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Boehm D, Menke H. Sepsis in Burns-Lessons Learnt from Developments in the Management of Septic Shock. MEDICINA (KAUNAS, LITHUANIA) 2021; 58:26. [PMID: 35056334 PMCID: PMC8779285 DOI: 10.3390/medicina58010026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/23/2022]
Abstract
After surviving the acute phase of resuscitation, septic shock is the cause of death in the majority of burn patients. Therefore, the management of septic shock is a cornerstone in modern burn care. Whereas sepsis therapy in general has undergone remarkable developments in the past decade, the management of septic shock in burn patients still has a long way to go. Instead, the differences of burn patients with septic shock versus general patients have been emphasized and thus, burn patients were excluded in every sepsis study which are the basis for modern sepsis therapy. However, due to the lack of evidence in burn patients, the standards of procedure for general sepsis therapy have been adopted in burn care. This review identifies the differences of burn patients with sepsis versus other septic patients and summarizes the scientific basis for modern sepsis therapy in general ICU patients and burn patients. Consequently, the results in general sepsis research should be transferred to burn care, which means the implementation of effective screening, early resuscitation, and efficient antimicrobial treatment. Therefore, on the basis of past developments and in the light of the current update of the Surviving Sepsis Campaign guidelines, this review introduces the "Burn SOFA score" and the "3 H's of burn sepsis" as a screening tool for early sepsis recognition in burn patients.
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Affiliation(s)
- Dorothee Boehm
- Department of Plastic, Aesthetic and Hand Surgery, Specialized Burn Center, Sana Klinikum Offenbach, Starkenburgring 66, 63069 Offenbach, Germany;
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2
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Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. Evidence for the Application of Sepsis Bundles in 2021. Semin Respir Crit Care Med 2021; 42:706-716. [PMID: 34544188 DOI: 10.1055/s-0041-1733899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
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3
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Lee JY, Molani S, Fang C, Jade K, O'Mahony DS, Kornilov SA, Mico LT, Hadlock JJ. Ambulatory Risk Models for the Long-Term Prevention of Sepsis: Retrospective Study. JMIR Med Inform 2021; 9:e29986. [PMID: 34086596 PMCID: PMC8299345 DOI: 10.2196/29986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a life-threatening condition that can rapidly lead to organ damage and death. Existing risk scores predict outcomes for patients who have already become acutely ill. Objective We aimed to develop a model for identifying patients at risk of getting sepsis within 2 years in order to support the reduction of sepsis morbidity and mortality. Methods Machine learning was applied to 2,683,049 electronic health records (EHRs) with over 64 million encounters across five states to develop models for predicting a patient’s risk of getting sepsis within 2 years. Features were selected to be easily obtainable from a patient’s chart in real time during ambulatory encounters. Results The models showed consistent prediction scores, with the highest area under the receiver operating characteristic curve of 0.82 and a positive likelihood ratio of 2.9 achieved with gradient boosting on all features combined. Predictive features included age, sex, ethnicity, average ambulatory heart rate, standard deviation of BMI, and the number of prior medical conditions and procedures. The findings identified both known and potential new risk factors for long-term sepsis. Model variations also illustrated trade-offs between incrementally higher accuracy, implementability, and interpretability. Conclusions Accurate implementable models were developed to predict the 2-year risk of sepsis, using EHR data that is easy to obtain from ambulatory encounters. These results help advance the understanding of sepsis and provide a foundation for future trials of risk-informed preventive care.
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Affiliation(s)
- Jewel Y Lee
- Institute for Systems Biology, Seattle, WA, United States
| | - Sevda Molani
- Institute for Systems Biology, Seattle, WA, United States
| | - Chen Fang
- Institute for Systems Biology, Seattle, WA, United States
| | - Kathleen Jade
- Institute for Systems Biology, Seattle, WA, United States
| | - D Shane O'Mahony
- Swedish Center for Research and Innovation, Swedish Medical Center, Seattle, WA, United States
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Xu HP, Zhuo XA, Yao JJ, Wu DY, Wang X, He P, Ouyang YH. Prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation. World J Clin Cases 2021; 9:3008-3013. [PMID: 33969086 PMCID: PMC8080751 DOI: 10.12998/wjcc.v9.i13.3008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sepsis usually causes hemodynamic abnormalities. Hemodynamic index is one of the factors to identify the severity of sepsis and an important parameter to guide the procedure of fluid resuscitation. The present study investigated whether the assessment of hemodynamic indices can predict the outcomes of septic patients undergoing resuscitation therapy.
AIM To evaluate the prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation.
METHODS A retrospective study was conducted in 120 patients with sepsis at Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University between October 2016 and October 2019. All patients were treated with sodium chloride combined with dextran glucose injection for fluid resuscitation. Patients’ hemodynamic parameters were monitored, including heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI), mean arterial pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation. The prognostic value of hemodynamic indices was determined based on the prognosis status.
RESULTS During fluid resuscitation, 86 patients developed septic shock and 34 did not. Ninety-nine patients survived and 21 patients died at 28 d after the treatment. Heart rate, CI, mean arterial pressure, SVRI, and CVP were higher in patients with septic shock and patients who died from septic shock than in non-shock patients and patients who survived, and central venous oxygen saturation was lower in patients with shock and patients who died than in non-shock patients and the survivors (P < 0.05). When prognosis was considered as a dependent variable and hemodynamic parameters was considered as independent variables, the results of a logistic regression analysis showed that CI, SVRI, and CVP were independent risk factors for septic shock, and CI was an independent risk factor for 28-d mortality (P < 0.05).
CONCLUSION Hemodynamic indices can be used to evaluate the prognosis of septic patients after fluid resuscitation.
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Affiliation(s)
- He-Ping Xu
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
| | - Xiao-An Zhuo
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
| | - Jin-Jian Yao
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
| | - Duo-Yi Wu
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
| | - Xiang Wang
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
| | - Ping He
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
| | - Yan-Hong Ouyang
- Department of Emergency Medicine, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou 570311, Hainan Province, China
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Mollura M, Romano S, Mantoan G, Lehman LW, Barbieri R. Prediction of Septic Shock Onset in ICU by Instantaneous Monitoring of Vital Signs .. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:2768-2771. [PMID: 33018580 DOI: 10.1109/embc44109.2020.9176276] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Septic Shock is a critical pathological state that affects patients entering the intensive care unit (ICU). Many studies have been directed to characterize and predict the onset of the septic shock, both in ICU and in the Emergency Department employing data extracted from the Electronic Health Records. Recently, machine learning algorithms have been successfully employed to help characterize septic shock in a more objective and automatic fashion. Only a few of these studies employ information contained in the continuously recorded vital signs such as electrocardiogram and arterial blood pressure. In particular, we have devised a novel feature estimation procedure able to consider instantaneous dynamics related to cardiovascular control. This work aims at developing a short-term prediction algorithm for identifying patients experiencing septic shock among a population of 100 septic patients extracted from the MIMIC-III clinical and waveform database. Among all the results obtained from several trained machine learning models, the best performance reached an AUC on the test set equal to 0.93 (Accuracy=0.85, Sensitivity=0.89 and Specificity=0.82).
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Zaboli A, Ausserhofer D, Pfeifer N, Solazzo P, Magnarelli G, Siller M, Turcato G. Triage of patients with fever: The Manchester triage system's predictive validity for sepsis or septic shock and seven-day mortality. J Crit Care 2020; 59:63-69. [DOI: 10.1016/j.jcrc.2020.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/10/2020] [Accepted: 05/25/2020] [Indexed: 11/17/2022]
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Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:488. [PMID: 32762765 PMCID: PMC7409707 DOI: 10.1186/s13054-020-03204-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
Background The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock. Methods We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = − 1.39; 95% CI, − 1.81 to − 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = − 0.50; 95% CI, − 0.68 to − 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = − 0.11; 95% CI, − 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%). Conclusions Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.
