The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38:367-374. [PMID: 20035219 DOI: 10.1097/ccm.0b013e3181cb0cdc]

Serum Lactate: A Predictor of Septic Shock in Childhood Cancers with Febrile Neutropenia

Early recognition and management are the key elements to prevent febrile neutropenia associated mortality. The prospective observational study aimed to investigate prognostic accuracy of serum lactate to predict septic shock within 48 hours among hemodynamically stable children with febrile neutropenia. In all, 99 pediatric oncology patients who developed febrile neutropenia were enrolled in the study. Clinical information during 48 hours and serum lactate at the time of enrollment were analyzed. Among 99 participating patients, 10 developed septic shock and 4 of those expired. No significant difference was found of patients’ baseline characteristics and basic laboratory parameters between patients with and without septic shock. Serum lactate was significantly elevated among patients developing septic shock (P-value < .001) and those who expired (P-value .002). Receiver operating characteristic (ROC) curve was created to identify the best cutoff value for initial serum lactate associated with the development of septic shock within 48 hours. Baseline serum lactate more than 2.5 mmol/L showed the largest area under the ROC curve to predict the septic shock development within 48 hours (ROC area, 0.90; 95% confidence interval [CI], 0.81-0.98), with sensitivity, specificity, negative predictive value, and accuracy of 80.0%, 92.1%, 97.6%, and 90.9%, respectively. Serum lactate level determined early at the time of febrile neutropenia was an effective surrogate marker for developing septic shock within 48 hours among hemodynamically stable, pediatric oncology patients. The level more than 2.5 mmol/L was the best threshold to start preemptive aggressive hemodynamic monitoring and prompt treatment to ensure adequate tissue perfusion.

Incidence and Impact of Dysglycemia in Patients with Sepsis Under Moderate Glycemic Control

ABSTRACT

Glycemic control strategies for sepsis have changed significantly over the last decade, but their impact on dysglycemia and its associated outcomes has been poorly understood. In addition, there is controversy regarding the detrimental effects of hyperglycemia in sepsis. To evaluate the incidence and risks of dysglycemia under current strategy, we conducted a preplanned subanalysis of the sepsis cohort in a prospective, multicenter FORECAST study. A total of 1,140 patients with severe sepsis, including 259 patients with pre-existing diabetes, were included. Median blood glucose levels were approximately 140 mg/dL at 0 h and 72 h indicating that blood glucose was moderately controlled. The rate of initial and late hyperglycemia was 27.3% and 21.7%, respectively. The rate of early hypoglycemic episodes during the initial 24 h was 13.2%. Glycemic control was accompanied by a higher percentage of initial and late hyperglycemia but not with early hypoglycemic episodes, suggesting that glycemic control was targeted at excess hyperglycemia. In nondiabetic patients, late hyperglycemia (hazard ratio, 95% confidence interval; p-value: 1.816, 1.116-2.955, 0.016) and early hypoglycemic episodes (1.936, 1.180-3.175, 0.009) were positively associated with in-hospital mortality. Further subgroup analysis suggested that late hyperglycemia and early hypoglycemic episodes independently, and probably synergistically, affect the outcomes. In diabetic patients, however, these correlations were not observed. In conclusion, a significantly high incidence of dysglycemia was observed in our sepsis cohort under moderate glycemic control. Late hyperglycemia in addition to early hypoglycemia was associated with poor outcomes at least in nondiabetic patients. More sophisticated approaches are necessary to reduce the incidence of these serious complications.

Weekend admission and mortality among patients with sepsis: A nationwide cohort study in South Korea

BACKGROUND

This study aimed to investigate whether weekend admission was associated with a higher risk of 90-day mortality in patients with sepsis.

METHODS

This population-based cohort study was based on health records from the National Health Insurance Service database in South Korea. All adult patients (age ≥ 18 years) admitted for sepsis (A40, A41) or septic shock (R65.2) as diagnosed according to the International Classification of Diseases, 10th revision codes, during 2010-2018 were screened. Weekend admission was defined as admission for sepsis on weekends.

RESULTS

In all, 251 837 patients were enrolled, of which 43 327 (17.2%) were in the weekend admission group and 208 510 (82.8%) in the weekday admission group. After propensity score matching, 86 654 patients with sepsis (43 327 patients with sepsis in each group) were included in the analysis. The 90-day mortality rates in the weekend admission and weekday admission groups were 44.3% (19 204/43 327) and 41.9% (18 157/43 327), respectively. On Cox regression analysis, the risk of 90-day mortality in the weekend admission group was 1.09-times higher than that in the weekday admission group (hazard ratio: 1.09, 95% confidence interval: 1.07-1.12; P < .001).

