Early lactate clearance is associated with improved outcome in severe sepsis and septic shock

OBJECTIVE: Serial lactate concentrations can be used to examine disease severity in the intensive care unit. This study examines the clinical utility of the lactate clearance before intensive care unit admission (during the most proximal period of disease presentation) as an indicator of outcome in severe sepsis and septic shock. We hypothesize that a high lactate clearance in 6 hrs is associated with decreased mortality rate. DESIGN: Prospective observational study. SETTING: An urban emergency department and intensive care unit over a 1-yr period. PATIENTS: A convenience cohort of patients with severe sepsis or septic shock. INTERVENTIONS: Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. MEASUREMENTS AND MAIN RESULTS: Vital signs, laboratory values, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were obtained at hour 0 (emergency department presentation), hour 6, and over the first 72 hrs of hospitalization. Therapy given in the emergency department and intensive care unit was recorded. Lactate clearance was defined as the percent decrease in lactate from emergency department presentation to hour 6. Logistic regression analysis was performed to determine independent variables associated with mortality. One hundred and eleven patients were enrolled with mean age 64.9 +/- 16.7 yrs, emergency department length of stay 6.3 +/- 3.2 hrs, and overall in-hospital mortality rate 42.3%. Baseline APACHE II score was 20.2 +/- 6.8 and lactate 6.9 +/- 4.6 mmol/L. Survivors compared with nonsurvivors had a lactate clearance of 38.1 +/- 34.6 vs. 12.0 +/- 51.6%, respectively (p =.005). Multivariate logistic regression analysis of statistically significant univariate variables showed lactate clearance to have a significant inverse relationship with mortality (p =.04). There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance. Patients with a lactate clearance> or =10%, relative to patients with a lactate clearance <10%, had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p =.007). CONCLUSIONS: Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance.     

严重脓毒症和脓毒性休克的急诊集束化治疗依从性调查分析

目的 调查严重脓毒症和脓毒性休克在急诊患者中的发生率以及针对严重脓毒症和脓毒性休克早期集束化治疗的依从性.方法 选择2009年5月至6月由救护车送至上海交通大学医学院附属瑞金医院急诊科的患者为调查对象,统计严重脓毒症和脓毒性休克的发生率,对符合诊断标准的患者分别统计早期复苏集束化治疗各项指标完成的依从性.结果 共纳入急诊就诊患者917例,其中符合严重脓毒症和脓毒性休克诊断标准者96例,发生率为10.47%.在符合诊断标准的患者中,早期复苏集束化治疗、使用抗菌药物前留取病原学标本、2 h内放置深静脉导管并监测中心静脉压(CVP)与中心静脉血氧饱和度(ScvO2)、3 h内使用广谱抗菌药物、6 h内早期目标导向治疗(EGDT)达标、12 h内乳酸下降或原乳酸≤2 mmol/L的依从性分别为1.04%、3.12%、2.08%、83.33%、1.04%、23.96%,急诊内科各指标的依从性依次为1.19%、3.57%、2.38%、83.33%、1.19%、26.19%,急诊外科各指标的依从性依次为0、0、0、83.33%、0、8.33%,急诊内、外科依从性比较差异均无统计学意义(均P＞0.05).结论 严重脓毒症和脓毒性休克在急诊就诊患者中占相当比例,但医师的认识不足;早期集束化治疗依从性较低,需加大指南的教育及执行程度.

