Advanced Pediatric Emergency Medicine Assembly. March 11 14, 2013 Lake Buena Vista, FL

Transcription

1 Advanced Pediatric Emergency Medicine Assembly Andrea T. Cruz, MD Professor of Medicine, David Geffen School of Medicine at UCLA; Vice Chair and Chief of the Division of Pediatric Emergency Medicine, Director Pediatric Emergency Medicine and EMS Fellowships Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, California; Chair, 2013 Advanced Pediatric Emergency Medicine Assembly March 11 14, 2013 Lake Buena Vista, FL Improving Performance by EDs in Care of Children in Septic Shock Improving our response to critically ill pediatric patients in septic shock through goal directed methods is vital to improving outcome. This speaker will describe several evidence-based strategies, such as a computerized triage system and implementation of a septic shock protocol, to improve performance of ED staff to pediatric patients in septic shock. Using case scenarios discuss the implementation of a computer based triage protocol and its affect on performance of ED staff to respond to patients in septic shock. Compare and contrast methods to improve response of ED staff to pediatric patients in septic shock including a septic shock and care guideline. 3/12/2013 1:15pm 2:00pm (+)No significant financial relationships to disclose

2 Syllabus: Septic Shock Course Title: Improving Performance by EDs in Care of Children in Septic Shock Speaker Information: Andrea Cruz, MD, MPH is an assistant professor of pediatrics in the sections of emergency medicine and infectious diseases at Baylor College of Medicine. She received her undergraduate degree from Harvard, her medical degree from Vanderbilt, and her MPH in epidemiology and global health from the University of Texas. Upon completion of fellowships, she joined the Baylor faculty, where she is the chief of research for pediatric emergency medicine and director of the children s tuberculosis clinic. Her research interests include tuberculosis, septic shock, rapid viral diagnostics, and global health. Brief Course Description: delineation of topics, as well as rationale for inclusion Potential obstacles to implementation of goal-directed therapy in the ED Rationale: using the steps and time frames designated in the PALS/SCCM guidelines for the management of pediatric septic shock, recognize potential barriers to obtaining these goals in the ED Strategies to optimize recognition of compensated shock Rationale: discuss ways in which high-risk patients may be prioritized and screened for septic shock using a tool whose measures depend only upon initial triage vital signs and medical comorbidities, not practitioner expertise Strategies to mobilize resources for children with septic shock Rationale: understand potential strategies for harnessing nursing, pharmacy, radiology, laboratory, and ancillary support to care for the resource-intense child with septic shock Standardizing the evaluation and management of children in septic shock Rationale: review how using quality improvement methodology and minimizing unnecessary variation in care can improve patient outcomes Course Objectives To review the epidemiology of pediatric sepsis To understand the barriers to achieving goal-directed therapy in the ED To discuss evidence-based strategies to facilitate sepsis treatment along the continuum of care Course Outline Major Topics Review of Society for Critical Care Medicine and PALS guidelines for septic shock Potential obstacles to implementation of goal-directed therapy in the ED Prioritization of high-risk patients Recognition of compensated shock

3 Use of an electronic medical record to facilitate shock recognition: the bestpractice alert Prioritization of resources for children with shock Strategies to facilitate re-assessment after interventions and hand-offs in care Standardizing diagnostic and treatment approaches Distinct hemodynamic patterns in shock Intubation and other supportive care Highlights from slide copy (attached) References Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009;37:666. Brierley J, Peters MJ. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. 2008;122:272. Cruz AT, Perry AM, Williams EA, et al. Implementation of goal-directed therapy for children with suspected sepsis in the emergency department. 2011;127:e758. Cruz AT, Williams EA, Graf JM, et al. Test characteristics of an automated age- and temperature-adjusted tachycardia alert in pediatric septic shock. Pediatr Emerg Care 2012;28:889. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: Crit Care Med 2013;41:580. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. 2003;112:793. Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest 2009;136:1237. Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. 2011;127:e1585. Oliveira CF, Nogueira de Sa FR, Oliveira DS, et al. Time- and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to implementation of the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines in a pediatric intensive care unit in a developing country. Pediatr Emerg Care 2008;24:810. Watson RS, Carcillo JA, Linde-Zwirble WT, et al. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med 2003;167:695.