CONCLUSION

Using the national health claims database in South Korea, we showed that weekend admission for diagnosed sepsis was associated with an increased risk of 90-day mortality, compared to that for weekday admission. This might be due to the higher severity of illness in patients with sepsis admitted during the weekend or relatively lesser hospital staff during the weekend.

Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure

The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.

Efficacy of 4-hour rescue therapeutic plasma exchange in severe septic shock patients

BACKGROUND

Early intervention for septic shock is crucial to reduce mortality and improve outcome. There is still a great debate over the exact time of therapeutic plasma exchange (TPE) administration in septic shock patients. This study aims to investigate the effect of early initiation (within 4 hours) of TPE in severe septic shock on hemodynamics & outcome.

METHODS

We conducted a prospective, before-after case series study on 16 septic shock patients requiring high doses of vasopressors admitted in two ICUs from Cairo, Egypt. All of our patients received TPE within 4 hours of ICU admission. The fresh frozen plasma exchange volume = 1.5 × plasma volume.

RESULTS

In the 16 patients included in the study, mean arterial pressure was significantly improved after the initial TPE (p < 0.002) and norepinephrine dose which significantly reduced post TPE (p < 0.001). In addition, norepinephrine dose to mean arterial pressure significantly improved (p < 0.001). There was reduction of a net 6 hours fluid balances following the first TPE were observed in all the patients (p < 0.03) by a mean of 757 ml. Systemic vascular resistance index was markedly improved post-TPE along with statistically improved cardiac index (p < 0.01). Stroke volume variance was also significantly decreased after the TPE sessions (p < 0.01). C-reactive protein significantly improved after TPE (P < 0.01).

CONCLUSION

Early initiation of TPE in severe septic shock patients might improve hemodynamic measures.

Epidemiology of sepsis and septic shock

PURPOSE OF REVIEW

The epidemiology of sepsis and septic shock has been challenging to study for multiple reasons. These include changing diagnostic definitions, as well a high concentration of sepsis-related studies published from high-income countries (HICs), despite a large global burden. This section attempts to address the incidence of sepsis throughout the years and worldwide.

RECENT FINDINGS

The incidence of sepsis and septic shock has continued to increase since the first consensus definitions (Sepsis-1) were established in 1991, and the latest definitions (Sepsis-3) provide a better reflection of mortality risk for a diagnosis of sepsis. Several studies argue that the incidence of sepsis is overreported in HICs, based on billing and coding practices, and may lead to overutilization of resources. However, recent estimates of the true global burden of sepsis, including low-income countries, are likely much higher than reported, with calls for better allocation of resources.

SUMMARY

The true epidemiology of sepsis worldwide continues to be a highly debated subject, and more research is needed among low-income countries and high-risk subpopulations.

Association Between Early Administration of Norepinephrine in Septic Shock and Survival

INTRODUCTION

Septic shock still carries a high mortality rate despite all advances in emergency and critical care practices. Early interventions have been proven in many aspects to improve outcome. However, early administration of vasopressors namely norepinephrine in septic shock is still controversial.

OBJECTIVE

To identify the association between early norepinephrine administration and mortality in septic shock patients.

METHODS

A retrospective review of a prospectively collected ICU data for septic shock patients in medical and surgical intensive care units for one year period was carried out. Case definition was based on sepsis 3 definitions. Data included patients' characteristics of demographics, admission diagnosis, APACHE II score, physiological data (including vital signs and laboratory values). The primary outcome was 28 days of mortality.

RESULTS

A total of 243 patients identified during the study period, 132 (54.3%) were male. The mean age was found to be 58.9 ± 20.3. The overall rate of 28 days mortality was 87 (47.5%). Norepinephrine was started for 68.9% of the patients in ICU, the rest were started in the emergency department. The highest survival rates were among patients who received norepinephrine within first hour (58.1%) and second (51.5%). A binary logistic regression analysis has been performed to adjust for possible confounders. It was revealed that being intubated and mechanically ventilated or having higher APACHE II score were strongly associated with non-survival rates (OR=7.049, p-0.002), (OR=1.124, p-<0.001) respectively.

CONCLUSION

Our results showed that septic shock patients who had early administration of norepinephrine had a higher survival rate. Intubation and invasive ventilation and higher APACHE II score associated with higher none survival rate.

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Analysis of structure indicators influencing 3-h and 6-h compliance with the surviving sepsis campaign guidelines in China: a systematic review

Background

Compliance with the surviving sepsis campaign (SSC) guidelines (C_ssc) is a key factor affecting the effects of sepsis treatment. We designed this study to investigate the relationships of the structure indicators of ICU on 3 and 6-h C_ssc in China.