Abstract：

Objective To evaluate the occurrence of severe sepsis and septic shock and the rate of compliance with sepsis bundle in patients with severe sepsis and septic shock in emergency department.Methods A prospective study was conducted on consecutive adult patients who were sent to Emergency Department of Ruijin Hospital, Shanghai Jiaotong University School of Medicine by ambulance from May to June in 2009. The occurrence of severe sepsis and septic shock, and the number of the patients in whom who met the criteria of compliance with sepsis bundle were analyzed. Results Nine hundred and seventeen patients who were sent to the emergency department by ambulance in that period were enrolled in the study.The number of patients with severe sepsis and septic shock was 96. The incidence of severe sepsis and septic shock was 10.47%. Among these patients, the number of patients in whom the sepsis bundle was complied,i.e. sepsis bundle, appropriate cultures were taken before antimicrobial therapy, placement of central venous catheter and monitoring of central venous pressure(CVP)as well as central venous oxygen saturation (ScvO2)within 2 hours, antibiotic therapy within 3 hours, early goal-directed therapy(EGDT)within 6 hours, and lactate clearance in 12 hours reached 1.04%, 3. 12%, 2.08%, 83. 33%, 1.04%, 23.96%.The results were 1.19%, 3. 57%, 2.38%, 83.33%, 1.19%, 26.19% and 0, 0, 0, 83.33%, 0, 8. 33% in medical and surgical emergency department respectively. There was no statistical difference between the two divisions(all P＞0. 05). Conclusion The incidence of severe sepsis and septic shock was high in emergency department, but the rate of recognition of it and the compliance with sepsis bundle were inadequate. It is urgently necessary to enhance the learning and implementation of the guideline.     

Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle

Purpose

The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock.

Materials and Methods

This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed.

Results

Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (−0.46 to 1.80), and 4.00 (−8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01).

Conclusions

The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock.     

Development of ionized hypomagnesemia is associated with higher mortality rates

OBJECTIVE: Previous studies have shown a wide variation in the prevalence of total serum hypomagnesemia in intensive are unit (ICU) patients and in associated mortality rates. As the ionized part of magnesium is the active portion, we sought to define the prevalence of ionized hypomagnesemia in critically ill patients and to evaluate its relationship with organ dysfunction, length of stay, and mortality. DESIGN: Prospective observational study. SETTING: A 31-bed, medical-surgical, university hospital ICU. PATIENTS: A total of 446 consecutive patients admitted to the ICU over a 3-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The ionized magnesium level (normal value, 0.42-0.59 mmol/L) was measured at admission and then every day until discharge from the ICU. At admission, 18% of patients had ionized hypomagnesemia, 68% had normal ionized magnesium levels, and 14% had ionized hypermagnesemia. There was no significant difference in the length of stay or in the mortality rate between these three groups of patients. Hypomagnesemic patients more frequently had total and ionized hypocalcemia, hypokalemia, and hypoproteinemia. A total of 23 patients developed ionized hypomagnesemia during their ICU stay; these patients had higher Acute Physiology And Chronic Health Evaluation II (14.9 +/- 5.4 vs. 11.0 +/- 6.2) and Sequential Organ Failure Assessment (SOFA; 7.1 +/- 5.4 vs. 3.9 +/- 2.8) scores at admission (p <.01 for both), a higher maximum SOFA score during their ICU stay (10.0 +/- 5.6 vs. 4.4 +/- 3.2, p <.01), a higher prevalence of severe sepsis and septic shock (57 vs. 11%, p <.01), a longer ICU stay (15.4 +/- 15.5 vs. 2.8 +/- 4.7 days, p <.01), and a higher mortality rate (35% vs. 12%, p <.01) than the other patients. The major risk factors for developing hypomagnesemia during the ICU stay were a prolonged ICU stay, treatment with diuretics, and sepsis. CONCLUSION: Development of ionized hypomagnesemia during an ICU stay is associated with a worse prognosis. It is often associated with the use of diuretics and the development of sepsis. Monitoring of ionized magnesium levels may have prognostic, and perhaps therapeutic, implications.     

Barriers to implementing protocol-based sepsis resuscitation in the emergency department--results of a national survey