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Affiliation(s)
- Yuting Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hongxiang Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Dong Zhang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
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Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. CRITICAL CARE (LONDON, ENGLAND) 2020. [PMID: 32762765 DOI: 10.1186/s13054-020-03204-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The effect of the timing of norepinephrine initiation on clinical outcomes in patients with septic shock is uncertain. A systematic review and meta-analysis was performed to evaluate the impact of early and late start of norepinephrine support on clinical outcomes in patients with septic shock. METHODS We searched the PubMed, Cochrane, and Embase databases for randomized controlled trials (RCTs) and cohort studies from inception to the 1st of March 2020. We included studies involving adult patients (> 18 years) with septic shock. All authors reported our primary outcome of short-term mortality and clearly comparing early versus late norepinephrine initiation with clinically relevant secondary outcomes (ICU length of stay, time to achieved target mean arterial pressure (≥ 65 mmHg), and volume of intravenous fluids within 6 h). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). RESULTS Five studies including 929 patients were included. The primary outcome of this meta-analysis showed that the short-term mortality of the early group was lower than that of the late group (odds ratio [OR] = 0.45; 95% CI, 0.34 to 0.61; P < 0.00001; χ2 = 3.74; I2 = 0%). Secondary outcomes demonstrated that the time to achieved target MAP of the early group was shorter than that of the late group (mean difference = - 1.39; 95% CI, - 1.81 to - 0.96; P < 0.00001; χ2 = 1.03; I2 = 0%). The volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = - 0.50; 95% CI, - 0.68 to - 0.32; P < 0.00001; χ2 = 33.76; I2 = 94%). There was no statistically significant difference in the ICU length of stay between the two groups (mean difference = - 0.11; 95% CI, - 1.27 to 1.05; P = 0.86; χ2 = 0.85; I2 = 0%). CONCLUSIONS Early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality, shorter time to achieved target MAP, and less volume of intravenous fluids within 6 h. There was no significant difference in ICU length of stay between early and late groups. Further large-scale RCTs are still required to confirm these results.
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Affiliation(s)
- Yuting Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Hongxiang Li
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China
| | - Dong Zhang
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, Jilin, China.
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Abstract
Severe sepsis and septic shock cause significant morbidity and mortality with health care costs approximating $17 billion annually. The Surviving Sepsis Campaign 2012 recommended time-sensitive care bundles to improve outcomes for patients with sepsis. At our community teaching hospital, a review of sepsis management for patients admitted to a medical intensive care unit (ICU) between December 2015 and March 2016 found 70.8% compliance with timing of lactate draw, 65.3% compliance for blood cultures, and 51.4% compliance with antibiotic administration recommendations. Thus, a quality improvement initiative to improve detection and time to bundle completion for ICU-level patients was designed. Previous studies suggest that utilization of sepsis alert systems and sepsis response teams in the emergency department setting is associated with improved compliance with recommended sepsis bundles and improved hospital mortality. Therefore, a "sepsis alert" protocol was implemented that used both an electronic alert and an overhead team alert that mobilized nursing, pharmacy, phlebotomy, and a senior internal medicine resident to bedside. In addition, a template to document sepsis diagnosis and bundle adherence was created. After implementation, we noted improvement in appropriately timed serum lactate, 88.6% versus 70.8% (p = .008) with no significant improvements in blood cultures, antibiotic administration, or mortality.
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10
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Early Use of Norepinephrine Improves Survival in Septic Shock: Earlier than Early. Arch Med Res 2019; 50:325-332. [PMID: 31677537 DOI: 10.1016/j.arcmed.2019.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/26/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The timing of initiation of Norepinephrine (NEP) in septic shock is controversial. AIM OF THE STUDY We evaluated the impact of early NEP simultaneously with fluids in those patients. METHODS We randomized 101 patients admitted to the emergency department with septic shock to early NEP simultaneously with IV fluids (early group) or after failed fluids trial (late group). The primary outcome was the in-hospital survival while the secondary outcomes were the time to target mean arterial pressure (MAP) of 65 mmHg, lactate clearance and resuscitation volumes. RESULTS There was no significant difference between the two groups regarding the baseline characteristics. NEP infusion started after 25 (20-30) and 120 (120-180) min in the early and late groups (p = 0.000). MAP of 65 mmHg was achieved faster in the early group (2 [1-3.5] h vs. 3 [2-4.75] h, p = 0.003). Serum lactate was decreased by 37.8 (24-49%) and 22.2 (3.3-38%) in both groups respectively (p = 0.005). Patients with early NEP were resuscitated by significantly lower volume of fluids (25 [18.8-28.7] mL/kg vs. 32.5 [24.4-34.6] mL/kg) in the early and late groups (p = 0.000). The early group had survival rate of 71.9% compared to 45.5% in the late group (p = 0.007). NEP started after 30 (20-120 min) in survivors vs. 120 (30-165 min) in non-survivors (p = 0.013). CONCLUSIONS We concluded that early Norepinephrine in septic shock might cause earlier restoration of blood pressure, better lactate clearance and improve in-hospital survival.
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11
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LiSep LSTM: A Machine Learning Algorithm for Early Detection of Septic Shock. Sci Rep 2019; 9:15132. [PMID: 31641162 PMCID: PMC6805937 DOI: 10.1038/s41598-019-51219-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/24/2019] [Indexed: 12/13/2022] Open
Abstract
Sepsis is a major health concern with global estimates of 31.5 million cases per year. Case fatality rates are still unacceptably high, and early detection and treatment is vital since it significantly reduces mortality rates for this condition. Appropriately designed automated detection tools have the potential to reduce the morbidity and mortality of sepsis by providing early and accurate identification of patients who are at risk of developing sepsis. In this paper, we present “LiSep LSTM”; a Long Short-Term Memory neural network designed for early identification of septic shock. LSTM networks are typically well-suited for detecting long-term dependencies in time series data. LiSep LSTM was developed using the machine learning framework Keras with a Google TensorFlow back end. The model was trained with data from the Medical Information Mart for Intensive Care database which contains vital signs, laboratory data, and journal entries from approximately 59,000 ICU patients. We show that LiSep LSTM can outperform a less complex model, using the same features and targets, with an AUROC 0.8306 (95% confidence interval: 0.8236, 0.8376) and median offsets between prediction and septic shock onset up to 40 hours (interquartile range, 20 to 135 hours). Moreover, we discuss how our classifier performs at specific offsets before septic shock onset, and compare it with five state-of-the-art machine learning algorithms for early detection of sepsis.
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12
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Franco Palacios CR, Thompson AM, Gorostiaga F. A past medical history of heart failure is associated with less fluid therapy in septic patients. Rev Bras Ter Intensiva 2019; 31:340-346. [PMID: 31618353 PMCID: PMC7005955 DOI: 10.5935/0103-507x.20190049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/15/2019] [Indexed: 12/29/2022] Open
Abstract
Objective To identify the underlying factors that affect fluid resuscitation in septic patients. Methods The present study was a case-control study of 181 consecutive patients admitted to a Medical Intensive Care Unit between 2012 and 2016 with a diagnosis of sepsis. Demographic, clinical, radiological and laboratory data were analyzed. Results One hundred-thirty patients (72%) received ≥ 30mL/kg of IV fluids on admission. On univariate analyses, a past history of coronary artery disease and heart failure was associated with less fluid therapy. On multivariate analyses, a history of heart failure (OR = 2.31; 95%CI 1.04 - 5.14) remained significantly associated with receiving less IV fluids. Left ventricular ejection fraction, systolic/diastolic function, left ventricular hypertrophy and pulmonary hypertension were not associated with IV fluids. The amount of IV fluids was not associated with differences in mortality. During the first 24 hours, patients with a past history of heart failure received 2,900mLof IV fluids [1,688 - 4,714mL] versus 3,977mL [2,500 - 6,200mL] received by those without a history of heart failure, p = 0.02. Conclusion Septic patients with a past history of heart failure received 1L less IV fluids in the first 24 hours with no difference in mortality.
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Affiliation(s)
- Carlos Rodrigo Franco Palacios
- Hospital Medicine and Nephrology Department, Carris Health, Rice Memorial Hospital - Willmar, Minnesota, United States.,Pulmonary and Critical Care Medicine Department, Jackson Memorial Hospital, University of Miami - Miami, Florida, United States
| | - Amanda M Thompson
- Pharmacy Department, Carris Health, Rice Memorial Hospital - Willmar, Minnesota, United States
| | - Federico Gorostiaga
- Critical Care Department, Mount Sinai Medical Center - Miami Beach, Florida, United States
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Yébenes JC, Lorencio C, Esteban E, Espinosa L, Badia JM, Capdevila JA, Cisteró B, Moreno S, Calbo E, Jiménez-Fábrega X, Clèries M, Faixedas MT, Ferrer R, Vela E, Medina C, Rodríguez A, Netto C, Armero E, Solsona M, Lopez R, Granes A, Perez-Claveria V, Artigas A, Estany J. Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis. Med Intensiva 2019; 44:36-45. [PMID: 31542182 DOI: 10.1016/j.medin.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/10/2019] [Accepted: 05/27/2019] [Indexed: 12/29/2022]
Abstract
Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.