Methods

A total of 1854 hospitals were enrolled in a survey, led by the China National Critical Care Quality Control Center (China-NCCQC) from January 1, 2018, through December 31, 2018. We investigated the 1854 hospitals’ 3 and 6-h C_ssc, including compliance with each specific measure of the 3-h and 6-h SSC bundles. We also investigated the actual level of the structure indicators of ICU, released by China-NCCQC in 2015.The outcomes were in adherence with the SSC guidelines (2016). Monitoring indicators included 3 and 6-h C_ssc.

Results

In the subgroup, the rate of broad-spectrum antibiotic therapy was the highest, and the rate of CVP and ScvO2 measurement was the lowest among the items of 3 and 6-h C_ssc. Structure indicators related to 3 and 6-h C_ssc include the predicted mortality rate and the standardized mortality ratio (SMR). The relationships between 3 and 6-h C_ssc and the proportion of ICU in total inpatient bed occupancy, the proportion of acute physiology and chronic health evaluation (APACHE) II score ≥ 15 in all ICU patients were uncertain. There was no relationship of 3 and 6-h C_ssc with the proportion of ICU patients among total inpatients.

Conclusions

Structure indicators influencing 3 and 6-h C_ssc in China are the predicted mortality rate and the standardized mortality rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-021-00498-7.

The FAST-M complex intervention for the detection and management of maternal sepsis in low-resource settings: a multi-site evaluation

OBJECTIVE

To evaluate whether the implementation of the FAST-M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low-resource setting.

DESIGN

A before-and-after design.

SETTING

Fifteen government healthcare facilities in Malawi.

POPULATION

Women suspected of having maternal sepsis.

METHODS

The FAST-M complex intervention consisted of the following components: the FAST-M maternal sepsis treatment bundle and the FAST-M implementation programme. Performance of selected process outcomes was compared between a 2-month baseline phase and 6-month intervention phase with compliance used as a proxy measure of feasibility.

MAIN OUTCOME RESULT

Compliance with vital sign recording and use of the FAST-M maternal sepsis bundle.

RESULTS

Following implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.

CONCLUSION

Implementation of the FAST-M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low-resource setting such as Malawi.

TWEETABLE ABSTRACT

Implementation of a sepsis care bundle for low-resources improved recognition & management of maternal sepsis.

Low fluid intake volume during the first 24 h and persistent negative fluid balance from the second day are associated with favorable prognosis for patients with sepsis

For patients with sepsis and septic shock, it remains controversial when to restrict fluid intake and achieve a negative fluid balance. The present study aimed to evaluate the effects of the fluid intake volume during the first 24 h as well as fluid balance for 7 days on the prognosis of sepsis or septic shock. A total of 337 patients diagnosed with sepsis or septic shock at Ruijin Hospital (Shanghai, China) were enrolled in the present retrospective study. Patients with a low fluid intake volume during the first 24 h (fluid intake, 28.1±10.6 ml/kg) had lower in-hospital mortality rates (18.0 vs. 27.3%, P=0.043) and a shorter duration of mechanical ventilation [0 (0-6) vs. 3 (0-11), P=0.025] than the high-fluid volume intake group (62.6±17.6 ml/kg). Furthermore, survivors exhibited a daily negative net fluid balance from the second day (48 h), whereas non-survivors had a daily positive net fluid balance for 7 days, where fluid balance volumes were significantly lower in survivors compared with those in non-survivors. Finally, binary logistic regression analysis was used to determine whether the mean daily fluid balance (P<0.001) and the Acute Physiologic and Chronic Health Evaluation II score (P=0.048) were independent prognostic factors for patients with sepsis or septic shock. It was indicated that a low fluid intake volume during the first 24 h and a persistent negative fluid balance from the second day were associated with favorable outcomes. The mean daily fluid balance was an independent prognostic factor or patients with sepsis or septic shock.

Comparison of SOFA Score, SIRS, qSOFA, and qSOFA + L Criteria in the Diagnosis and Prognosis of Sepsis

Objective

Sepsis has been defined as a life-threatening organ dysfunction that develops as a result of impaired host response to infection. This study aimed to investigate sequential organ failure assessment (SOFA) score, systemic inflammatory response syndrome (SIRS), quick SOFA (qSOFA), and qSOFA + lactate criteria (qSOFA+L) in the diagnosis and prognosis of sepsis.

Materials and Methods

A retrospective study was performed that included all patients diagnosed with sepsis between January 1, 2013 and December 31, 2017 in Izmir Tepecik Training and Research Hospital Infectious Diseases and Clinical Microbiology Clinic.

