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2/12/2018 From Evidence-Based Medicine to Evidence-Based Care HALDEN F. SCOTT, MD Sepsis Treatment and Recognition Program Children’s Hospital Colorado Associate Professor of Pediatrics and Emergency Medicine University of Colorado School of Medicine This activity is jointly-provided by SynAptiv and the Colorado Hospital Association Conflict of Interest Dis isclosure Statement • I have no financial interest or other relationships with the industry relative to the topics being discussed. 1

2/12/2018 A Child Arrives in Triage . . . • 4 year old – language barrier • Won’t drink and has a fever • Previously healthy • Seen 14 days prior with febrile illness: treated with oseltamivir (sibling +Flu A) • Recovered, was back at school • Now 4 days of new fever, worsening cough • No urine output in 12 hours Triage Exam • T=100 HR:132 RR:30 SpO2: 86% • Moaning and grabbing abdomen • Refuses to walk – carried to stretcher Triage Exam • T=100 HR:132 RR:30 SpO2: 86% • Moaning and grabbing abdomen • Refuses to walk – carried to stretcher What do you notice? What do you do? 2

2/12/2018 Pop Quiz! What would you do next? 1. Give acetaminophen 2. Provide supplies for oral rehydration 3. Obtain a full set of vital signs 4. Place oxygen Pop Quiz! The ED is pretty full. Where would you put this patient? T=100 HR:132 RR:30 SpO2: 89% 1. A resuscitation/trauma room 2. A regular ED room (telling attending about patient) 3. A regular ED room (no notification) 4. Back to the waiting room (frequent rechecks) Brought Back to a Regular Room • Placed on 2L nasal cannula • HR to 160s • Acetaminophen • ORT teaching • Chest x-ray shows pneumonia • Amoxicillin ordered 3

2/12/2018 Two Hours Later • Did not take ORT. Threw up amoxicillin. • O2 had been turned up to 4-5L NC • Sleepy, HR 160s, RR 60-70 • Extremities cool, weak pulses • Cannot obtain access • Antibiotics ordered Uh Uh-Oh Oh • Moved to a front room, higher-level attending • IV, fluids started • Hypotensive, dopamine started • Gas: 7.02/67 Uh Uh-Oh Oh • Moved to a front room, higher-level attending • IV, fluids started • Hypotensive, dopamine started • Gas: 7.02/67 • Ketamine, versed - Intubation • Desaturation – bradycardia - asystole • CPR x 8 minutes, pulmonary hemorrhage at time of intubation 4

2/12/2018 Case • ECMO team called • Ceftriaxone 1 hour post-arrest • Vancomycin 1 hour post-arrest • Oseltamivir the next morning Case • ECMO team called • Ceftriaxone 1 hour post-arrest • Vancomycin 1 hour post-arrest • Oseltamivir the next morning • Group A Strep grew from pulmonary fluid • +Influenza What do you notice about this case? • What were the warning signs? • What were the reassuring signs? • What steps could have been better? 5

2/12/2018 Audience Poll Could this patient have a similar first several hours of care at your institution? 1. Yes 2. I would like to think no, but maybe… yes 3. No What Do You Notice About This Case? • Initial vitals not that bad • Exam findings may be subtle • Warning signs: o Return of fever after initial febrile prodrome o Urine output o Can’t get a blood pressure easily • No focus on blood pressure, early access, IV fluid, antibiotics in the treatment plan until too late Objectives 1. Review formal pediatric sepsis definitions and formulate a working definition that facilitates clinical recognition. 2. Understand current guidelines and landmark studies for critical elements of pediatric sepsis care: • Diagnosis • Fluid Resuscitation • Protocolized Treatment 3. Identify practical approaches to improving pediatric sepsis outcomes in your patients. 6

2/12/2018 Objectives 1. Review formal pediatric sepsis definitions and formulate a working definition that facilitates clinical recognition. 2. Understand current guidelines and landmark studies for critical elements of pediatric sepsis care: • Diagnosis • Fluid Resuscitation • Protocolized Treatment 3. Identify practical approaches to improving pediatric sepsis outcomes in your patients. Pop Quiz! What is sepsis? 1. Systemic Inflammatory Response Syndrome (SIRS) + Infection 2. Life-threatening organ dysfunction caused by a dysregulated host response to infection 3. I know it when I see it 4. qSOFA >= 2 Pediatric Definitions: SIRS Systemic Inflammatory Response Syndrome (2/4, 1 must be temp or wbc ): • Core Temp > 38.5°C or <36°C • Tachycardia / Bradycardia if <1 y/o • Tachypnea • WBC elevated or depressed Goldstein PCCM 2005 7