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Affiliation(s)
- J C Yébenes
- Servei de Medicina Intensiva, Hospital de Mataró, Mataró, España.
| | - C Lorencio
- Servei de Medicina Intensiva, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E Esteban
- Servei de Medicina Intensiva, Hospital Sant Joan de Déu, Barcelona, España
| | - L Espinosa
- Consorci Sanitari de Barcelona, CatSalut-Servei Català de la Salut, Barcelona, España
| | - J M Badia
- Servei de Cirurgia General, Hospital Fundació Asil de Granollers, Granollers, España
| | - J A Capdevila
- Servei de Medicina Interna, Hospital de Mataró, Mataró, España
| | - B Cisteró
- Servei d'Urgències, Corporació Sanitària Parc Taulí, Sabadell, España
| | - S Moreno
- Àrea Bàsica de Salut Gràcia, Barcelona, España
| | - E Calbo
- Servei de Medicina Interna-Malalties Infeccioses, Hospital Mutua de Terrassa, Terrassa, España
| | | | - M Clèries
- Unitat d'Informació i Coneixement, CatSalut-Servei Català de la Salut, Barcelona, España
| | - M T Faixedas
- Oficina Tècnica dels Registres de Codis d'Activació, CatSalut-Servei Català de la Salut, Barcelona, España
| | - R Ferrer
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - E Vela
- Unitat d'Informació i Coneixement, CatSalut-Servei Català de la Salut, Barcelona, España
| | - C Medina
- Oficina Tècnica dels Registres de Codis d'Activació, CatSalut-Servei Català de la Salut, Barcelona, España
| | - A Rodríguez
- Servei de Medicina Intensiva, Hospital Universitari Joan XXIII, Tarragona, España
| | - C Netto
- Servei d'Urgències, Corporació Sanitària Parc Taulí, Sabadell, España
| | - E Armero
- Servei d'Urgències, Hospital Comarcal de Blanes, Blanes, España
| | - M Solsona
- Servei de Medicina Intensiva, Hospital de Mataró, Mataró, España
| | - R Lopez
- Consorci Sanitari de Barcelona, CatSalut-Servei Català de la Salut, Barcelona, España
| | - A Granes
- Sistema d'Emergències Mèdiques (SEM)
| | | | - A Artigas
- Servei de Medicina Intensiva, Corporació Sanitària Parc Taulí, Sabadell, España
| | - J Estany
- Consorci Sanitari de Barcelona, CatSalut-Servei Català de la Salut, Barcelona, España
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Lee MR, Lai CL, Chan KA. Intensive Care Unit Admission and Survival in Stage IV Cancer Patients with Septic Shock: A Population-Based Cohort Study. J Cancer 2019; 10:3179-3187. [PMID: 31289588 PMCID: PMC6603387 DOI: 10.7150/jca.30278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 04/15/2019] [Indexed: 01/06/2023] Open
Abstract
Background: The impact of intensive care unit (ICU) admission during life-threatening critical illness on survival of patients with advanced cancer remains unknown. Methods: We identified incident stage IV cancer patients from Taiwan Cancer Registry during 2009-2013 and ascertained the first episode of septic shock after cancer diagnosis. Patient was classified as ICU admission and no ICU admission during the index hospitalization. Primary outcome of interest was overall survival. Propensity score (PS) and proportional hazards regression were used to control potential confounders. Results: A total of 11,825 stage IV cancer patients with septic shock were identified. Among them, 6,089 (51.5%) patients were admitted to ICU during the index hospitalization and 3,626 (30.7%) patients survived the index hospitalization. A 1:1 propensity score (PS)-matched cohort of 7,186 patients were created for patients with/without ICU admission among the total study population. Both the PS-stratified analysis among the overall population (pooled hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.74-0.81) and analysis among the PS-matched population (HR: 0.76, 95% CI: 0.72-0.79) showed association between ICU admission and better overall survival. ICU admission was also associated with a lower risk of in-hospital mortality in both PS-stratified analysis (pooled odds ratio [OR]: 0.69, 95% CI: 0.63-0.75) and PS-matched analysis (OR: 0.61, 95% CI: 0.55-0.68). In PS-stratified analysis for long-term survival after discharge among hospital survivors, ICU admission was associated with improved long-term survival after discharge (pooled HR: 0.73, 95% CI: 0.68-0.80). Also ICU admission was associated with better long-term survival after discharge (HR: 0.77, 95% CI: 0.70-0.85) in PS-matched analysis. Conclusions: Though ICU admission with aggressive treatment may be associated with improved survival, the majority (70%) of stage IV cancer patients with septic shock were unable to survive until hospital discharge.
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Affiliation(s)
- Meng-Rui Lee
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.,Center for Critical Care Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - K Arnold Chan
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
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15
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Bias TE, Vincent WR, Trustman N, Berkowitz LB, Venugopalan V. Impact of an antimicrobial stewardship initiative on time to administration of empirical antibiotic therapy in hospitalized patients with bacteremia. Am J Health Syst Pharm 2019; 74:511-519. [PMID: 28336761 DOI: 10.2146/ajhp160096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The impact of an antimicrobial stewardship initiative on time to first antibiotic dose and clinical outcomes in bacteremic patients was evaluated. METHODS A single-center, retrospective study was conducted for adult inpatients who received antibiotics before and after implementation of a rapid administration of antimicrobials by an infectious diseases specialist (RAIDS) protocol. Patients admitted to an inpatient service from June to October 2011 (pre-RAIDS protocol) and from December 2011 to February 2012 (post-RAIDS protocol) were eligible for inclusion if (1) they were age 18 years or older, (2) their infection occurred two or more days after hospital admission, and (3) they had a blood culture growing an organism other than common skin contaminants (i.e., coagulase-negative staphylococci, Bacillus species). The primary outcome was the time to the first antibiotic dose (TFAD), defined as the time that elapsed from a positive blood culture result to administration of the first empirical antimicrobial dose. RESULTS A total of 111 bacteremic patients were included in the analysis. Implementation of the RAIDS protocol led to significantly faster antibiotic order entry, verification, and administration of empirical antibiotics in patients with bacteremia. The median TFAD was approximately 8 hours faster in the post-RAIDS group than in the pre-RAIDS group (9:09 hr:min versus 1:23 hr:min, p < 0.001). Patients in the post-RAIDS group had a significant reduction in infection-related mortality (p = 0.047), though all-cause 30-day mortality was similar. CONCLUSION Early notification of an infectious diseases pharmacist about positive blood cultures using the RAIDS protocol led to increased appropriateness of empirical drug selection and a dramatic reduction in the administration of antibiotics and was associated with decreased infection-related mortality.