4 Improving Performance by EDs in Care of Children in Septic Shock Andrea T. Cruz, MD, MPH Sections of Emergency Medicine & Infectious Diseases Department of March 12, 2013 Disclosures I have no disclosures or conflicts of interest to report Page 1 Objectives To review the epidemiology of pediatric sepsis To understand barriers to achieving goal-directed therapy in the ED To discuss evidence-based strategies to facilitate sepsis treatment along the continuum of ED care Page 2 1

5 Epidemiology of Pediatric Sepsis ~42,000 children/year Highest risk are children with indwelling vascular catheters, short gut, hematogenous malignancies, and solid organ malignancies Most common organisms vary by comorbidity: Previously healthy children: Staph aureus, pneumococcus, meningococcus Children with comorbidities: Gram-negative enterics, coagulase-negative staphylococci, S. aureus Page 3 Am J Respir Crit Care Med. 2003;167: Annual Pediatric US Hospital Admissions Disease process # of annual admissions Asthma 300,000 Appendicitis 76,000 Poisonings 48,000 Severe sepsis 42,400 Leukemia 34,000 Diabetes 27,000 Page 4 Watson RS et al, Am J Respir CCM 2003 Conditions associated with high hospital resource use Disease Cost ($) Median LOS (d) Severe sepsis 40, Infant respiratory distress syndrome 35, Spinal cord injury 25, Prematurity 24, Valvular heart disease $23,000 9 Page 5 Watson RS et al, Am J Respir CCM

6 Pediatric Septic Shock Guidelines Early aggressive fluid resuscitation (up to 60 cc/kg in the first 15 minutes) Proportionally larger quantities of fluid in children Initial volume resuscitation commonly requires cc/kg but can be as much as 200 cc/kg in the 1 st hour Reassess between boluses for signs of volume overload hepatomegaly, rales, gallops Vasoactive agents for fluid refractory shock Can be given through peripheral IV until central access is obtained Initiate dopamine for fluid-refractory shock Initiate norepinephrine (warm shock) or epinephrine (cold shock) for fluid-dopamine-refractory shock Remember short half life therefore rapid titrations are needed Hydrocortisone for adrenal insufficiency Identify need for invasive cardiovascular monitoring for fluid-refractory shock Page 6 Carcillo Crit Care Med (6): ACCM Guidelines: 60 cc/kg in 15 minutes PALS Guidelines: 60 cc/kg in 60 minutes Page 7 Page 8 3

7 Mortality Rate (%) 2/14/2013 Each hour of delay associated with 50% increased odds of mortality 2003;112:793 Page 9 Improving Outcomes from Pediatric Severe Sepsis/Septic Shock with Continuous Innovation and Early Recognition DuPont, Spink, Medicine 1969; Pollack et al, CCM 1985; Watson et al, Am J Respir Page 10 CCM 2003; Booy et al, Arch Dis Child 2001; Nhan et al, Clin Infect Des 2001; xxx00.#####.ppt 2/14/2013 Odetola 4:00:21 et al, PM 2007 So, we all know what we need to be doing, but how do we do it faster and better? Page 11 4

8 # of Transports 2/14/2013 Potential Bottlenecks Recognition (0-5 min): Failure to prioritize high-risk patients Failure to identify compensated shock Initial resuscitation (0-15 min): Difficulty in vascular access Prioritization of IVF, antibiotics from pharmacy Failure to reassess after interventions Lack of standardization of diagnosis and care Page 12 Page 13 Shock commonly was not recognized Fewer patients were referred for shock than had shock (335 vs 1803) % % 0 referred for shock not referred for shock shock no shock (Slides are courtesy of Dr. Carcillo) Page 14 Carcillo et al.,

9 Prioritization of High-Risk Patients List of comorbidities resulting in higher risk of shock: Malignancy, immunodeficiency, asplenia, transplant recipient, indwelling central line Posted in triage, entered into EMR Led to RNs being able to trigger protocol initiation Goal: optimize sensitivity, allow triage personnel with varying level of experience to appropriately categorize patients Page 15 Awareness of Patient Before Arrival Subspecialty service notifies ED MD and charge RN Referral checklist with pre-populated patient-specific information Standardized order set completed at time of referral Median time to antibiotics: minutes Page 16 Alessandrini et al PAS 2012 Abstract Recognizing Compensated Shock Use of best-practice alert which alarmed for heart rate over a temperature-corrected cutoff by age (done automatically by EHR) Corrected HR by 5 BPM for every 1 F over 100 F No correction of HR by RR, as no standard norms existed Integrated PALS/CCCM vital sign norms by age Again, goal was to maximize sensitivity Page 17 6