2/12/2018 Pediatric Definitions • Infection o Suspected or proven infection caused by any pathogen OR a clinical syndrome w/probability of infection • Sepsis o SIRS in the presence of infection • Severe Sepsis o Sepsis + CV dysfunction OR ARDS OR ≥ 2 other organ dysfunction • Septic Shock o Sepsis and CV organ dysfunction (hypotension, pressors or elevated lactate) Goldstein PCCM 2005 Pediatric Definitions • Infection o Suspected or proven infection caused by any pathogen OR a clinical syndrome w/probability of infection • Sepsis o SIRS in the presence of infection • Severe Sepsis o Sepsis + CV dysfunction OR ARDS OR ≥ 2 other organ dysfunction • Septic Shock o Sepsis and CV organ dysfunction (hypotension, pressors or elevated lactate) Goldstein PCCM 2005 Weiss BMC Critical Care 2015 8

2/12/2018 What is Sepsis? • Infection + Organ Dysfunction • Lowest hanging fruit: Infection + Hypotension Age Systolic BP 0-30 days <60 mm Hg 1-12 months <70 mm Hg 1 year <72 mm Hg 2 years <74 mm Hg 3 years <76 mm Hg 4 years <78 mm Hg 5 years <80 mm Hg 6 years <82 mm Hg 7 years <84 mm Hg 8 years <86 mm Hg 9 years <88 mm Hg 10 years and older <90 mm Hg What is Sepsis? • Many competing, evolving definitions • Pick a case definition for quality work o Goldstein 2005 o pSOFA o Children’s Hospital Association Improving Pediatric Sepsis Outcomes collaborative o Centers for Medicare Services • Develop a useful clinical definition Children’s Hospital Colorado: ED ED/UC Cl Clinical Cr Criteria 9

2/12/2018 Objectives 1. Review formal pediatric sepsis definitions and formulate a working definition that facilitates clinical recognition. 2. Understand current guidelines and landmark studies for critical elements of pediatric sepsis care: • Diagnosis • Fluid Resuscitation • Protocolized Treatment 3. Identify practical approaches to improving pediatric sepsis outcomes in your patients. Brierley CCM 2009 Capillary Refill Time 10

2/12/2018 Mortality Referred for Transport to Pediatric ICU Carcillo Pediatrics 2009 Physical Exam for Detection Inclusion: ED, SIRS, receiving IV Outcome: Organ dysfunction within 24 hours Scott BMC Emer Med 2014 Physical Exam for Detection Inclusion: ED, SIRS, receiving IV Outcome: Organ dysfunction within 24 hours Scott BMC Emer Med 2014 11

2/12/2018 Physical Exam for Detection • Capillary refill time, peripheral pulse quality, mottled extremities o Useful in patients already identified as critically ill/septic o Less useful for triage • Altered mental status o Better than the other findings o 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) 1. 20% 2. 40% 3. 60% 4. 80% 12

2/12/2018 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 13

2/12/2018 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 22% SIRS No SIRS 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? • Of course they help • Not the only answer 14

2/12/2018 Diagnosis of Pediatric Sepsis: ED Experiences Features of Tool Sensitivity Reference Texas Children’s Electronic 92% Cruz Pediatric Comorbid condition + Emergency Care 2012 fever/tachycardia The Children’s Electronic / AAP-based 94% Balamuth Annals of Hospital of Staged, huddle process Emergency Medicine Philadelphia 2017 Primary Children’s Paper triage screen / Lane Pediatrics 2017 81% (Salt Lake) AAP-based, huddle Children’s Hospital Clinical diagnosis, not a Tertiary ED: 94% Scott JPes 2018 (in Colorado screening tool Network sites: press) 76% Two Critical Diagnostic Elements • Hypotension • Lactate 15

2/12/2018 Lactate in Adult Sepsis 239 Children in in the ED w/Systemic Inflammatory Response Syndrome 25 Risk of Organ Failure Percentage with Organ Dysfunction 5 Times Higher 20 RR= 5.5 [1.9-16.0] 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 16