Physical Exam for Detection • Capillary refill time, peripheral pulse quality, mottled extremities – Useful in patients already identified as critically ill/septic – Less useful for triage • Altered mental status – Better than the other findings – Still misses half of severe sepsis patients
What about SIRS vital signs?
Pop Quiz! Of all children who come to the ED and end up intubated or on vasopressors within 24 hours, how many have SIRS? (excluding trauma) A) 20% B) 40% C) 60% D) 80%
SIRS for Sepsis Triage All Medical ED Visits in 2011-12 40,356 Scott Acad Emer Med 2015
SIRS for Sepsis Triage All Medical ED Visits in 2011-12 40,356 SIRS No SIRS 6,122 34,234 Scott Acad Emer Med 2015
SIRS for Sepsis Triage All Medical ED Visits in 2011-12 40,356 SIRS No SIRS 6,122 34,234 Vasopressor or Intubation Vasopressor or Intubation 23 (0.38%) 76 (0.22%) Scott Acad Emer Med 2015
SIRS for Sepsis Triage All Medical ED Visits in 2011-12 40,356 SIRS No SIRS 6,122 34,234 Vasopressor or Intubation Vasopressor or Intubation 23 (0.38%) 76 (0.22%) Scott Acad Emer Med 2015
SIRS for Sepsis Triage All Medical ED Visits in 2011-12 40,356 SIRS No SIRS 22% 6,122 34,234 Sensitive Vasopressor or Intubation Vasopressor or Intubation 23 (0.38%) 76 (0.22%) Scott Acad Emer Med 2015
So physical exam and vitals don’t help?
So physical exam and vitals don’t help? • Of course they help! • Consider others besides – Capillary Refill – Peripheral Pulses – Cold Extremities – SIRS
So physical exam and vitals don’t help? • Likely Better • Of course they help! • Hypotension • Consider others besides • Altered mental status – Capillary Refill • Urine output decreased – Peripheral Pulses • Respiratory distress/fast – Cold Extremities breathing – SIRS • Overall ‘looks sick’ • Can’t sit up or walk
“I passed out at home” • Healthy 16 yo female • Fever, muscle pain x 1 day. Tried to stand and passed up. • 39, HR 122, RR 28, BP 92/47, Pox 95%
“I passed out at home” • Healthy 16 yo female • Fever, muscle pain x 1 day. Tried to stand and passed up. • 39, HR 122, RR 28, BP 92/47, Pox 95% What do you notice? What do you do?
“I passed out at home” • IV placed, 1L bolus started • Patient tries to sit up and passes out • HR=125, BP = 85/35 • Receives more boluses • Antibiotics given • Develops rash, lips peeling, red all over
Pop Quiz! What is the most likely source of infection? A) Pneumonia B) Urinary Tract Infection C) Toxic Shock Syndrome D) Bacteremia
You ask another question… • Currently on day 7 of menstrual period, tampon use • Antibiotics given, tampon removed, good recovery • Toxic Shock Syndrome: Usually Strep or Staph – 20% source not identified – 50% related to tampon use • CDC Criteria: – >38.9°C – Hypotension – Erythroderma, desquamation – >= 3 organ systems
Diagnosis of Pediatric Sepsis: ED Experiences
Algorithmic Alert vs. Physician Judgment Algorithmic (EHR) Alert: Physician Judgment • • Fever (complaint or ≥ 38.5 or <36) Treatment pathway used • Any 3: – Temperature – Heart rate – Respiratory rate – Blood pressure – High risk condition – Capillary refill – Pulse quality – Abnormal mental status Outcome: Severe sepsis or septic shock within 24 hours Balamuth Acad EM 2015
Algorithmic Alert vs. Physician Judgment Algorithmic Alert Physician Judgment 73% sensitive 92% sensitive 99% specific 83% specific Severe Severe Severe Severe Sepsis + Sepsis - Sepsis + Sepsis - Alert + 81 3220 PJ + 64 95 Alert - 7 16,216 PJ - 24 19,341
Algorithmic Alert vs. Physician Judgment Algorithmic Alert Physician Judgment 73% sensitive 92% sensitive 99% specific 83% specific Severe Severe Severe Severe Sepsis + Sepsis - Sepsis + Sepsis - Alert + 81 3220 PJ + 64 95 Alert - 7 16,216 PJ - 24 19,341
Algorithmic Alert vs. Physician Judgment Algorithmic Alert Physician Judgment 73% sensitive 92% sensitive 99% specific 83% specific Severe Severe Severe Severe Sepsis + Sepsis - Sepsis + Sepsis - Alert + 81 3220 PJ + 64 95 Alert - 7 16,216 PJ - 24 19,341
Audience Poll Does your hospital use a sepsis screening tool for children? A) Yes – in the ED B) Yes – in inpatient C) Yes – in both ED and inpatient D) I don’t know E) No