OBJECTIVE: To identify barriers to implementation of a written protocol for early goal-directed therapy for severe sepsis in the busiest emergency departments in the United States. DESIGN: Telephone survey with both quantitative and qualitative analysis. SETTING: Two busiest teaching and two busiest nonteaching emergency departments in each of the 25 most densely populated combined statistical areas in the United States. SUBJECTS: Twenty-four physician directors and 40 nursing managers representing 53% of the 100 emergency departments surveyed. INTERVENTIONS: Survey questionnaire. MEASUREMENTS AND MAIN RESULTS: Respondents identified lack of available nursing staff to perform the procedure, the inability to monitor central venous pressure in the emergency department, and challenges in identifying septic patients as the most frequent barriers. Although nurse managers and physicians identified similar barriers, nurses were more likely than physicians to list central venous catheter insertion as an important barrier (38% vs. 5%; p = .01), and physicians were more likely to endorse lack of agreement with the early goal-directed therapy resuscitation protocol (16% vs. 0%; p = .03). There were no statistically significant differences in the rankings assigned by clinicians from teaching and nonteaching hospitals. Qualitative analysis of open-ended questions identified barriers in a number of areas, including barriers to initiating the protocol process and factors that distinguish sepsis from other time-sensitive diseases in the emergency department. CONCLUSIONS: Nurse managers and physician directors of busy emergency departments representing the largest urban areas in the United States identify multiple barriers to implementing time-sensitive resuscitation to patients with severe sepsis. More than half of all respondents recognized a critical shortage of nursing staff, problems in obtaining central venous pressure monitoring, and challenges in identification of patients with sepsis as the largest roadblocks to overcome in implementing early goal-directed therapy.     

Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit

OBJECTIVE: Numerous factors can cause delays in transfer to an intensive care unit for critically ill emergency department patients. The impact of delays is unknown. We aimed to determine the association between emergency department "boarding" (holding admitted patients in the emergency department pending intensive care unit transfer) and outcomes for critically ill patients. DESIGN: This was a cross-sectional analytical study using the Project IMPACT database (a multicenter U.S. database of intensive care unit patients). Patients admitted from the emergency department to the intensive care unit (2000-2003) were included and divided into two groups: emergency department boarding >or=6 hrs (delayed) vs. emergency department boarding <6 hrs (nondelayed). Demographics, intensive care unit procedures, length of stay, and mortality were analyzed. Groups were compared using chi-square, Mann-Whitney, and unpaired Student's t-tests. SETTING: Emergency department and intensive care unit. PATIENTS: Patients admitted from the emergency department to the intensive care unit (2000-2003). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Main outcomes were intensive care unit and hospital survival and intensive care unit and hospital length of stay. During the study period, 50,322 patients were admitted. Both groups (delayed, n = 1,036; nondelayed, n = 49,286) were similar in age, gender, and do-not-resuscitate status, along with Acute Physiology and Chronic Health Evaluation II score in the subgroup for which it was recorded. Among hospital survivors, the median hospital length of stay was 7.0 (delayed) vs. 6.0 days (nondelayed) (p < .001). Intensive care unit mortality was 10.7% (delayed) vs. 8.4% (nondelayed) (p < .01). In-hospital mortality was 17.4% (delayed) vs. 12.9% (nondelayed) (p < .001). In the stepwise logistic model, delayed admission, advancing age, higher Acute Physiology and Chronic Health Evaluation II score, male gender, and diagnostic categories of trauma, intracerebral hemorrhage, and neurologic disease were associated with lower hospital survival (odds ratio for delayed admission, 0.709; 95% confidence interval, 0.561-0.895). CONCLUSIONS: Critically ill emergency department patients with a >or=6-hr delay in intensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality. This suggests the need to identify factors associated with delayed transfer as well as specific determinants of adverse outcomes.     

National estimates of severe sepsis in United States emergency departments

OBJECTIVE: The emergency department (ED) often serves as the first site for the recognition and treatment of patients with suspected severe sepsis. However, few evaluations of the national epidemiology and distribution of severe sepsis in the ED exist. We sought to determine national estimates of the number, timing, ED length of stay, and case distribution of patients presenting to the ED with suspected severe sepsis. DESIGN: Analysis of 2001-2004 ED data from the National Hospital Ambulatory Medical Care Survey. SETTING: National multistage probability sample of United States ED data. PATIENTS: Adult (age, >or=18 yrs) patients with suspected severe sepsis, defined as the concurrent presence of an infec-tion (ED International Classification of Diseases, 9th Revision; ICD-9) diagnosis of infection, or a triage temperature <96.8 degrees F or >or=100.4 degrees F) and organ dysfunction (ED ICD-9) diagnosis of organ dysfunction, intubation, or a triage systolic blood pressure 6 hrs in the ED. Of suspected severe sepsis patients, 20.6% presented to a low-volume ED (相似文献   