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Affiliation(s)
- Tiffany E Bias
- Department of Pharmacy, Hahnemann University Hospital, Philadelphia, PA.
| | | | | | | | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL
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16
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Abd El-Hamid MI, El-Sayed ME, Ali AR, Abdallah HM, Arnaout MI, El-Mowalid GA. Marjoram extract down-regulates the expression of Pasteurella multocida adhesion, colonization and toxin genes: A potential mechanism for its antimicrobial activity. Comp Immunol Microbiol Infect Dis 2018; 62:101-108. [PMID: 30711039 DOI: 10.1016/j.cimid.2018.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/16/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
Due to the emergence of virulent and antibiotic-resistant microbes, natural antimicrobials from herbal origins have been given more attention as an alternative therapy. This study provides an in vitro research framework to investigate the antibacterial activities of 5 herbal (marjoram, garlic, onion, cinnamon and black seed) oil extracts against 16 multidrug-resistant (MDR) and virulent P. multocida serogroup A isolates recovered from dead and clinically diseased rabbits. Pathogenicity of the screened isolates was further proven experimentally and was verified by PCR analyses of 5 randomly selected virulence genes encoding attachment and colonization proteins (ptfA, pfhA, and omp87), sialidases (nanB) and dermonecrotoxin (toxA). A total of 12 P. multocida isolates were highly pathogenic with the possession of all examined virulence genes, while the other 4 isolates were of lower pathogenicity with expression of the target genes except toxA. In vitro anti-P. multocida activities of the 5 extracts and their synergism rates with 4 antibiotic drugs revealed that marjoram and cinnamon extracts had the highest antibacterial activities and the highest synergism rates against the screened isolates. Pasteurella multocida virulence gene expression profiles were assessed via real-time quantitative reverse transcription PCR (qRT-PCR) in response to marjoram extract. The quantitative analyses showed less than five-fold reduction in the targeted virulence genes expression in presence of marjoram extract compared with the control. The findings from this study document a novel molecular inhibitory activity of marjoram against P. multocida multiple virulence genes and provide a proof of concept for its implementation as an alternative candidate for the treatment of pasteurellosis in farm animals in future.
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Affiliation(s)
- Marwa I Abd El-Hamid
- Department of Microbiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - M E El-Sayed
- Department of Microbiology, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
| | - Aisha R Ali
- Department of Serology, Animal Health Research Institute, Dokki, Giza, Egypt
| | - H M Abdallah
- Department of Microbiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Marwa I Arnaout
- Department of Serology, Animal Health Research Institute, Dokki, Giza, Egypt
| | - Gamal A El-Mowalid
- Department of Microbiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt.
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17
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Garg B, Kumar N, Anthwal P, Manchanda A. Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study. Indian J Crit Care Med 2018; 22:852-857. [PMID: 30662224 PMCID: PMC6311982 DOI: 10.4103/ijccm.ijccm_147_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aim: The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock. Methodology: The study was conducted at a tertiary care hospital. Patients aged 1 month–13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged. Results: Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre- and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group. Conclusion: Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.
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18
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Differences in Hypotensive vs. Non-Hypotensive Sepsis Management in the Emergency Department: Door-to-Antibiotic Time Impact on Sepsis Survival. Med Sci (Basel) 2018; 6:medsci6040091. [PMID: 30309044 PMCID: PMC6313793 DOI: 10.3390/medsci6040091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Sepsis diagnosis can be incorrectly associated with the presence of hypotension during an infection, so the detection and management of non-hypotensive sepsis can be delayed. We aimed to evaluate how the presence or absence of hypotension, on admission at the emergency department, affects the initial management and outcomes of patients with community-onset severe sepsis. Methods: Demographic, clinical, laboratory, process of care, and outcome variables were recorded for all patients, at the emergency department of our university hospital, who presented with community-onset severe sepsis, between 1 March and 31 August in three consecutive years. Patient management consisted of standardized bundled care with five measures: Detection, blood cultures and empirical antibiotics, oxygen supplementation and fluid resuscitation (if needed), clinical monitoring, and noradrenalin administration (if needed). We compared all variables between patients who had hypotension (mean arterial pressure <65 mmHg), on admission to the emergency department, and those who did not. Results: We identified 153 episodes (84 (54.5%) men; mean age 73.6 ± 1.2; mean Sequential Organ Failure Assessment (SOFA) score 4.9 ± 2.7, and 41.2% hospital mortality). Hypotension was present on admission to the emergency department in 57 patients (37.2%). Hemodynamic treatment was applied earlier in patients who presented hypotension initially. Antibiotics were administered 48 min later in non-hypotensive sepsis (p = 0.08). A higher proportion of patients without initial hypotension required admission to the intensive care unit (ICU) (43.1% for patients initially hypotensive vs. 56.9% in those initially non-hypotensive, p < 0.05). Initial hypotension was not associated with mortality. A delay in door-to-antibiotic administration time was associated with mortality [OR 1.150, 95%CI: 1.043–1.268). Conclusions: Initial management of patients with community-onset severe sepsis differed according to their clinical presentation. Initial hypotension was associated with early hemodynamic management and less ICU requirement. A non-significant delay was observed in the administration of antibiotics to initially non-hypotensive patients. The time of door-to-antibiotic administration was related to mortality.
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19
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Kim HI, Park S. Sepsis: Early Recognition and Optimized Treatment. Tuberc Respir Dis (Seoul) 2018; 82:6-14. [PMID: 30302954 PMCID: PMC6304323 DOI: 10.4046/trd.2018.0041] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 06/29/2018] [Accepted: 07/20/2018] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition caused by infection and represents a substantial global health burden. Recent epidemiological studies showed that sepsis mortality rates have decreased, but that the incidence has continued to increase. Although a mortality benefit from early-goal directed therapy (EGDT) in patients with severe sepsis or septic shock was reported in 2001, three subsequent multicenter randomized studies showed no benefits of EGDT versus usual care. Nonetheless, the early administration of antibiotics and intravenous fluids is considered crucial for the treatment of sepsis. In 2016, new sepsis definitions (Sepsis-3) were issued, in which organ failure was emphasized and use of the terms "systemic inflammatory response syndrome" and "severe sepsis" was discouraged. However, early detection of sepsis with timely, appropriate interventions increases the likelihood of survival for patients with sepsis. Also, performance improvement programs have been associated with a significant increase in compliance with the sepsis bundles and a reduction in mortality. To improve sepsis management and reduce its burden, in 2017, the World Health Assembly and World Health Organization adopted a resolution that urged governments and healthcare workers to implement appropriate measures to address sepsis. Sepsis should be considered a medical emergency, and increasing the level of awareness of sepsis is essential.
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Affiliation(s)
- Hwan Il Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea.
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20
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Trent SA, Havranek EP, Ginde AA, Haukoos JS. Effect of Audit and Feedback on Physician Adherence to Clinical Practice Guidelines for Pneumonia and Sepsis. Am J Med Qual 2018; 34:217-225. [PMID: 30205697 DOI: 10.1177/1062860618796947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The objective was to estimate the effect of feedback with blinded peer comparison on emergency physician adherence to guidelines for appropriate antibiotic administration for inpatient pneumonia and completion of the 3-hour Surviving Sepsis Bundle for severe sepsis. The authors performed a quasi-experiment using a stepped wedge design at a single urban safety net hospital. Attending emergency physicians were randomized into 6 clusters. Once a cluster crossed into the intervention group, physicians in that cluster began receiving detailed feedback with blinded peer comparison on their adherence to guidelines for pneumonia and sepsis. Feedback with blinded peer comparison significantly improved guideline adherence from 52% without feedback to 65% with feedback (difference = 13%, 95% confidence interval = 4% to 22%). In adjusted analyses, the odds of providing guideline adherent care were 1.8 (95% confidence interval = 1.01-3.2) after the introduction of feedback with blinded peer comparison. Feedback with blinded peer comparison significantly improved emergency physician guideline adherence.
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Affiliation(s)
- Stacy A Trent
- 1 Denver Health Medical Center, Denver, CO.,2 University of Colorado, Aurora, CO
| | - Edward P Havranek
- 1 Denver Health Medical Center, Denver, CO.,2 University of Colorado, Aurora, CO
| | - Adit A Ginde
- 2 University of Colorado, Aurora, CO.,3 Colorado School of Public Health, Aurora, CO
| | - Jason S Haukoos
- 1 Denver Health Medical Center, Denver, CO.,2 University of Colorado, Aurora, CO.,3 Colorado School of Public Health, Aurora, CO
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21
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Dummitt B, Zeringue A, Palagiri A, Veremakis C, Burch B, Yount B. Using survival analysis to predict septic shock onset in ICU patients. J Crit Care 2018; 48:339-344. [PMID: 30290359 DOI: 10.1016/j.jcrc.2018.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the efficacy of survival analysis for predicting septic shock onset in ICU patients. MATERIALS AND METHODS We performed a retrospective analysis on ICU cases from Mercy Hospital St. Louis from 2012 to 2016. As part of the procedure for inclusion in the Apache Outcomes database, each case is reviewed by critical care clinicians to identify septic shock patients as well as the time of septic shock onset. We used survival analysis to predict septic shock onset in these cases and employed lagging to compensate for uncertainties in septic shock onset time. RESULTS Survival analysis was highly effective at predicting septic shock onset, producing AUC values of >0.87. The methodology was robust to lag times as well as the specific method of survival analysis used. CONCLUSIONS This methodology has the potential to be implemented in the ICU for real time prediction and can be used as a building block to expand the approach to other hospital wards or care environments.