Results

A total of 976 patients diagnosed with sepsis (mean age 72.5±13.7 years, 52.7% women) over five years were included in this study. Of all patients admitted to the emergency department and diagnosed with sepsis, 37.4% (n=365) were hospitalized and 52.3% (n=191) of these patients died. Emergency department mortality was 12.5% (n=122). The mortality rate was higher in patients with qSOFA and qSOFA+L criteria ≥2 in the emergency department. There was no statistically significant difference in terms of SIRS, qSOFA, or qSOFA+L criteria among patients who died in the hospital. The SOFA score (area under receiver operator characteristic curve, AUC=0.89) was highly discriminative in predicting sepsis. When the SOFA score was>11, its sensitivity and negative predictive values were both 100%. The SOFA score (AUC=0.75 and 0.72, respectively) was also highly discriminative in predicting emergency and in-hospital mortality. When the SOFA score was>11, the sensitivity and specificity of predicting emergency department mortality were 63.5% and 78.8%, respectively. The sensitivity was 65.8% and the specificity was 75.5% when describing in-hospital mortality for SOFA scores>9.

Conclusion

The SOFA score was highly sensitive and predictive in the diagnosis of sepsis. The SOFA score had a high discriminative ability to predict emergency and in-hospital mortality.

Beclin-1 improves mitochondria-associated membranes in the heart during endotoxemia

Mitochondria‐associated membranes (MAMs) are essential to mitochondria. This study was to determine whether endotoxemia rearranges MAMs in the heart, and whether Beclin‐1 regulates this process. Wild‐type mice and mice with a cardiac‐specific overexpression of Beclin‐1 (Becn1‐Tg), or a heterozygous knockout of Beclin‐1 (Becn1^+/−) were given lipopolysaccharide (LPS) challenge. In the heart, the ultrastructure of MAMs was examined by electron microscopy and the histology evaluated by immunostaining. Additionally, MAMs were isolated by ultracentrifugation, and their content and function were quantified. The effects of Beclin‐1‐activating peptide (TB‐peptide) on MAMs were also examined. Data showed that endotoxemia decreased both the total mass and the function of MAMs, and these deficiencies became worse in Becn1^+/− mice but were alleviated in Becn1‐Tg and TB‐peptide‐treated mice. Responses of myocardial MAMs to LPS and to TB‐peptide were additionally examined in AC16 human cardiomyocytes. In vitro findings recaptured the effects of LPS and TB‐peptide in cardiomyocytes; the challenge of LPS reduced the level and activity of MAMs, and TB‐peptide attenuated this defect. Together, the results suggest a new function of Beclin‐1 in improving cardiac MAMs during endotoxemia, providing a mechanism for the previously identified role of Beclin‐1 in protection of mitochondria and cardiac function.

Hydrogen Sulfide and its Interaction with Other Players in Inflammation

Hydrogen sulfide (H₂S) plays a vital role in human physiology and in the pathophysiology of several diseases. In addition, a substantial role of H₂S in inflammation has emerged. This chapter will discuss the involvement of H₂S in various inflammatory diseases. Furthermore, the contribution of reactive oxygen species (ROS), adhesion molecules, and leukocyte recruitment in H₂S-mediated inflammation will be discussed. The interrelationship of H₂S with other gasotransmitters in inflammation will also be examined. There is mixed literature on the contribution of H₂S to inflammation due to studies reporting both pro- and anti-inflammatory actions. These apparent discrepancies in the literature could be resolved with further studies.

Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study

BACKGROUND

Delay to theatre for patients with intra-abdominal sepsis is cited as a particular risk factor for death. Our aim was to evaluate the potential relationship between hourly delay from admission to surgery and post-operative mortality in patients with perforated peptic ulcer (PPU).

METHODS

All patients entered in the National Emergency Laparotomy Audit who had an emergency laparotomy for PPU within 24 h of admission from December 2013 to November 2017 were included. Time to theatre from admission was modelled as a continuous variable in hours. Outcome was 90-day mortality. Logistic regression adjusting for confounding factors was performed.

RESULTS

3809 patients were included, and 90-day mortality rate was 10.61%. Median time to theatre was 7.5 h (IQR 5-11.6 h). The odds of death increased with time to operation once adjustment for confounding variables was performed (per hour after admission adjusted OR 1.04 95% CI 1.02-1.07). In patients who were physiologically shocked (N = 334), there was an increase of 6% in risk-adjusted odds of mortality for every hour Em Lap was delayed after admission (OR 1.06 95% CI 1.01-1.11).

CONCLUSION

Hourly delay to theatre in patients with PPU is independently associated with risk of death by 90 days. Therefore, we suggest that surgical source control should occur as soon as possible after admission regardless of time of day.

Efficacy and safety of antimicrobial de-escalation of treatment for sepsis: A protocol for systematic review and meta-analysis

BACKGROUND

Sepsis has become a global healthcare problem and continues to be one of the leading causes of death due to infection. In essence, early recognition and diagnosis of sepsis is needed to inhibit the transition into septic shock, which is correlated with higher mortality. Many studies have suggested antimicrobial de-escalation as one of the strategies to replace the empirical broad-spectrum antimicrobial treatment using a narrower antimicrobial therapy, especially among patients with sepsis. However, antimicrobial de-escalation therapeutic effects in sepsis remains unclear. We therefore performed the present study in an attempt to assess efficacy and safety of antimicrobial de-escalation therapy in patients with sepsis.