感染性休克集束治疗对病死率影响的前瞻性临床研究

目的 探讨集束治疗对感染性休克患者病死率的影响.方法 采用前瞻性研究方法,将2007年1月-2008年6月重症加强治疗病房(ICU)收治的成人感染性休克患者分为培训前(2007年1-9月)和培训后(2007年10月-2008年6月)两个阶段进行感染性休克集束治疗.分析6 h及24 h感染性休克集柬治疗各指标与预后的关系;采用多元回归分析方法,筛选出集束治疗对感染性休克预后影响的独立相关因素,并研究两个阶段感染性休克集束治疗的依从性、机械通气时间、ICU住院时间以及28 d病死率.结果 研究期间共收治符合条件的感染性休克患者100例,其中培训前51例,培训后49例;存活36例,死亡64例.多元回归分析显示,6 h早期目标导向治疗(EGDT)、24 h EGDT是与感染性休克28 d病死率相关的两个独立保护因素,优势比(OR)分别为0.046和0.120(P均<0.01).培训后集束治疗依从性均有明显提高,其中6 h EGDT和24 h EGDT分别从19.6%、35.3%提升至55.1%、65.3%(P均<0.01).培训后机械通气时间[(166.6±156.4)h比(113.6±73.6)h3、ICU住院时间[(9.4±7.6)d比(6.0±3.9)d]及28 d病死率(72.5%比55.1%)较培训前明显缩短(P<0.05或P<0.01).结论 继续教育培训可提高医务人员对感染性休克集束治疗的依从性,降低感染性休克患者的病死率.     

Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol

OBJECTIVES: To describe the effectiveness of a comprehensive, interdisciplinary sepsis treatment protocol with regard to both implementation and outcomes and to compare the mortality rates and therapies of patients with septic shock with similar historical controls. DESIGN: Prospective, interventional cohort study with a historical control comparison group. SETTING: Urban, tertiary care, university hospital with 46,000 emergency department visits and 4,100 intensive care unit admissions annually. PATIENTS: Inclusion criteria were a) emergency department patients aged > or =18 yrs, b) suspected infection, and c) lactate of >4 mmol/L or septic shock. Exclusion criteria were a) emergent operation, b) prehospital cardiac arrest, and c) comfort measures only. Time period: protocol, November 10, 2003, through November 9, 2004; historical controls, February 1, 2000, through January 31, 2001. INTERVENTION: A sepsis treatment pathway incorporating empirical antibiotics, early goal-directed therapy, drotrecogin alfa, steroids, intensive insulin therapy, and lung-protective ventilation. MEASUREMENTS AND MAIN RESULTS: There were 116 protocol patients, with a mortality rate of 18% (11-25%), of which 79 patients had septic shock. Comparing these patients with 51 historical controls, protocol patients received more fluid (4.0 vs. 2.5 L crystalloid, p < .001), earlier antibiotics (90 vs. 120 mins, p < .013), more appropriate empirical coverage (97% vs. 88%, p < .05), more vasopressors in the first 6 hrs (80% vs. 45%, p < .001), tighter glucose control (mean morning glucose, 123 vs. 140, p < .001), and more frequent assessment of adrenal function (82% vs. 10%, p < .001), with a nonstatistically significant increase in dobutamine use (14% vs. 4%, p = .06) and red blood cell transfusions (30% vs. 18%, p = .07) in the first 24 hrs. For protocol patients with septic shock, 28-day in-hospital mortality was 20.3% compared with 29.4% for historical controls (p = .3). CONCLUSIONS: Clinical implementation of a comprehensive sepsis treatment protocol is feasible and is associated with changes in therapies such as time to antibiotics, intravenous fluid delivery, and vasopressor use in the first 6 hrs. No statistically significant decrease in mortality was demonstrated, as this trial was not sufficiently powered to assess mortality benefits.     

Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: We could go faster

Purpose

The aim of this study is to evaluate the feasibility of applying sepsis bundles in the intensive care unit (ICU) and their effect on outcomes.

Methods

In this prospective, observational study in a 31-bed capacity department of intensive care, we measured the time taken to perform sepsis bundle interventions in 69 consecutive patients with severe sepsis or septic shock.