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Affiliation(s)
- Benjamin Dummitt
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
| | - Angelique Zeringue
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
| | - Ashok Palagiri
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
| | | | - Benjamin Burch
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA; Department of Data Science, Maryville University, 650 Maryville University Drive, St. Louis, MO 63141, USA
| | - Byron Yount
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
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22
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Correlations between ACE single nucleotide polymorphisms and prognosis of patients with septic shock. Biosci Rep 2017; 37:BSR20170145. [PMID: 28336767 PMCID: PMC5408661 DOI: 10.1042/bsr20170145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/19/2017] [Accepted: 03/23/2017] [Indexed: 12/31/2022] Open
Abstract
The aim of the present study is to investigate association between septic shock (SS) and angiotensin I-converting enzyme (ACE) single nucleotide polymorphisms (SNPs). From October 2009 to December 2016, 238 SS patients and 242 healthy individuals were selected for our study. ACE activity was detected, ACE rs4291 and rs4646994 polymorphisms were detected using PCR-restriction fragment length polymorphism (PCR-RFLP). The Kaplan–Meier survival curve was employed to evaluate the association between ACE SNPs and patients’ survival and univariate and multivariate analyses to estimate risk factors for SS. ACE activity in the case group was increased in comparison with the control group. Allele and genotype frequencies of rs4291 and rs4646994 were different between the case and control groups. The TT genotype frequency of the rs4291 polymorphisms and the DD genotype of the rs4646994 polymorphisms of the case group were higher than those in the control group. The AT and TT genotypes indicated a significant elevation of ACE activity than the AA genotype, while a significant decline was found in the DI and II genotypes in comparison with the DI genotype. Patients with TT or DD genotypes had increased fatality rate within 7 and 30 days when compared with those with non-TT or non-DD genotypes. Lower sepsis-related organ failure assessment (SOFA) scores, rs4291, serum ACE and rs4646994 were all considered as risky factors for SS patients. The study demonstrates that TT genotype of rs4291 or DD genotype of rs4646994 may be indicative of a higher risk of SS and a poorer prognosis in SS patients.
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Guirgis FW, Jones L, Esma R, Weiss A, McCurdy K, Ferreira J, Cannon C, McLauchlin L, Smotherman C, Kraemer DF, Gerdik C, Webb K, Ra J, Moore FA, Gray-Eurom K. Managing sepsis: Electronic recognition, rapid response teams, and standardized care save lives. J Crit Care 2017; 40:296-302. [PMID: 28412015 DOI: 10.1016/j.jcrc.2017.04.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/23/2017] [Accepted: 04/05/2017] [Indexed: 12/29/2022]
Abstract
PURPOSE Sepsis can lead to poor outcomes when treatment is delayed or inadequate. The purpose of this study was to evaluate outcomes after initiation of a hospital-wide sepsis alert program. MATERIALS AND METHODS Retrospective review of patients ≥18years treated for sepsis. RESULTS There were 3917 sepsis admissions: 1929 admissions before, and 1988 in the after phase. Mean age (57.3 vs. 57.1, p=0.94) and Charlson Comorbidity Scores (2.52 vs. 2.47, p=0.35) were similar between groups. Multivariable analyses identified significant reductions in the after phase for odds of death (OR 0.62, 95% CI 0.39-0.99, p=0.046), mean intensive care unit LOS (2.12days before, 95%CI 1.97, 2.34; 1.95days after, 95%CI 1.75, 2.06; p<0.001), mean overall hospital LOS (11.7days before, 95% CI 10.9, 12.7days; 9.9days after, 95% CI 9.3, 10.6days, p<0.001), odds of mechanical ventilation use (OR 0.62, 95% CI 0.39, 0.99, p=0.007), and total charges with a savings of $7159 per sepsis admission (p=0.036). There was no reduction in vasopressor use (OR 0.89, 95% CI 0.75, 0.1.06, p=0.18). CONCLUSION A hospital-wide program utilizing electronic recognition and RRT intervention resulted in improved outcomes in patients with sepsis.
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Affiliation(s)
- Faheem W Guirgis
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, USA.
| | - Lisa Jones
- University of Florida College of Medicine, Jacksonville, Division of Pulmonary Critical Care Medicine, Department of Medicine, Jacksonville, FL, USA.
| | - Rhemar Esma
- UF Health Jacksonville, Quality Management, Jacksonville, FL, USA.
| | - Alice Weiss
- UF Health Jacksonville, Quality Management, Jacksonville, FL, USA.
| | - Kaitlin McCurdy
- University of Florida College of Medicine, Jacksonville, Department of Medicine, USA.
| | - Jason Ferreira
- University of Florida College of Pharmacy, Jacksonville, USA.
| | - Christina Cannon
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, USA.
| | - Laura McLauchlin
- University of Florida College of Medicine, Jacksonville, Department of Neurosurgery, USA.
| | - Carmen Smotherman
- University of Florida College of Medicine, Jacksonville, Center for Health Equity and Quality Research, USA.
| | - Dale F Kraemer
- University of Florida College of Medicine, Jacksonville, Center for Health Equity and Quality Research, USA.
| | | | - Kendall Webb
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, USA.
| | - Jin Ra
- University of Florida College of Medicine, Jacksonville, Department of Surgery, USA.
| | - Frederick A Moore
- University of Florida College of Medicine, Gainesville, Department of Surgery, USA.
| | - Kelly Gray-Eurom
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, USA.
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Zhang Z, Hong Y, Smischney NJ, Kuo HP, Tsirigotis P, Rello J, Kuan WS, Jung C, Robba C, Taccone FS, Leone M, Spapen H, Grimaldi D, Van Poucke S, Simpson SQ, Honore PM, Hofer S, Caironi P. Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002. J Thorac Dis 2017; 9:392-405. [PMID: 28275488 PMCID: PMC5334094 DOI: 10.21037/jtd.2017.02.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many investigators opt for an "expanded" EGDT (as suggested by the Surviving Sepsis Campaign). Evidence is also presented on the effectiveness of automated systems for early sepsis alert. Early recognition of sepsis and well-timed initiation of the SSC bundle may improve patient outcome.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | | | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Vall d’Hebron Institute of Research, Universitat Autonoma de Barcelona, Spain
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore and the Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Box 1, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Herbert Spapen
- Intensive Care Department, University Hospital, Vrije Universiteit, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sven Van Poucke
- Department of Anesthesiology, Emergency Medicine, Critical Care and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Steven Q. Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas, USA
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Mukherjee V, Brosnahan SB, Bakker J. How to Use Fluid Responsiveness in Sepsis. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2017. [DOI: 10.1007/978-3-319-51908-1_6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
BACKGROUND Many investigators have reproduced the mortality reduction shown in the original trial of early goal directed therapy (EGDT) in patients with severe sepsis and/or septic shock. Three large randomized controlled trials (RCTs) found neutral results when compared to usual care and a modified form of EGDT. Some have interpreted these studies as a reason to question the efficacy of EGDT. OBJECTIVES The purpose of this study was to comprehensively examine the effect of EGDT in the treatment of severe sepsis and/or septic shock in the literature. METHODS A systematic review and meta-analysis of RCTs and prospective studies were performed, which extracted studies from PubMed, Elsevier ScienceDirect, Cochrane, Clinicaltrials.gov, Google Scholar, China Knowledge Resource Integrated Database, and Wanfang Database. The mortality trend in the control group from included studies was analyzed. RESULTS Seven RCTs and twelve prospective studies enrolling 3502 EGDT and 3791 usual care participants were included in the analysis. EGDT was found to reduce overall mortality compared to usual care groups. This reduction in mortality was apparent in prospective and randomized control trials conducted before 2010. Over this time period there was a reduction in mortality in patients receiving usual care. LIMITATIONS This conclusion was limited by the small size of some selected studies and complicated by the long range of time during the conduction of these studies. These studies were further biased because of the lack of blinding and the crossover of care between the EGDT and usual care groups. CONCLUSIONS EGDT significantly reduced mortality in patients with severe sepsis and/or septic shock over 15 years since its publication. Recent studies examining usual care with EGDT have similar mortality benefit because of the diminished treatment effect. This treatment effect is diminished for multiple reasons. With progress in the management of this disease the benefit of EGDT on overall mortality has become comparable with the usual care for sepsis patients. This is because many of the components of EGDT have been incorporated into usual care protocols. As a result, the conclusion that EGDT is ineffective cannot be made. A more rigorous RCT which adjusts for the factors that narrows the treatment effect between groups is required. Given the current state of sepsis care and equipoise that exist, this would be difficult.