METHODS

We will carry out a systematic literature search to establish the potentially eligible trials from electronic databases, including EMBASE (1980 to October 16, 2020), MEDLINE via PubMed (1966 to October 16, 2020), Web of Science (1965 to October 16, 2020), Cochrane Library (CENTRAL; 2020, Issue 10), WanFang databases (last searched October 16, 2020), and China National Knowledge Infrastructure (CNKI; last searched October 16, 2020). For this study, the language restrictions are English or Chinese. Two authors independently examined quality based on the Cochrane Risk of Bias Tool V.2.0 and extracted data. Data obtained from the study will be synthesised using applicable statistical methods.

RESULTS

The results of the present study will systematically assess efficacy and safety of antimicrobial de-escalation therapy among patients with sepsis.

CONCLUSION

The results of the present study will help to establish the efficacy and safety of antimicrobial de-escalation to treat patients with sepsis. It can also help to identify the most efficient and safe therapeutically-relevant method.

ETHICS AND DISSEMINATION

The present study is a meta-analysis and the pooled results are based on published evidence. Therefore, ethics approval is not necessary.

OSF REGISTRATION NUMBER

October 22, 2020.osf.io/93wym. (https://osf.io/93wym/).

A Multimodal Sepsis Quality-Improvement Initiative Including 24/7 Screening and a Dedicated Sepsis Response Team-Reduced Readmissions and Mortality

Objectives

To evaluate if a hospitalwide sepsis performance improvement initiative improves compliance with the Centers for Medicare and Medicaid Services-mandated sepsis bundle interventions and patient outcomes.

Study Design

Retrospective analysis comparing 6 months before and 14 months after intervention.

Setting

Tertiary teaching hospital in Washington, DC.

Subjects

Patients admitted with a diagnosis of sepsis to a tertiary hospital.

Interventions

Implementation of a multimodal quality-improvement initiative.

Measurements and Main Results

A total of 4,102 patients were diagnosed with sepsis, severe sepsis, or septic shock during the study period, 861 patients (21%) were diagnosed during a 6-month preintervention period, and 3,241 (79%) were diagnosed in a 13-month postintervention period. Adjusted for patient case-mix, the prevalence of simple sepsis increased by 12%, but it decreased for severe sepsis and septic shock by 5.3% and 6.9%, respectively. Compliance with all sepsis bundle interventions increased by 31.1 percentage points (p < 0.01). All-cause hospital readmission and readmission due to infection were both reduced by 1.6% and 1.7 percentage points (p < 0.05). Death from any sepsis diagnosis was reduced 4.5% (p < 0.01). Death from severe sepsis and septic shock both was reduced by 5% (p < 0.01) and 6.5% (p < 0.01), respectively.

Conclusions

After the implementation of multimodal sepsis performance initiatives, we observed a higher prevalence of sepsis secondary to screening but a lower prevalence of severe sepsis and septic shock, an improvement in compliance with the sepsis bundle interventions bundle, as well as reduction in hospital readmission and all- cause mortality rate.

Association between thrombomodulin and high mobility group box 1 in sepsis patients

BACKGROUND

High mobility group box 1 (HMGB1) has been studied as a molecule associated with severe outcomes in sepsis and thrombomodulin (TM) seems to decrease HMGB1 activity.

AIM

To investigate the role of the thrombomodulin/high mobility group box 1 (T/H) ratio in patients with sepsis and their association with their clinic, testing the hypothesis that higher ratios are associated with better outcomes.

METHODS

Twenty patients diagnosed with sepsis or septic shock, according to the 2016 criteria sepsis and septic shock (Sepsis-3), were studied. Patients were followed until they left the intensive care unit or until they achieved 28 d of hospitalization (D28). The following clinical outcomes were observed: Sequential Organ Failure Assessment (SOFA) score; Need for mechanical pulmonary ventilation; Presence of septic shock; Occurrence of sepsis-induced coagulopathy; Need for renal replacement therapy (RRT); and Death.

RESULTS

The results showed that patients with SOFA scores greater than or equal to 12 points had higher serum levels of TM: 76.41 ± 29.21 pg/mL vs 37.41 ± 22.55 pg/mL among those whose SOFA scores were less than 12 points, P = 0.003. The T/H ratio was also higher in patients whose SOFA scores were greater than or equal to 12 points, P = 0.001. The T/H ratio was, on average, three times higher in patients in need of RRT (0.38 ± 0.14 vs 0.11 ± 0.09), P < 0.001.