Results

Compliance with the 6-hour bundle was obtained in 44 (72%) of 61 patients; these patients had a lower mortality rate (16% vs 41%, P = .04) and shorter ICU stay (median [range], 5 [3-10] vs 9 [6-19] days, P = .01) than other patients. Compliance with the 24-hour bundle was obtained in 30 (67%) of 44 eligible patients. The mortality rate and duration of ICU stay were not significantly lower in the 24-hour compliant as compared with the noncompliant group (23% vs 33% and 6 [4-11] vs 9 [6-25] days, respectively; P value is not significant). Patients who complied with the 24-hour sepsis bundle after only 12 hours had a lower mortality rate (10% vs 39%, P = .036) and shorter stay (6 [4-10] vs 9 [6-25] days, P = .055) than those who were compliant after 24 hours.

Conclusions

Correct application of the sepsis bundles was associated with reduced mortality and length of ICU stay. Earlier implementation of the 24-hour management bundle could result in better outcomes.     

The Utility of a Quality Improvement Bundle in Bridging the Gap between Research and Standard Care in the Management of Severe Sepsis and Septic Shock in the Emergency Department

The research in the management of severe sepsis and septic shock has resulted in a number of therapeutic strategies with significant survival benefits. These results also emphasize the primary importance of early hemodynamic resuscitation, or early goal-directed therapy (EGDT), and place the emergency physician in the center of the multidisciplinary team caring for patients with this disease. However, in a busy emergency department, the translation of research into clinical practice is far from ideal. While the benefits are significant, the successful implementation of EGDT is filled with challenges and obstacles. In this article, we will discuss the steps taken at our institution to create, implement, measure, and improve on a six-hour severe sepsis and septic shock treatment bundle incorporating EGDT in the emergency department setting, resulting in significant mortality benefit.     

Operational performance of validated physiologic scoring systems for predicting in-hospital mortality among critically ill emergency department patients

OBJECTIVES: New Simplified Acute Physiology Score (SAPS) II, Morbidity Probability Model at admission (MPM0 II), and Logistic Organ Dysfunction System (LODS) have all demonstrated high accuracy for predicting mortality in intensive care unit populations. We tested the prognostic accuracy of these instruments for predicting mortality among a cohort of critically ill emergency department patients. DESIGN: Secondary analysis of a randomized controlled trial. SETTING: Urban, tertiary emergency department, census >100,000. PATIENTS: Nontrauma emergency department patients admitted to an intensive care unit, aged >17 yrs, with initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and with agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. INTERVENTIONS: Emergency department variables needed for calculation of each scoring system were prospectively collected, and published formulas were used to calculate the probability of in-hospital death for each scoring system. The main outcome was actual in-hospital mortality. The area under the receiver operating characteristic curve was used to evaluate the predictive ability of each scoring system. MEASUREMENTS AND MAIN RESULTS: Ninety-one of 202 patients (45%) were included. The mean age was 56 +/- 16 yrs, 42% were female, the mean initial systolic blood pressure was 84 +/- 13 mm Hg, and the average length of stay in the emergency department was 4.2 +/- 2.0 hrs. The in-hospital mortality rate was 21%. The area under the receiver operating characteristic curve for calculated probability of in-hospital mortality for SAPS II was 0.72 (95% confidence interval, 0.57-0.87), for MPM0 II 0.69 (95% confidence interval, 0.54-0.84), and for LODS 0.60 (95% confidence interval, 0.45-0.76). CONCLUSIONS: Using variables available in the emergency department, three previously validated intensive care unit scoring systems demonstrated moderate accuracy for predicting in-hospital mortality.     