Diagnosis: Screening/Triage Tests • Some system probably better than none • Several examples available – AAP Septic Shock Collaborative – Balamuth Acad Emerg Med 2015 – Cruz Pediatrics 2011, Ped Emerg Care 2012 – Goldstein Ped Crit Care Med 2005 • Nothing proven
Sepsis Stat Fever and/or concern for infection AND: • Tachycardia despite absence or treatment of fever & dehydration? • Immunosuppression/immuno- deficiency or central line? • Consider for clinically uncertain / borderline abnormalities in: o Mental status o Capillary refill o Peripheral pulse quality
Two Critical Diagnostic Elements • Hypotension • Lactate
Lactate in sepsis • Produced by anaerobic metabolism – Global hypoperfusion – Regional hypoperfusion – Adrenergic state – Metabolic and mitochondrial dysfunction? – Lung? • Hepatic clearance • Renal clearance
Lactate in Adult Sepsis
Lactate in Pediatric Sepsis
Brierley Crit Care Med 2009
Lactate & Organ Dysfunction in Pediatric Sepsis • Setting: ED tertiary pediatric hospital • Population: <18 years, ED, SIRS, IV placed • Intervention: – Measurement of lactate (blinded to clinicians) • Outcome: Organ dysfunction within 24 hours (Goldstein) • 239 enrolled • Routine clinical care Scott Acad EM 2012
239 Children in the ED with Systemic Inflammatory Response Syndrome Fever + Fast Heart Rate Scott Acad EM 2012
Risk of Organ Failure 5 Times Higher RR= 5.5 [1.9-16.0] 25 Percentage with Organ Dysfunction 20 15 Organ Dysfunction In ED 22% Organ Dysfunction Within 10 24 Hours 17% 5 4% 3% 0 Lactate<4 mmol/L Lactate≥4mmol/L Scott Acad Emer Med 2012
Risk of Death 2 Times Higher RR= 2.90 [1.11-7.57] 8.0% 7.0% 6.0% 5.0% Mortality 4.0% 30-Day Mortality 3-Day Mortality 3.0% 2.0% 1.0% 0.0% ≤ 36 mg/dL (4 mmol/L) >36 mg/dL (4 mmol/L) Initial Lactate Level Scott PAS 2016
Risk of Death 2 Times Higher RR= 2.90 [1.11-7.57] 8.0% 7.0% 6.0% 5.0% Mortality 4.0% 30-Day Mortality 3-Day Mortality 3.0% 2.0% 1.0% 0.0% ≤ 36 mg/dL (4 mmol/L) >36 mg/dL (4 mmol/L) Initial Lactate Level Scott PAS 2016
Risk of Death 2 Times Higher RR= 2.90 [1.11-7.57] 8.0% 7.0% 6.0% 5.0% Mortality 4.0% 30-Day Mortality 3-Day Mortality 3.0% 2.0% 1.0% 0.0% ≤ 36 mg/dL (4 mmol/L) >36 mg/dL (4 mmol/L) Initial Lactate Level Scott PAS 2016
Scott PAS 2016
Among children in the ED with clinical sepsis, across all outcomes, more severe outcomes occur more frequently in patients with higher lactate Scott PAS 2016
Definitions • Lactate Clearance Decrease by ≥10%, or <2 mmol/L if initial level <2 mmol/L • Lactate Normalization: Lactate < 2 mmol/L Scott JPeds 2015
Scott JPeds 2015
Diagnosis • Diagnosis prior to late-stage illness is ideal • Many institutions fail even AFTER hypotension or high lactate … and these are patients most likely to die • QI Teams: Check your institution’s performance in hypotensive patients • Consider use of lactate testing in your sepsis program
Objectives 1. Develop a working definition of pediatric sepsis that facilitates clinical recognition. 2. Discuss key evidence surrounding elements of pediatric sepsis care: 1. Diagnosis 2. Fluid Resuscitation 3. Protocolized Treatment 3. Develop practical approaches to improving outcomes despite incomplete “proof” of effectiveness.
Pop Quiz! What is the right amount of IV fluid to give a 15-kg child with septic shock? A) 60 mL/kg in the first 15 minutes B) 60 mL/kg in the first 60 minutes C) 40 mL/kg in the first 60 minutes D) It depends
Fluid in Pediatric Sepsis Brierley Crit Care Med 2009
• All children with septic shock with PA catheter by 6 hours • 34 patients, mean age 13.5 months 1 st Hour Fluid n Mortality Group 1 <20 ml/kg 14 57% Group 2 20-40 ml/kg 11 64% Group 3 >40 ml/kg 9 11% • ARDS (n=11), cardiogenic pulmonary edema (n=5) not associated with volume received • At time of PA placement: Hypovolemia more frequent in Groups 1&2, all hypovolemic patients died (n=8) Carcillo JAMA 1991
Paul Pediatrics 2012
Populations: Landmark Pediatric Sepsis Studies • Severe febrile illness • Maitland NEJM 2011 (Africa)
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