CONCLUSION

Higher serum levels of TM and, therefore, higher T/H ratio in the first 24 h after the diagnosis of sepsis were associated with more severe disease and the need for renal replacement therapy, while those with better clinical outcomes and those who were discharged before D28 showed a tendency for lower T/H ratio values.

Effect of sedation with dexmedetomidine or propofol on gastrointestinal motility in lipopolysaccharide-induced endotoxemic mice

Background

Sepsis often accompanies gastrointestinal motility disorder that contributes to the development of sepsis in turn. Propofol and dexmedetomidine, as widely used sedatives in patients with sepsis, are likely to depress gastrointestinal peristalsis. We queried whether propofol or dexmedetomidine, at sedative doses, aggravated sepsis-induced ileus.

Methods

Sedative/Anesthetic Scores and vital signs of lipopolysaccharide (LPS)-induced endotoxemic mice were measured during sedation with propofol or dexmedetomidine. Endotoxemic mice were divided into 10% fat emulsion, propofol, saline, and dexmedetomidine group. The gastric emptying, small intestinal transit, tests of colonic motility, gastrointestinal transit and whole gut transit were evaluated at 15 mins and 24 h after intraperitoneal injection of sedatives/vehicles respectively.

Results

40 mg·kg^− 1propofol and 80 μg·kg^− 1 dexmedetomidine induced a similar depth of sedation with comparable vital signs except that dexmedetomidine strikingly decreased heart rate in endotoxemic mice. Dexmedetomidine markedly inhibited gastric emptying (P = 0.006), small intestinal transit (P = 0.006), colonic transit (P = 0.0006), gastrointestinal transit (P = 0.0001) and the whole gut transit (P = 0.034) compared with the vehicle, whereas propofol showed no depression on all parts of gastrointestinal motility 15 mins after administration. The inhibitive effects of dexmedetomidine in these tests vanished 24 h after the administration.

Conclusions

Deep sedation with dexmedetomidine, but not propofol, significantly inhibited gastrointestinal peristalsis in endotoxemic mice while the inhibitory effect disappeared 24 h after sedation. These data suggested that both propofol and dexmedetomidine could be applied in septic patients while dexmedetomidine should be used cautiously in patients with cardiac disease or ileus.

Antibiotics in the first hour: is there new evidence?

INTRODUCTION

International guidelines have recommended for many years to start antimicrobials as early as possible in sepsis and shock. This concept has been challenged by the controversial results of experimental studies and clinical cohorts and resulted in intense debate in the literature. This review aims to summarize the available knowledge on early antimicrobial therapy and to consider perspectives.

AREAS COVERED

First, after a research using MEDLINE, we reviewed the studies that advocated the implementation of early antimicrobial therapy. We then discussed the drawbacks of these studies. Finally, we suggested possible explanations of the benefit and then absence of the prognostic impact of early antimicrobial therapy i.e. confounding factors, irreversibility of the inflammatory process, non-control of the source of the infection, pharmacodynamic considerations and the harmful effect of antimicrobial drugs.

EXPERT OPINION

Sepsis is very heterogeneous. The first antimicrobial therapy should be personalized. The sickest patients should be given early antimicrobial therapy, whereas a 'watch and wait process' should be preferred for less severe patients, to allow confirmation of sepsis, identification of pathogens and administration of adequate antimicrobial therapy. We propose steps to personalize the first antimicrobial therapy. New early diagnostic tools will assist the physicians in the future.

Notice to comply: A systematic review of clinician compliance with guidelines surrounding acute hospital-based infection management

PURPOSE

To identify and characterize studies evaluating clinician compliance with infection-related guidelines, and to explore trends in guideline design and implementation strategies.

DATA SOURCES

PubMed database, April 2017. Followed the PRISMA Statement for systematic reviews.

STUDY SELECTION

Scope was limited to studies reporting compliance with guidelines pertaining to the prevention, detection, and/or treatment of acute hospital-based infections. Initial search (1,499 titles) was reduced to 49 selected articles.

DATA EXTRACTION

Extracted publication and guideline characteristics, outcome measures reported, and any results related to clinician compliance. Primary summary measures were frequencies and distributions of characteristics. Interventions that led to improved compliance results were analyzed to identify trends in guideline design and implementation.

RESULTS OF DATA SYNTHESIS

Of the 49 selected studies, 18 (37%), 13 (27%), and 10 (20%) focused on sepsis, pneumonia, and general infection, respectively. Six (12%), 17 (35%), and 26 (53%) studies assessed local, national, and international guidelines, respectively. Twenty studies (41%) reported 1-instance compliance results, 28 studies (57%) reported 2-instance compliance results (either before-and-after studies or control group studies), and 1 study (2%) described compliance qualitatively. Average absolute change in compliance for minimal, decision support, and multimodal interventions was 10%, 14%, and 25%, respectively. Twelve studies (24%) reported no patient outcome alongside compliance.