Implementation of a disease-specific care plan changes clinician behaviors

The study objective was to determine the impact on quality of care, resource use, and outcomes by developing an emergency department (ED)-based asthma-specific care plan. The design was a time based, prospective cohort and set at an urban university/trauma center, EM residency site, combined adult/pediatric department. Best practice was defined prospectively for ED asthma patients, leading to an asthma care plan (ACP). Triage nurses were instructed to begin use of ACP when patients presented with asthma as the primary complaint. Charts of all patients diagnosed with asthma during 3-month study period were retrospectively reviewed against predefined outcomes. Results were analyzed with chi2 or student's t tests. After ACP introduction, the timeliness of beta agonist treatments (three beta agonist treatments within 90 minutes; 86% versus 63%, P < .05) and ED length of stay (LOS) (3.39 +/- 1.88 hrs versus 3.87 +/- 2.12 hrs, P < .05) improved. After introduction of ACP, only 55% of patients diagnosed with asthma had care documented on the ACP (ACP+ group). ACP+ group had more timely beta agonist treatment (93% versus 74%, P < .01), shorter LOS (3.29 +/- 1.90 vs. 3.53 +/- 1.86 hrs, P < 0.5) more appropriate steroid dosages (67% versus 41%, P < .01), and fewer tests (41% versus 59%, P < .05). No improvements were noted in admission or relapse rates. In conclusion, care plans can improve quality of care and decrease LOS, but may have limited impact on outcomes of admission/discharge or relapse rates.     

An Interdisciplinary Code Sepsis Team to Improve Sepsis-Bundle Compliance: A Quality Improvement Project

ProblemSepsis is one of the leading causes of mortality, with more than 700,000 hospitalizations and 200,000 deaths annually. Various tools exist to aid in the early identification and treatment of sepsis, including electronic alert systems, standardized order sets, nurse-initiated protocols (NIPs) and specially trained teams. Despite available guidelines, mortality rates for severe sepsis and septic shock are near 50%.MethodsThe aims of this rapid cycle quality improvement project were to develop and implement an interdisciplinary team to address early implementation of sepsis bundles in the emergency department and to compare sepsis bundle compliance 3 months pre- and 3 months postintervention implementation. The population included all patients above 18 years of age presenting to the emergency department with clinical indications of sepsis, severe sepsis, or septic shock. Data were collected via electronic health records (EHRs), switchboard-paging records, and a billing database.ResultsThe pre-post intervention analysis shows an improvement in time to each bundle element except antibiotics and completion of blood cultures. There were noteworthy changes in meeting bundle compliance in fluid resuscitation volume (χ² = 16.3, P ≤ 0.001): initial lactate collected within 180 min (χ² = 11.3, P ≤ 0.01) and time to second lactate within 360 min (χ² = 27.7, P ≤ 0.001). Mortality rates showed a steady decline from over 12% to 5%. No differences were found in mortality rates related to age or gender.DiscussionInterprofessional teams can use existing knowledge, skills, and tools to improve sepsis-bundle compliance and mortality outcomes in patients with sepsis presenting to the emergency department.     

Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle

Physiologic scoring systems are often used to prognosticate mortality in critically ill patients. This study examined the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality in Emergency Department Sepsis (MEDS), and Mortality Probability Models (MPM) II0 in predicting in-hospital mortality of patients in the emergency department meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The discrimination and calibration characteristics of APACHE II, SAPS II, MEDS, and MPM II0 were evaluated. Data are presented as median and quartiles (25th, 75th). Two-hundred forty-six patients aged 68 (52, 81) years were analyzed from a prospectively maintained sepsis registry, with 76.0% of patients in septic shock, 45.5% blood culture positive, and 35.0% in-hospital mortality. Acute Physiology and Chronic Health Evaluation II, SAPS II, and MEDS scores were 29 (21, 37), 54 (40, 70), and 13 (11, 16), with predicted mortalities of 64% (40%, 85%), 58% (25%, 84%), and 16% (9%, 39%), respectively. Mortality Probability Models II0 showed a predicted mortality of 60% (27%, 80%). The area under the receiver operating characteristic curves was 0.73 for APACHE II, 0.71 for SAPS II, 0.60 for MEDS, and 0.72 for MPM II0. The standardized mortality ratios were 0.59, 0.63, 1.68, and 0.64, respectively. Thus, APACHE II, SAPS II, MEDS, and MPM II0 have variable abilities to discriminate early and estimate in-hospital mortality of patients presenting to the emergency department requiring the severe sepsis resuscitation bundle. Adoption of these prognostication tools in this setting may influence therapy and resource use for these patients.     

Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study

OBJECTIVE: Intraabdominal hypertension is associated with significant morbidity and mortality in surgical and trauma patients. The aim of this study was to assess, in a mixed population of critically ill patients, whether intraabdominal pressure at admission was an independent predictor for mortality and to evaluate the effects of intraabdominal hypertension on organ functions. DESIGN: Multiple-center, prospective epidemiologic study. SETTING: Fourteen intensive care units in six countries. PATIENTS: A total of 265 consecutive patients admitted for >24 hrs during the 4-wk study period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intraabdominal pressure was measured twice daily via the bladder. Data recorded on admission were the patient demographics with Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II score, and type of admission; during intensive care stay, Sepsis-Related Organ Failure Assessment score and intraabdominal pressure were measured daily together with fluid balance. Nonsurvivors had a significantly higher mean intraabdominal pressure on admission than survivors: 11.4 +/- 4.8 vs. 9.5 +/- 4.8 mm Hg. Independent predictors for mortality were age (odds ratio, 1.04; 95% confidence interval, 1.01-1.06; p = .003), Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1; 95% confidence interval, 1.05-1.15; p < .0001), type of intensive care unit admission (odds ratio, 2.5 medical vs. surgical; 95% confidence interval, 1.24-5.16; p = .01), and the presence of liver dysfunction (odds ratio, 2.5; 95% confidence interval, 1.06-5.8; p = .04). The occurrence of intraabdominal hypertension during the intensive care unit stay was also an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12-3.06; p = .01). Patients with intraabdominal hypertension at admission had significantly higher Sepsis-Related Organ Failure Assessment scores during the intensive care unit stay than patients without intraabdominal hypertension. CONCLUSIONS: Intraabdominal hypertension on admission was associated with severe organ dysfunction during the intensive care unit stay. The mean intraabdominal pressure on admission was not an independent risk factor for mortality; however, the occurrence of intraabdominal hypertension during the intensive care unit stay was an independent outcome predictor.     

Low serum level of high-density lipoprotein cholesterol is a poor prognostic factor for severe sepsis

OBJECTIVE: To assess the initial serum levels of lipids and lipoproteins and their correlations with the clinical outcome for patients with severe sepsis. The ability of high-density lipoprotein (HDL) to attenuate lipopolysaccharide (LPS)-induced cytokine production was also examined in vitro. DESIGN: Prospective, observational cohort study. SETTING: Medical intensive care unit (ICU) of a tertiary-level university hospital. PATIENTS: Sixty-three consecutive patients with severe sepsis. INTERVENTIONS: Blood samples were drawn within the first day of severe sepsis and the subsequent 14 days. Clinical outcome, including length of ICU stay, infection subsequent to hospital stay, and death, were monitored prospectively. MEASUREMENTS AND RESULTS: Compared with the survivors, patients who died within 30 days had significantly lower levels of HDL cholesterol and apolipoprotein A-I during the first 4 days of severe sepsis. On day 1, HDL cholesterol levels correlated inversely with interleukin-6 (r = -0.72; p < .01) and tumor necrosis factor (TNF)-alpha (r = -0.70; p < .01) concentrations. Not only the overall and sepsis-attributable 30-day mortality rates but also the risk of prolonged ICU stay (>7 days) and the hospital-acquired infection rate were increased among patients with day 1 levels of HDL cholesterol of <20 mg/dL and apolipoprotein A-I of <100 mg/dL. Multivariate analysis identified an HDL cholesterol level of <20 mg/dL on day 1 (odds ratio, 12.92; 95% confidence interval, 2.73-61.29) and Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.15; 95% confidence interval, 1.04-1.26) as independent predictors of the overall 30-day mortality rate. In human macrophages, LPS-induced TNF-alpha release was attenuated by incremental doses of HDL cholesterol added simultaneously (p < .01). However, HDL failed to suppress LPS-induced TNF-alpha production when administered after macrophages were exposed to LPS. CONCLUSIONS: A low HDL cholesterol level on day 1 of severe sepsis is significantly associated with an increase in mortality and adverse clinical outcomes. In cultured macrophages, HDL can attenuate LPS-induced TNF-alpha production only if added concomitantly with, but not after, LPS exposure.     