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Affiliation(s)
- Bing Liu
- a Zhongnan Hospital of Wuhan University , Wuhan , China
| | - Xun Ding
- a Zhongnan Hospital of Wuhan University , Wuhan , China
| | - Jiong Yang
- a Zhongnan Hospital of Wuhan University , Wuhan , China
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Jozwiak M, Monnet X, Teboul JL. Implementing sepsis bundles. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:332. [PMID: 27713890 DOI: 10.21037/atm.2016.08.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis bundles represent key elements of care regarding the diagnosis and treatment of patients with septic shock and allow ones to convert complex guidelines into meaningful changes in behavior. Sepsis bundles endorsed the early goal-directed therapy (EGDT) and their implementation resulted in an improved outcome of septic shock patients. They induced more consistent and timely application of evidence-based care and reduced practice variability. These benefits mainly depend on the compliance with sepsis bundles, highlighting the importance of dedicated performance improvement initiatives, such as multifaceted educational programs. Nevertheless, the interest of early goal directed therapy in septic shock patients compared to usual care has recently been questioned, leading to an update of sepsis bundles in 2015. These new sepsis bundles may also exhibit, as the previous bundles, some limits and pitfalls and the effects of their implementation still needs to be evaluated.
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Affiliation(s)
- Mathieu Jozwiak
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
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Lee WK, Kim HY, Lee J, Koh SO, Kim JM, Na S. Protocol-Based Resuscitation for Septic Shock: A Meta-Analysis of Randomized Trials and Observational Studies. Yonsei Med J 2016; 57:1260-70. [PMID: 27401660 PMCID: PMC4960395 DOI: 10.3349/ymj.2016.57.5.1260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/31/2015] [Accepted: 01/06/2016] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Owing to the recommendations of the Surviving Sepsis Campaign guidelines, protocol-based resuscitation or goal-directed therapy (GDT) is broadly advocated for the treatment of septic shock. However, the most recently published trials showed no survival benefit from protocol-based resuscitation in septic shock patients. Hence, we aimed to assess the effect of GDT on clinical outcomes in such patients. MATERIALS AND METHODS We performed a systematic review that included a meta-analysis. We used electronic search engines including PubMed, Embase, and the Cochrane database to find studies comparing protocol-based GDT to common or standard care in patients with septic shock and severe sepsis. RESULTS A total of 13269 septic shock patients in 24 studies were included [12 randomized controlled trials (RCTs) and 12 observational studies]. The overall mortality odds ratio (OR) [95% confidence interval (CI)] for GDT versus conventional care was 0.746 (0.631-0.883). In RCTs only, the mortality OR (95% CI) for GDT versus conventional care in the meta-analysis was 0.93 (0.75-1.16). The beneficial effect of GDT decreased as more recent studies were added in an alternative, cumulative meta-analysis. No significant publication bias was found. CONCLUSION The result of this meta-analysis suggests that GDT reduces mortality in patients with severe sepsis or septic shock. However, our cumulative meta-analysis revealed that the reduction of mortality risk was diminished as more recent studies were added.
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Affiliation(s)
- Woo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jinae Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Ok Koh
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jeong Min Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care 2016; 20:160. [PMID: 27364620 PMCID: PMC4929762 DOI: 10.1186/s13054-016-1288-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
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Affiliation(s)
- H. Bryant Nguyen
- />Department of Medicine, Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA USA
- />Department of Emergency Medicine, Loma Linda University, Loma Linda, CA USA
| | - Anja Kathrin Jaehne
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Quality Assurance, Aspirus Hospital, Iron River, MI USA
| | - Namita Jayaprakash
- />Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN USA
| | - Matthew W. Semler
- />Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN USA
| | - Sara Hegab
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Angel Coz Yataco
- />Department of Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY USA
| | - Geneva Tatem
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Dhafer Salem
- />Department of Internal Medicine, Mercy Hospital Medical Center, Chicago, IL USA
| | - Steven Moore
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Kamran Boka
- />Department of Internal Medicine, Division of Critical Care Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jasreen Kaur Gill
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jayna Gardner-Gray
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jacqueline Pflaum
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Juan Pablo Domecq
- />Department of Internal Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />CONEVID, Conocimiento y Evidencia Research Unit, Universidad Peruana Cayetano Heredia, Lima, PERU
| | - Gina Hurst
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Justin B. Belsky
- />Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond Fowkes
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Ronald B. Elkin
- />Pulmonary and Critical Care Medicine, California Pacific Medical Center, San Francisco, CA USA
| | - Steven Q. Simpson
- />Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas USA
| | - Jay L. Falk
- />Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA
- />University of Central Florida College of Medicine, Orlando, Florida USA
- />University of Florida College of Medicine, Orlando, Florida USA
- />University of South Florida College of Medicine, Orlando, Florida USA
- />Florida State University College of Medicine, Orlando, Florida USA
| | - Daniel J. Singer
- />Department of Surgery, Division of Surgical Critical Care, Icahn School of Medicine, Mount Sinai Hospital,, New York, NY USA
| | - Emanuel P. Rivers
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, MI USA
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Henry KE, Hager DN, Pronovost PJ, Saria S. A targeted real-time early warning score (TREWScore) for septic shock. Sci Transl Med 2016; 7:299ra122. [PMID: 26246167 DOI: 10.1126/scitranslmed.aab3719] [Citation(s) in RCA: 282] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sepsis is a leading cause of death in the United States, with mortality highest among patients who develop septic shock. Early aggressive treatment decreases morbidity and mortality. Although automated screening tools can detect patients currently experiencing severe sepsis and septic shock, none predict those at greatest risk of developing shock. We analyzed routinely available physiological and laboratory data from intensive care unit patients and developed "TREWScore," a targeted real-time early warning score that predicts which patients will develop septic shock. TREWScore identified patients before the onset of septic shock with an area under the ROC (receiver operating characteristic) curve (AUC) of 0.83 [95% confidence interval (CI), 0.81 to 0.85]. At a specificity of 0.67, TREWScore achieved a sensitivity of 0.85 and identified patients a median of 28.2 [interquartile range (IQR), 10.6 to 94.2] hours before onset. Of those identified, two-thirds were identified before any sepsis-related organ dysfunction. In comparison, the Modified Early Warning Score, which has been used clinically for septic shock prediction, achieved a lower AUC of 0.73 (95% CI, 0.71 to 0.76). A routine screening protocol based on the presence of two of the systemic inflammatory response syndrome criteria, suspicion of infection, and either hypotension or hyperlactatemia achieved a lower sensitivity of 0.74 at a comparable specificity of 0.64. Continuous sampling of data from the electronic health records and calculation of TREWScore may allow clinicians to identify patients at risk for septic shock and provide earlier interventions that would prevent or mitigate the associated morbidity and mortality.
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Affiliation(s)
- Katharine E Henry
- Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Peter J Pronovost
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD 21202, USA. Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 21202, USA. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Suchi Saria
- Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA. Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD 21202, USA. Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. Department of Applied Math and Statistics, Johns Hopkins University, Baltimore, MD 21218, USA.
