SEPSIS KILLS program

Paediatric Inpatients

Learning Objectives Recognise that sepsis is a medical emergency Identify the risk factors, signs and symptoms Outline the escalation of the septic patient Define the initial A-G management actions Discuss the requirements for 48 hour sepsis management including referral Apply the pathway to a case study

Paediatric Sepsis Many paediatric sepsis related deaths are preventable Sepsis is one of the leading causes of death in children Mortality rates are as high as 10%

Sepsis continuum •

Infection

Systemic Inflammatory Response Syndrome Sepsis

Increasing Mortality

Severe Sepsis Septic Shock

Sepsis recognition & management …..is there a problem in your facility?

• Sepsis program linkages with other paediatric resources

Surviving Sepsis Campaign Infuse 20ml/kg 0.9% sodium chloride bolus over no more than 10 minutes Rapid administration of antibiotic therapy BP is not a reliable target. Treatment should be titrated to clinical signs of adequate cardiac output -Heart rate in normal range -Improved capillary refill time -Improved LOC -Urine output ≥ 1ml/kg/hr Early intubation recommended

Pitfalls…….

Sepsis is a difficult diagnosis to make Often under appreciate the mortality Do not see sepsis as time critical

Sepsis is a medical emergency

You can make a difference for patients in this hospital

Sepsis Pathway aims to: Provide clear guidelines regarding sepsis notification escalation and initial management Early involvement of senior clinicians in diagnosis and management of sepsis Prompt administration of resuscitation fluids Prompt administration of antibiotics (goal is within one hour of recognition) Timely referral, clinical supervision and escalation

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Case Study

Transferred to the ward

20:09 22:00

7 year old girl Admitted via the Emergency Department with 3 day history of flu-like symptoms Preliminary diagnosis of asthma

21 RA FD 21 A FD Bloods VBG: pH 7.31; BE -5.3mmol/L Lactate 3.4mmol/L; CO 2 48mmHg

Arrive on ward Observations stable

22:00 23:10 00:42

C/O “tummy pain” Reviewed by RMO Given analgesia +  ventolin 2/24 Oral antibiotics ordered

21 22 2340          RARA RA    Sepsis pathway activated with obs in Yellow Zone and deterioration despite treatment  21 22  2340 

2 nd Clinical Review Obs in Yellow Zone and “looks tired” CO 2 Bloods 01:46 Repeat VBG pH 7. 35; 52mmHg; BE -7.1mmol/L; Lactate 5.6mmol/L;

22:00 00:42 01:30 01:46

SPO2 drop to 91% with NP O2 3 rd review by RMO Ordered IV antibiotics

21 22 2340130             RARA RA6LH     21 22 2340130     

IVAB administered Bloods 02:30 Repeat VBG pH 7.19

CO2 57mmHg; BE -7.1mmol, Lactate 6.3mmol/L 01:30 02:10 02:20 02:40 Refusing to keep Hudson mask on SPO 2 91% with NP oxygen Becomes irritable Now grunting as Hudson mask held on by RN Administered ventolin nebuliser and IV hydrocortisone

Nil improvement Paediatrician contacted 10ml/kg 0.9% sodium chloride bolus and IV ceftriaxone and fluclox

03:05 04:10 04:26

Reviewed by paediatrician Requested repeat CXR Contacts NETS requesting transfer to tertiary hospital

21 22 2340130 03                RARA RA6L 6L             

Rapid Response call made Decision to intubate NETS arrive Adrenaline infusion commenced Arrested while transferring on to equipment 04:26 05:00 06:00 Asystole CPR 07:20 2 nd arrest Significant deterioration Difficulty keeping SPO 2 >88% (NRB)

Aystole CPR 07:20 2

nd

arrest Post mortem

What is the evidence for urgent delivery of first dose antibiotics and aggressive fluid resuscitation?

Antibiotics For each hour of delay to administration of antibiotics, after the onset of hypotension, there is a 7.6% increase in mortality (in adults) Kumar Crit Care Med 2006

Time - and Fluid - Sensitive Resuscitation for Hemodynamic Support of Children in Septic Shock Oliveira et al Time-and fluid- sensitive resuscitation for haemodynamic support of children in septic shock. Pediatr Emerg Care 2008

91 children retrieved to Pittsburgh 1993-2001 for “septic shock”

“For every hour a child remains in shock their mortality rate doubles”

Points to remember Senior clinician review is crucial Beware of a lactate over 2mmol/L Not all children with sepsis will be febrile Persistent tachycardia is often consistent with sepsis For every hour a child remains in shock their mortality rate doubles Sepsis is an emergency Rapid antibiotic therapy and early aggressive fluid resuscitation improves survival

SEPSIS KILLS TIME IS LIFE

R

ecognise

R

esuscitate

R

efer