Emergency care staff can improve survival rates from sepsis

Patients die from sepsis. Reports of mortality as high as 50% are associated with patients who have severe sepsis. Often the signs and symptoms are unmanaged within the emergency care environment. This paper discusses the Surviving Sepsis Campaign and outlines a number of management steps that practitioners caring for patients within emergency care can use to reduce mortality. The sepsis resuscitation bundle is discussed in depth as its goals can be achieved within the emergency department. A number of relevant web sites are provided that guide interested readers to other information on the Surviving Sepsis Campaign.     

Prognostic value of noninvasive measures of contractility in emergency department patients with severe sepsis and septic shock undergoing early goal-directed therapy

Purpose

Reversible ventricular dysfunction is common in sepsis. Impedance cardiography allows for noninvasive measurement of contractility through time interval or amplitude-based measures. This study evaluates the prognostic capacity of these measures in patients with severe sepsis or septic shock in the emergency department.

Methods

This is a prospective observational cohort study of 56 patients older than 18 years meeting criteria for early goal-directed therapy (lactate level >4 mmol/L or systolic blood pressure <90 mm Hg after 2-L isotonic sodium chloride solution). Continuous collections of contractility measures were performed, and patients were followed until discharge or in-hospital death.

Results

A significant 57% reduction in the accelerated contractility index (ACI) in nonsurvivors (71 1/s² [41-102]) compared with survivors (123 1/s² [98-147]) existed. Only ACI predicted in-hospital mortality (area under the receiver operating characteristic curve = 0.70, P < .01). Accelerated contractility index did not correlate with amount of prior fluid administration, central venous pressure, number of cardiac risk factors, or troponin I value. An ACI of less than 40 1/s² is 95% (84-99) specific with a positive likelihood ratio of 8.8 for predicting in-hospital mortality.

Conclusions

A reduced ACI is associated with mortality in critically ill emergency department patients presenting with severe sepsis and septic shock meeting criteria for early goal-directed therapy. This association appears to be independent of clinical or laboratory predictors of cardiac dysfunction or preload.     

Predictive value of N-terminal pro-brain natriuretic peptide in severe sepsis and septic shock

OBJECTIVE: The aim of this study was to evaluate the predictive value of N-terminal pro-brain natriuretic peptide (NT-proBNP) on mortality in a large, unselected patient population with severe sepsis and septic shock. DESIGN AND SETTING: Prospective observational cohort study about incidence and prognosis of sepsis in 24 intensive care units in Finland (the FINNSEPSIS study). PATIENTS: A total of 254 patients with severe sepsis or septic shock. MEASUREMENTS: After informed consent, the blood tests for NT-proBNP analyses were drawn on the day of admission and 72 hrs thereafter. Patients' demographic data were collected, and intensive care unit and hospital mortality and basic hemodynamic and laboratory data were recorded daily. MAIN RESULTS: NT-proBNP levels at admission were significantly higher in hospital nonsurvivors (median, 7908 pg/mL) compared with survivors (median, 3479 pg/mL; p = .002), and the difference remained after 72 hrs (p = .002). The receiver operating characteristic curves of admission and 72-hr NT-proBNP levels for hospital mortality resulted in area under the curve values of 0.631 (95% confidence interval, 0.549-0.712; p = .002) and 0.648 (95% confidence interval, 0.554-0.741; p = .002), respectively. In logistic regression analyses, NT-proBNP values at 72 hrs after inclusion and Simplified Acute Physiology Score for the first 24 hrs were independent predictors of hospital mortality. Pulmonary artery occlusion pressure (p < .001), plasma creatinine clearance (p = .001), platelet count (p = .03), and positive blood culture (p = .04) had an independent effect on first-day NT-proBNP values, whereas after 72 hrs, only plasma creatinine clearance (p < .001) was significant in linear regression analysis. CONCLUSION: NT-proBNP values are frequently increased in severe sepsis and septic shock. Values are significantly higher in nonsurvivors than survivors. NT-proBNP on day 3 in the intensive care unit is an independent prognostic marker of mortality in severe sepsis.