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Lu J, Wang X, Chen Q, Chen M, Cheng L, Dai L, Jiang H, Sun Z. The effect of early goal-directed therapy on mortality in patients with severe sepsis and septic shock: a meta-analysis. J Surg Res 2016; 202:389-97. [DOI: 10.1016/j.jss.2015.12.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/29/2015] [Accepted: 12/10/2015] [Indexed: 01/11/2023]
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Wira CR, Dodge K, Sather J, Dziura J. Meta-analysis of protocolized goal-directed hemodynamic optimization for the management of severe sepsis and septic shock in the Emergency Department. West J Emerg Med 2015; 15:51-9. [PMID: 24696750 PMCID: PMC3952890 DOI: 10.5811/westjem.2013.7.6828] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 02/14/2012] [Accepted: 07/07/2013] [Indexed: 12/25/2022] Open
Abstract
Introduction: To perform a meta-analysis identifying studies instituting protocolized hemodynamic optimization in the emergency department (ED) for patients with severe sepsis and septic shock. Methods: We modeled the structure of this analysis after the QUORUM and MOOSE published recommendations for scientific reviews. A computer search to identify articles was performed from 1980 to present. Studies included for analysis were adult controlled trials implementing protocolized hemodynamic optimization in the ED for patients with severe sepsis and septic shock. Primary outcome data was extracted and analyzed by 2 reviewers with the primary endpoint being short-term mortality reported either as 28-day or in-hospital mortality. Results: We identified 1,323 articles with 65 retrieved for review. After application of inclusion and exclusion criteria 25 studies (15 manuscripts, 10 abstracts) were included for analysis (n=9597). The mortality rate for patients receiving protocolized hemodynamic optimization (n=6031) was 25.8% contrasted to 41.6% in control groups (n=3566, p<0.0001). Conclusion: Protocolized hemodynamic optimization in the ED for patients with severe sepsis and septic shock appears to reduce mortality.
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Affiliation(s)
- Charles R Wira
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
| | - Kelly Dodge
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
| | - John Sather
- Yale University, Department of Emergency Medicine and Surgical Critical Care, New Haven, Connecticut
| | - James Dziura
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
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Siontis B, Elmer J, Dannielson R, Brown C, Park J, Surani S, Ramar K. Multifaceted interventions to decrease mortality in patients with severe sepsis/septic shock-a quality improvement project. PeerJ 2015; 3:e1290. [PMID: 26500811 PMCID: PMC4614979 DOI: 10.7717/peerj.1290] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 09/14/2015] [Indexed: 02/05/2023] Open
Abstract
Despite knowledge that EGDT improves outcomes in septic patients, staff education on EGDT and compliance with the CPOE order set has been variable. Based on results of a resident survey to identify barriers to decrease severe sepsis/septic shock mortality in the medical intensive care unit (MICU), multifaceted interventions such as educational interventions to improve awareness to the importance of early goal-directed therapy (EGDT), and the use of the Computerized Physician Order Entry (CPOE) order set, were implemented in July 2013. CPOE order set was established to improve compliance with the EGDT resuscitation bundle elements. Orders were reviewed and compared for patients admitted to the MICU with severe sepsis/septic shock in July and August 2013 (controls) and 2014 (following the intervention). Similarly, educational slide sets were used as interventions for residents before the start of their ICU rotations in July and August 2013. While CPOE order set compliance did not significantly improve (78% vs. 76%, p = 0.74), overall EGDT adherence improved from 43% to 68% (p = 0.0295). Although there was a trend toward improved mortality, this did not reach statistical significance. This study shows that education interventions can be used to increase awareness of severe sepsis/septic shock and improve overall EGDT adherence.
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Affiliation(s)
- Brittany Siontis
- Department of Internal Medicine, Mayo Clinic , Rochester, MN , United States
| | - Jennifer Elmer
- Department of Pulmonary & Critical Care, Mayo Clinic , Rochester, MN , United States
| | - Richard Dannielson
- Department of Pulmonary & Critical Care, Mayo Clinic , Rochester, MN , United States
| | - Catherine Brown
- Department of Pulmonary & Critical Care, Mayo Clinic , Rochester, MN , United States
| | - John Park
- Department of Pulmonary & Critical Care, Mayo Clinic , Rochester, MN , United States
| | - Salim Surani
- Division of Pulmonary, Critical Care & Sleep Medicine, Texas A&M University , Corpus Christi, TX , United States
| | - Kannan Ramar
- Division of Pulmonary and Critical Care, Mayo Clinic , Rochester, MN , United States
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Wawrzeniak IC, Loss SH, Moraes MCM, De La Vega FL, Victorino JA. Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting? Indian J Crit Care Med 2015; 19:159-65. [PMID: 25810612 PMCID: PMC4366915 DOI: 10.4103/0972-5229.152759] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
CONTEXT Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended. AIMS The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting. SETTINGS AND DESIGN retrospective and observational cohort study at tertiary hospital. SUBJECTS AND METHODS All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT. RESULTS A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively). CONCLUSIONS Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.
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Affiliation(s)
- Iuri Christmann Wawrzeniak
- Department of Critical Care, Hospital Mãe de Deus, Porto Alegre, Brazil ; Department of Critical Care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Sergio Henrique Loss
- Department of Critical Care, Hospital Mãe de Deus, Porto Alegre, Brazil ; Department of Critical Care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - Josue Almeida Victorino
- Department of Critical Care, Hospital Mãe de Deus, Porto Alegre, Brazil ; Department of Critical Care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Armen SB, Freer CV, Showalter JW, Crook T, Whitener CJ, West C, Terndrup TE, Grifasi M, DeFlitch CJ, Hollenbeak CS. Improving Outcomes in Patients With Sepsis. Am J Med Qual 2014; 31:56-63. [PMID: 25216849 DOI: 10.1177/1062860614551042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = -1.98 to -0.16), 2.15 fewer hospital days (95% CI = -3.45 to -0.86), and incurred on average $1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.
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Affiliation(s)
| | | | | | - Tonya Crook
- The Pennsylvania State University, Hershey, PA
| | | | - Cheri West
- The Pennsylvania State University, Hershey, PA
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Sohn CH, Ryoo SM, Seo DW, Lee JH, Oh BJ, Lim KS, Huh JW, Kim WY. Outcome of delayed resuscitation bundle achievement in emergency department patients with septic shock. Intern Emerg Med 2014; 9:671-6. [PMID: 24913353 DOI: 10.1007/s11739-014-1092-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 05/23/2014] [Indexed: 01/14/2023]
Abstract
The aim of this study was to assess whether delayed resuscitation bundle compliance from 6 to 12 h after a diagnosis of septic shock has an impact upon 28-day mortality. A prospective observational study on consecutive adult patients with septic shock was performed in the Emergency Department (ED) of a tertiary care university-affiliated hospital between January 2010 and July 2012. Compliance with the resuscitation bundle was assessed at 6 and 12 h after a septic shock diagnosis (time 0). Patients were divided into three groups: early compliance (≤6 h), delayed compliance (>6 but ≤12 h), and non-compliance (>12 h). The 28-day mortality was compared among the groups. A total of 332 patients were included, with an overall 28-day mortality of 17.2%. The mean age was 63.9 years; 57.8% were men. Early compliance was achieved in 195 patients (58.7%), delayed compliance in 59 patients (19.8%), and non-compliance in 78 patients (23.5%). The groups did not differ in baseline sequential organ failure assessment illness severity. However, the non-compliance group had a significantly higher mortality (29.5%) than the delayed-compliance (13.6%) and early-compliance (13.3%) groups (p = 0.04). Delayed compliance was associated with a lower mortality risk than non-compliance (adjusted odds ratio 0.32, 95% confidence interval: 0.13-0.82, p = 0.02). In conclusion, if bundle therapy be started at the time of presentation, the outcome of delayed resuscitation bundle compliance within 12 h is same as that of early resuscitation bundle compliance within 6 h, and these are better than that of the patients who had late or no compliance.
