Early Goal-Directed Therapy in Pediatric Sepsis - Improving Care Protocols and Outcomes

1. Early Goal-Directed Therapy in Pediatric Sepsis Derek S. Wheeler, MD, FAAP, FCCP, FCCM Associate Professor of Clinical Pediatrics University of Cincinnati College of Medicine Clinical Director, Division of Critical Care Medicine Cincinnati Children’s Hospital Medical Center The James M. Anderson Center for Health Systems Excellence Co-Director, The Center for Acute Care Nephrology

2. Early Goal-directed Therapy

3. Early Goal-directed Therapy Protocolized Care for Early Septic Shock (ProCESS) NCT00510835 (expected study completion August 2013)

4. Surviving Sepsis Campaign Sepsis Resuscitation (6 H) Bundle Measure Serum Lactate Administer broad-spectrum antibiotics (<3 h) Early resuscitation to EGDT Targets Sepsis Management Bundle Low-dose corticosteroids Drotrecogin alfa Tight glucose control Plateau Pressure < 30 cm H2O N=15,022 Crit Care Med 2010; 38:367

5. Early Antibiotics “Door to antibiotics” decreased from 143 to 38 minutes N=2,731 adults with septic shock TCH Sepsis Protocol Cruz et al. Pediatrics 2011; 127:e758 Only 50% of pts received antimicrobial therapy within 6 h of documented hypotension! Crit Care Med 2006; 34:1589

6. Early Antibiotics “Door to Antibiotics” < 3 hours N=2,731 adults with septic shock Primary Children’s Sepsis Protocol Larsen et al. Pediatrics 2011; 127:e1585 Only 50% of pts received antimicrobial therapy within 6 h of documented hypotension! Crit Care Med 2006; 34:1589

7. Early Resuscitation Reduction in mortality from 23% to 2.5%! Arch Dis Child 2001; 85:386

8. Early Resuscitation Pediatrics 2003; 112:793

9. Early Resuscitation Minimize variation Intensive Care Med 2008; 34:1065

10. Early Resuscitation Minimize variation Intensive Care Med 2008; 34:1065

11. Early Resuscitation Minimize variation 28-day Mortality 39.2% versus 11.8% Intensive Care Med 2008; 34:1065

12. Early Resuscitation Minimize variation No differences in HR, MAP, CVP, ScvO2, or Lactate at Baseline, 6 H, or 72 H Intensive Care Med 2008; 34:1065

13. Early Resuscitation Minimize variation Significant differences in amount of fluid volume administered at 6 H No differences in TOTAL fluid volume administered at 72 H Early administration of inotropes Intensive Care Med 2008; 34:1065

14. Final Thoughts • Protocolized care to minimize practice variations. • Early recognition = Early Treatment • Better therapeutic endpoints are on the horizon

15. Thank You! Division of Critical Care Medicine Hector R. Wong, MD Carley Riley, MD Erika Stalets, MD The James M. Anderson Center for Health Systems Excellence Stephen Muething, MD Patrick Brady, MD Uma Kotagal, MBBS, MSc Janet Jacob, RN, MBA Cincinnati Children’s Center for Simulation and Research Gary Geis, MD John Whitt, MD Tom LeMaster, RN, MSN, MEd, REMT-P, EMSI University of Cincinnati College of Medicine Amy Bunger, PhD Children’s Hospital of Akron Mary D. Patterson, MD, MEd University of Michigan Ross School of Business Kathleen M. Sutcliffe, MSN, PhD R18 HS020455 Applied Decision Science, LLC Laura Militello, MA MacroCognition, LLC Gary Klein, PhD derek.wheeler@cchmc.org