CONCLUSIONS

Multimodal interventions and quality improvement initiatives seem to produce the greatest improvement in compliance, but trends in other factors were inconsistent. Additional research is required to investigate these relationships and understand the implications behind various approaches to guideline design, communication, and implementation, in addition to effectiveness of protocol impact on relevant patient outcomes.

PDK1/mTOR Signaling in Myeloid Cells Differentially Regulates the Early and Late Stages of Sepsis

The cecal ligation and perforation (CLP) model is the gold standard for the polymicrobial sepsis. In the CLP mice, the myeloid cells play an important role in septic shock. The phenotypes and the activation state of the macrophage and neutrophil correlate with their metabolism. In the present study, we generated the specific myeloid deletion of PDK1 and mTOR mice, which was the important regulator of metabolic signaling. We found that the deletion of PDK1 in the myeloid cells could aggravate the early septic shock in the CLP mice, as well as the deletion of mTORC1 and mTORC2. Moreover, PDK1 deletion attenuated the inflammation induced by LPS in the late stage on CLP mice, which was exacerbated in mTORC1 and mTORC2 knockout mice. Both PDK1 and mTORC1/2 could not only regulate the cellular metabolism but also play important roles on the myeloid cells in the secondary stimulation of sepsis. The present study will provide a theoretical prospect for the therapy of the septic shock in different stages.

Epidemiology of sepsis and septic shock in intensive care units between sepsis-2 and sepsis-3 populations: sepsis prognostication in intensive care unit and emergency room (SPICE-ICU)

Background

Diagnosing sepsis remains difficult because it is not a single disease but a syndrome with various pathogen- and host factor-associated symptoms. Sepsis-3 was established to improve risk stratification among patients with infection based on organ failures, but it has been still controversial compared with previous definitions. Therefore, we aimed to describe characteristics of patients who met sepsis-2 (severe sepsis) and sepsis-3 definitions.

Methods

This was a multicenter, prospective cohort study conducted by 22 intensive care units (ICUs) in Japan. Adult patients (≥ 16 years) with newly suspected infection from December 2017 to May 2018 were included. Those without infection at final diagnosis were excluded. Patient’s characteristics and outcomes were described according to whether they met each definition or not.

Results

In total, 618 patients with suspected infection were admitted to 22 ICUs during the study, of whom 530 (85.8%) met the sepsis-2 definition and 569 (92.1%) met the sepsis-3 definition. The two groups comprised different individuals, and 501 (81.1%) patients met both definitions. In-hospital mortality of study population was 19.1%. In-hospital mortality among patients with sepsis-2 and sepsis-3 patients was comparable (21.7% and 19.8%, respectively). Patients exclusively identified with sepsis-2 or sepsis-3 had a lower mortality (17.2% vs. 4.4%, respectively). No patients died if they did not meet any definitions. Patients who met sepsis-3 shock definition had higher in-hospital mortality than those who met sepsis-2 shock definition.

Conclusions

Most patients with infection admitted to ICU meet sepsis-2 and sepsis-3 criteria. However, in-hospital mortality did not occur if patients did not meet any criteria. Better criteria might be developed by better selection and combination of elements in both definitions.

Trial registration

UMIN000027452

Lactate/albumin ratio: An early prognostic marker in critically ill patients

OBJECTIVES

We investigate the clinical utility of the lactate/albumin (L/A) ratio as an early prognostic marker of ICU mortality in a large cohort of unselected critically ill patients.

METHODS

A retrospective single-center study using data from the Multiparameter Intelligent Monitoring Intensive Care III (MIMIC-III) database collected between 2001 and 2012. We screened adult patients (age ≥ 15) with measured lactate and albumin on the first day of ICU stay to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for ICU mortality prediction.

RESULTS

The overall ICU mortality in the 6414 eligible ICU patients was 16.4%. L/A showed a receiver-operating characteristics area under the curve (ROC-AUC) value of 0.69 (95% CI: 0.67, 0.70) to predict ICU mortality, higher than lactate 0.67 (95%CI: 0.65, 0.69). Regardless of the lactate level, L/A yielded better ROC-AUC compared to the lactate level [normal lactate (<2.0 mmol/L): 0.63 vs 0.60; intermediate lactate (2.0 mmol/L ≤ lactate <4.0 mmol/L): 0.58 vs 0.56; high lactate (≥4.0 mmol/L): 0.67 vs 0.66]. L/A was a better prognostic marker for ICU mortality in patients with decreased lactate elimination [hepatic dysfunction: 0.72 vs 0.70; renal dysfunction 0.70 vs 0.68]. The L/A ratio ROC-AUC was better in patients with sepsis (0.68 vs 0.66) and those who developed severe sepsis or septic shock (0.68 vs 0.66).

