria.

He does not appear to have any of these abnormalities.

1 high risk condition + ≥ 2 clinical criteria Identify the patient as meeting septic shock triage criteria, transfer to a room immediately and alert physician

6 yo previously healthy boy Temp: 39° C HR: 155 bpm Resp: 28 BP: 88/55 Skin: mottled Cap refill: > 3 seconds Does he meet criteria to trigger the triage tool? The next patient is a previously healthy 6 year old boy brought in from home by parents with fever x 3 days.

To trigger the tool, the patient needs to have 3 or more of the 8 clinical criteria. Or, if it is a high-risk patient they need to meet 2 or more of the 8 clinical criteria.

Table 1. High Risk Conditions Malignancy Asplenia (including SCD) Bone marrow transplant Central or indwelling line/catheter Solid organ transplant Severe MR/CP Immunodeficiency, immunocompromise, or immunosuppression He does not have any high risk conditions.

His heart rate (155) and temperature meet criteria (39) His heart rate (155) and temperature meet criteria (39). However, that is only 2 criteria.

He does have central capillary refill of > 3 seconds and skin is mottled.

≥ 3 clinical criteria Identify the patient as meeting septic shock triage criteria, transfer to a room immediately and alert physician

OR Activate Septic Shock Pathway After quickly evaluating the patient, if the doctor’s assessment concurs with triage the septic shock protocol should be initiated. If the doctor’s assessment does not agree with the triage assessment then regular triage and care can be continued. However, it is important to monitor the patient to make sure they do not evolve.

Escalate Care Rapidly. Once the septic shock protocol is initiated, the primary goal is to escalate care and initiate interventions rapidly.

Early Goal Directed Therapy Decreases Mortality in Children N=91, 29% overall mortality % Mortality The reason that fluids is emphasized so early on is that there are studies showing that EGDT decreases mortality in children. This study showed that Early Reversal of Pediatric-Neonatal Septic Shock by Community Physicians Is Associated With Improved Outcome. 92-96% survival with shock reversal; 62-63% survival with persistent shock Shock reversal associated with 6-9 fold increase in odds of survival Only 45% all pts but just 25% pts with persistent shock received approp fluid (ave 23 cc/kg total); only 4% received PALS compliant therapy: SHOCK REVERSAL in 1 HOUR!!! Use of MV, and vasoactive gtts, doubled in pts with persistent shock Ave time of transport team arrival: 75 min 26% pts had shock reversal by time of transport team arrival Resuscitation consistent with the new ACCM-PALS Guidelines resulted in 92% survival versus 62% survival among patients who did not receive resuscitation consistent with the new ACCM-PALS Guidelines. *P < .001 versus shock reversed Resuscitation following ACCM-PALS Guidelines Han Pediatrics 2003 112:793-9

Early Rapid Fluid Resuscitation in Pediatric Septic Shock is Associated with Improved Outcomes Time-sensitive Fluid-sensitive % Mortality In addition, the guidelines call for early and aggressive fluid resuscitation. It has been shown that mortality is both fluid-sensitive, where mortality increases with decreased amount of fluids given. And is time sensitive, where mortality increases with delays to fluid administration. Oliveira Ped Emergency Care 24:2008

Early Antibiotic Administration Saves Lives In adults, it has been shown that each hour of delay to receiving effective antibiotics was associated with an almost 8% decrease in survival. Every hour delay in receiving effective antibiotics is associated with a 7.6% decrease in survival in adults with septic shock Kumar Crit Care Med 34:2006

With that evidence in mind –let’s review the clinical pathway.

Recognize abnormal vital signs and altered mental status and perfusion 0 – minute mark The first step is to recognize abnormal vital signs and altered mental status and/or perfusion. This is when the clock starts.

Recognize abnormal vital signs and altered mental status and perfusion It is important to remember that patients may evolve in the ED. Some patients may be recognized in triage – others may either evolve while in the department. (ANIMATED)

Place all Children on Oxygen All children should be placed on Oxygen

Consider early intubation for respiratory distress

Obtain Access. Draw Labs. The most important step is to obtain access and then draw labs including a blood culture. Obtain Access. Draw Labs.

Obtain IO access if IV access not successful. If access can not be quickly obtained, IO placement should be performed. Discuss when to start trying for alternative access. (WHO DOES IO insertion AT YOUR INSTITUTION?- If nurses/paramedics consider reviewing supplies here)

20 cc/kg NS bolus within 20 minutes How can this be done? A 20 cc/kg NS bolus needs to be given within 20 minutes. How can this be done?

Administer 1st bolus of 20 mL/kg NS via 20 cc/kg NS needs to be Administer 1st bolus of 20 mL/kg NS via push-pull, rapid infuser, or pressure bag within 20 minutes

Demonstration/Practice What system do you use? What supplies do you need? Push/pull system, rapid infuser or pressure bag Have demonstration (what supplies do you need?) MODIFY THIS BASED ON YOUR SITE

Broad spectrum antibiotics in first hour! BE SURE TO MODIFY TO INCLUDE ABX AT YOUR INSTITUTION (for example – is ceftriaxone routine care?)

Frequent assessments should be performed to see how the patient is responding. After the first bolus is complete, determine if the patient has clinically improved.

Off Algorithm Manage as indicated If they have improved, the patient can be taken off the algorithm and can be managed as indicated.

Off Algorithm Manage as indicated If the patient has not improved, consider starting a 2nd IV and give a 2nd and then 3rd bolus of 20 cc/kg NS until perfusion improves or signs of fluid overload appear.

After the first 60 minutes….. After receiving 60 cc/kg, if the patient is still in shock it is called fluid refractory shock and additional mediations need to be used. These may be started earlier in the course depending on the patient’s clinical status.

Cold Shock vs. Warm Shock Cool extremities CR > 2 seconds Myocardial dysfunction Low CO and high SVR* Sick heart and vasoconstriction to maintain perfusion of vital organs Warm Shock Warm extremities Flash CR Hi CO and low SVR Hyperdynamic heart with vasodilation To choose the most appropriate medication, it is important to determine if the patient is in cold shock or warm shock if possible. Cold shock is associated with low cardiac output and high systemic vascular resistance while in warm shock there is high cardiac output and low systemic vascular resistance. Cold shock patients present with cold extremities and delayed cap refill while warm shock patients have warm extremities and flash capillary refill. Septic shock is a spectrum; clinical findings can overlap “Luke warm shock”

Medication Selection Cold Shock Warm Shock Titrate Dopamine up to 10 μg/kg/min If resistant, titrate epinephrine up to 0.05 μg/kg/min Warm Shock Titrate norepinephrine Dose range: 0.1 to 2 μg/kg/min If norepi is not available, use Dopamine For patients in cold shock, start with Dopamine and titrate up to 10. If patient is resistant to this, start epi and titrate to 0.05. For patients in warm shock, start norepinephrine if it is available. If it is not available, use Dopamine.

What if you only have a PIV? Animation for the answer What if you only have a PIV? Can any of these medications go through a PIV? All of these medications can be started through a PIV!

After the first 60 minutes….. For patients that are still in shock after fluids and after inotrope therapy, these patients are in catecholamine resistant shock. If the patient is at risk for absolute adrenal insufficiency (for prolonged steroid use or underlying HPA disease) then start hydrocortisone.

To The Best of Our Ability . . . This is Our Goal . . . . . Not this . . . . .

Although this probably seems a bit overwhelming, there are tools to help us as we are taking care of patients. Remember to look at the triage trigger tool and pathway to help guide you. Together we will help improve the care of these patients!