10 Best-Practice Alert Page 18 Best Practice Alert Page 19 Best-Practice Alert Could be disregarded by RN, but would still alarm for the first PEM MD (attending, fellow) who signed up for the child Later generation of BPA: had RN/MD click on reason for not starting the protocol (e.g., febrile but not high-risk, alternative explanation for tachycardia, etc) Alarms on subsequent vital sign checks in ED Page 20 7

11 BPA Performance Pediatr Emerg Care Page 2012;28: BPA Performance 99% Negative Predictive Value Pediatr Emerg Care Page 2012;28: BPA Limitations & Next Steps User fatigue (alarmed in 11% of children) We wanted to maximize sensitivity at expense of specificity May have led to overtreatment of some tachycardic children None had evidence of fluid overload, and our rates of renal replacement therapy have dropped since shock protocol implementation Calculate an ROC curve to determine what cutoffs should be used to optimize both sensitivity and specificity Determine how to incorporate anemia into algorithm Page 23 8

12 Page 24 Vascular Access Rapidly accessing central lines/ports Replace Ela-max with Ethyl chloride spray Work on 2 nd line even in children with CVLs Low threshold for starting IO Page 25 Prioritization of IVF, Antibiotics Pharmacy often has no way of prioritizing medication dispensing When IV medications arrive, there is often question about what to give first, if IVF boluses must be interrupted Page 26 9

13 % Mortality 2/14/2013 Retrospective, Single center PICU in Brazil 90 pediatric patients with severe sepsis and septic shock over 1 year period Fluid-sensitive Time-sensitive Page 27 Oliveira et al, Pediatr Emerg Care 2008;24 Every hour delayed of receiving effective antibiotics is associated with a 7.6% decrease in survival in adults with septic shock Page 28 Kumar et al, Chest 2009:136:1237 Page 29 10

14 Continual Patient Reassessment In many EDs, children may have vitals checked q4h In shock protocol, reassessed between boluses and q15m and documented on a flowsheet to facilitate providers monitoring response to therapy Also included pre-transfer assessment to assure child has not decompensated between resuscitation and placement on the floor Page 30 Page 31 Interventions: Culture Changes Pre-intervention Post-intervention Port-A-Cath access Topical anesthetic (Ela max) Ethyl chloride spray Bolus delivery time IVF on pump over 1 hr Push-pull or rapid infuser Antibiotic delivery RN walks to pharmacy Pharmacist walks to room Lab results Prolonged Sent as life-threatening Disposition Variable Standardized Page 32 11

15 Minimize unnecessary variation Physicians Nursing Pharmacy Disposition Page 33 Page 34 Larsen et al. Page 2011;127: 35 e1585 e

16 Standardizing Diagnostic Evaluation Decrease variation in clinician ordering Increase use of: BUN/Creatinine Viral studies Standardize CXRs Page 36 Standardizing Empiric Antibiotics Know what is circulating in your community: Common organisms in specific patients (e.g., short gut) Antibiotic resistance patterns Then, tailor to your patient: Prior cultures for that child If a call-back to ED due to bacteremia, Gram stain should let you broaden, but not narrow, your coverage Look for focus of infection Remember influenza! Page 37 Bacteremia Rates Pediatr Infect Dis J 2012;28:889 Page 38 13

17 ED Septic Shock Order Set Page 39 Page 40 Single center, PICU, 1 year 30 children with suspected fluid-resistant (> 40 cc/kg) septic shock Non-invasive Ultrasound Cardiac Output Monitor Central line infection presents with warm septic shock Community acquired infection presents with cold septic shock Page 41 Brierley and Peters, 122:

18 Intubation and Septic Shock Low threshold for ET intubation even without primary respiratory failure Up to 40% of cardiac output may be devoted to work of breathing; this can be unloaded Atropine, ketamine preferred agents for sedation Caution with etomidate Page 42 Page 43 Time Metric Outcomes Page ;127e758 e766 15

19 Recognizing limitations of what can be done Mixed venous saturations Central venous catheter placement Involve critical care colleagues early If not at a facility with a pediatric ICU, initiate transfer early (and consider use of a transport team from the pediatric facility) Page 45 Time to 1 st bolus Page ;127e758 e766 Time to 1 st antibiotic Page ;127e758 e766 16

20 Conclusions Standardization of processes improve care and let you evaluate outcomes Any proposed interventions must have stakeholders at the table The approach to pediatric septic shock management is multidisciplinary and should be independent of the provider(s) in the ED Page 48 17