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Affiliation(s)
- Chang Hwan Sohn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, 86, Asanbyeongwon-gil, Songpa-gu, Seoul, 138-736, Korea
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Carmona F, Soares Pereira AM. Herbal medicines: Old and new concepts, truths and misunderstandings. REVISTA BRASILEIRA DE FARMACOGNOSIA-BRAZILIAN JOURNAL OF PHARMACOGNOSY 2013. [DOI: 10.1590/s0102-695x2013005000018] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cannon CM, Holthaus CV, Zubrow MT, Posa P, Gunaga S, Kella V, Elkin R, Davis S, Turman B, Weingarten J, Milling TJ, Lidsky N, Coba V, Suarez A, Yang JJ, Rivers EP. The GENESIS project (GENeralized Early Sepsis Intervention Strategies): a multicenter quality improvement collaborative. J Intensive Care Med 2012; 28:355-68. [PMID: 22902347 DOI: 10.1177/0885066612453025] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Improved outcomes for severe sepsis and septic shock have been consistently observed with implementation of early best practice intervention strategies or the 6-hour resuscitation bundle (RB) in single-center studies. This multicenter study examines the in-hospital mortality effect of GENeralized Early Sepsis Intervention Strategies (GENESIS) when utilized in community and tertiary care settings. METHODS This study was comprised of 2 strategies to assess treatment. The first was a prospective before-and-after observational comparison of historical controls to patients receiving the RB after implementation of GENESIS in 4 community and 4 tertiary hospitals. The second was a concurrent examination comparing patients not achieving all components of the RB to those achieving all components of the RB in 1 community and 2 tertiary care hospitals after implementation of GENESIS. These 4 subgroups merged to comprise a control (historical controls treated before GENESIS and RB not achieved after GENESIS) group and treatment (patients treated after GENESIS and RB achieved after GENESIS) group for comparison. RESULTS The control group comprised 1554 patients not receiving the RB (952 before GENESIS and 602 RB not achieved after GENESIS). The treatment group comprised 4801 patients receiving the RB (4109 after GENESIS and 692 RB achieved after GENESIS). Patients receiving the RB (treatment group) experienced an in-hospital mortality reduction of 14% (42.8%-28.8%, P < .001) and a 5.1 day decrease in hospital length of stay (20.7 vs 15.6, P < .001) compared to those not receiving the RB (control group). Similar mortality reductions were seen in the before-and-after (43% vs 29%, P < .001) or concurrent RB not achieved versus achieved (42.5% vs 27.2%, P < .001) subgroup comparisons. CONCLUSIONS Patients with severe sepsis and septic shock receiving the RB in community and tertiary hospitals experience similar and significant reductions in mortality and hospital length of stay. These findings remained consistent when examined in both before-and-after and concurrent analyses. Early sepsis intervention strategies are associated with 1 life being saved for every 7 treated.
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LaRosa JA, Ahmad N, Feinberg M, Shah M, DiBrienza R, Studer S. The use of an early alert system to improve compliance with sepsis bundles and to assess impact on mortality. Crit Care Res Pract 2012; 2012:980369. [PMID: 22461981 PMCID: PMC3296210 DOI: 10.1155/2012/980369] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 09/14/2011] [Accepted: 10/15/2011] [Indexed: 01/20/2023] Open
Abstract
Introduction. Diagnostic and therapeutic guidelines, organized as sepsis bundles, have been shown to improve mortality, but timely and consistent implementation of these can be challenging. Our study examined the use of a screening tool and an early alert system to improve bundle compliance and mortality. Methods. A screening tool was used to identify patients with severe sepsis or septic shock and an overhead alert system known as Code SMART (Sepsis Management Alert Response Team) was activated at the physician's discretion. Data was collected for 6 months and compliance with bundle completion and mortality were compared between the Code SMART and non-Code SMART groups. Results. Fifty eight patients were enrolled -34 Code SMART and 24 non-Code SMART. The Code SMART group achieved greater compliance with timely antibiotic administration (P < 0.001), lactate draw (P < 0.001), and steroid use (P = 0.02). Raw survival and survival adjusted for age, leucopenia, and severity of illness scores, were greater in the Code SMART group (P < 0.05, P = 0.03, and P = 0.01). Conclusions. A screening tool and an alert system can improve compliance with sepsis bundle elements and improve survival from severe sepsis and septic shock.
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Napoli AM, Seigel TA. The role of lactate clearance in the resuscitation bundle. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:199. [PMID: 22078132 PMCID: PMC3334784 DOI: 10.1186/cc10478] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The sepsis resuscitation bundle is the result of an effort on behalf of the Surviving Sepsis Campaign and the Institute for Healthcare Improvement to translate individual guideline recommendations into standardized, achievable goals for physicians caring for the critically ill patient. Implementation of this bundle is associated with decreased mortality. Many of the bundle items reflect components of therapy shown to improve mortality in the seminal early goal-directed therapy trial for severe sepsis and septic shock, including an initial lactate measurement. Elevations in serum lactate are associated with increased mortality, and may result from either increased lactate production or impaired lactate clearance. Lactate clearance may be an important addition to the monitoring and management bundles of patients with severe sepsis and septic shock, However, specific mechanisms of lactate clearance, the relation of lactate clearance to traditional hemodynamic parameters, and the importance of lactate clearance as a therapeutic target or monitoring tool remain unclear.
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Affiliation(s)
- Anthony M Napoli
- Department of Emergency Medicine, Warren Alpert School of Medicine at Brown University, 593 Eddy Street, Davol 142, Providence, RI 02903, USA.
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Rivers EP, Rubinfeld IS, Manteuffel J, Dagher GA, McGregor K, Mlynarek M. Implementing Sepsis Quality Initiatives in a Multiprofessional Care Model. ACTA ACUST UNITED AC 2011. [DOI: 10.1177/1944451611421488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Studies of acute myocardial infarction, trauma, and stroke have resulted in improved outcomes through earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most critical therapies for these diseases are frequently instituted prior to admission to an ICU. This systems-based approach to the sepsis patient has been lacking. To change this paradigm, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using specific criteria for the early identification of high-risk sepsis patients and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. One decade later, EGDT has been shown to modulate inflammation, decrease the progression of organ failure, improve microcirculatory function, and decrease health resource consumption and mortality. A standard operating procedure beginning with EGDT for severe sepsis and septic shock is a hospital-wide initiative.
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Affiliation(s)
| | | | | | | | | | - Mark Mlynarek
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, Michigan
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Nguyen HB, Kuan WS, Batech M, Shrikhande P, Mahadevan M, Li CH, Ray S, Dengel A. Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R229. [PMID: 21951322 PMCID: PMC3334775 DOI: 10.1186/cc10469] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 08/30/2011] [Accepted: 09/27/2011] [Indexed: 01/20/2023]
Abstract
Introduction Implementation of the Surviving Sepsis Campaign (SSC) guidelines has been associated with improved outcome in patients with severe sepsis. Resolution of lactate elevations or lactate clearance has also been shown to be associated with outcome. The purpose of the present study was to examine the compliance and effectiveness of the SSC resuscitation bundle with the addition of lactate clearance. Methods This was a prospective cohort study over 18 months in eight tertiary-care medical centers in Asia, enrolling adult patients meeting criteria for the SSC resuscitation bundle in the emergency department. Compliance and outcome results of a multi-disciplinary program to implement the Primary SSC Bundle with the addition of lactate clearance (Modified SSC Bundle) were examined. The implementation period was divided into quartiles, including baseline, education and four quality improvement phases. Results A total of 556 patients were enrolled, with median (25th to 75th percentile) age 63 (50 to 74) years, lactate 4.1 (2.2 to 6.3) mmol/l, central venous pressure 10 (7 to 13) mmHg, mean arterial pressure (MAP) 70 (56 to 86) mmHg, and central venous oxygen saturation 77 (69 to 82)%. Completion of the Primary SSC Bundle over the six quartiles was 13.3, 26.9, 37.5, 45.9, 48.8, and 54.5%, respectively (P <0.01). The Modified SSC Bundle was completed in 10.2, 23.1, 31.7, 40.0, 42.5, and 43.6% patients, respectively (P <0.01). The ratio of the relative risk of death reduction for the Modified SSC Bundle compared with the Primary SSC Bundle was 1.94 (95% confidence interval = 1.45 to 39.1). Logistic regression modeling showed that the bundle items of fluid bolus given, achieve MAP >65 mmHg by 6 hours, and lactate clearance were independently associated with decreased mortality - having odds ratios (95% confidence intervals) 0.47 (0.23 to 0.96), 0.20 (0.07 to 0.55), and 0.32 (0.19 to 0.55), respectively. Conclusions The addition of lactate clearance to the SSC resuscitation bundle is associated with improved mortality. In our study patient population with optimized baseline central venous pressure and central venous oxygen saturation, the bundle items of fluid bolus administration, achieving MAP >65 mmHg, and lactate clearance were independent predictors of outcome.
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Affiliation(s)
- H Bryant Nguyen
- Department of Emergency Medicine, Loma Linda University, 11234 Anderson Street, Loma Linda, CA 92354, USA.
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