CONCLUSIONS

The performance of L/A and lactate were equivalent in predicting ICU mortality and can be used as early prognostic markers for ICU patients with different initial lactate level and the presence of hepatic or renal dysfunction.

Association of weekend admission and clinical outcomes in hospitalized patients with sepsis: An observational study

Sepsis is associated with impaired clinical outcomes. It requires timely diagnosis and urgent therapeutic management. Because staffing during after-hours is limited, we explored whether after-hour admissions are associated with worse clinical outcomes in patients with sepsis.In this retrospective cohort study, we analyzed nationwide acute care admissions for a main diagnosis of sepsis in Switzerland between 2006 and 2016 using prospective administrative data. The primary outcome was in-hospital mortality using multivariable logistic regression models. Secondary outcomes were intensive care unit (ICU) admission, intubation, and 30-day readmission.We included 86,597 hospitalizations for sepsis, 60.1% admitted during routine-hours, 16.8% on weekends and 23.1% during night shift. Compared to routine-hours, we found a higher odds ratio (OR) for in-hospital mortality in patients admitted on weekends (Adjusted OR 1.05, 95% confidence interval [95% CI] 1.01, 1.10, P = .041). Also, the OR for ICU admission (OR 1.14, 95% CI 1.10, 1.19, P < .001) and intubation (OR 1.18, 95% CI 1.12, 1.25 P < .001) was higher for weekends compared to routine-hours. Regarding 30-day readmission, evidence for an association could not be observed. Night shift admission, compared to routine-hours, was associated with a higher OR for ICU admission and intubation (ICU admission: OR 1.28 (1.23, 1.32), P < .001; intubation: OR 1.31, 95% CI 1.25, 1.37, P < .001) but with a lower OR for in-hospital mortality (OR 0.93, 19% CI 0.89, 0.97, P = .001).Among hospitalizations with a main diagnosis of sepsis, weekend admissions were associated with higher OR for in-hospital mortality, ICU admission, and intubation. Whether these findings can be explained by staffing-level differences needs to be addressed.

Time to vasopressor initiation and organ failure progression in early septic shock

OBJECTIVE

Research evaluating the relationship between vasopressor initiation timing and clinical outcomes is limited and conflicting. We investigated the association between time to vasopressors, worsening organ failure, and mortality in patients with septic shock.

METHODS

This was a retrospective study of patients with septic shock (2013-2016) within 24 hours of emergency department (ED) presentation. The primary outcome was worsening organ failure, defined as an increase in Sequential Organ Failure Assessment (SOFA) score ≥2 at 48 hours compared to baseline, or death within 48 hours. The secondary outcome was 28-day mortality. Time to vasopressor initiation was categorized into 6, 4-hour intervals from time of ED triage. Multiple logistic regression was used to identify predictors of worsening organ failure.

RESULTS

We analyzed data from 428 patients with septic shock. There were 152 patients with the composite primary outcome (SOFA increase ≥2 or death at 48 hours). Of these, 77 patients died in the first 48 hours and 75 patients had a SOFA increase ≥2. Compared to the patients who received vasopressors in the first 4 hours, those with the longest time to vasopressors (20-24 hours) had increased odds of developing worsening organ failure (odds ratios [OR] = 4.34, 95% confidence intervals [CI] = 1.47-12.79, P = 0.008). For all others, the association between vasopressor timing and worsening organ failure was non-significant. There was no association between time to vasopressor initiation and 28-day mortality.

CONCLUSIONS

Increased time to vasopressor initiation is an independent predictor of worsening organ failure for patients with vasopressor initiation delays >20 hours.

Neutrophil and monocyte receptor expression in patients with sepsis: implications for diagnosis and prognosis of sepsis

Understanding the complex immune responses in sepsis is crucial to provide insight into the clinical syndrome. We evaluated the changes in the surface receptors of the cells of innate immunity, neutrophils and monocytes, in patients with sepsis. Since sepsis remains a clinical challenge, we aimed to assess the significance of altered receptor expression in diagnosis and prognosis. Critically ill patients with sepsis (n=31) were investigated for the expression of receptors for IgG heavy chain CD64 and CD16 on neutrophils and CD64 and the lipopolysaccharide receptor CD14 on monocytes by flow cytometry and compared to 23 patients with no sepsis. Patients with sepsis had increased expression of neutrophil CD64. Neutrophil CD64 was specific for discriminating patients with sepsis but showed weak sensitivity. When integrated in a scoring system, neutrophil CD64 in combination with C-reactive protein (CRP) and SOFA score showed a diagnostic accuracy of 0.93 for sepsis and significantly predicted increased mortality risk. While neutrophil CD16 did not discriminate for sepsis, decreased expression was associated with increased mortality risk. In contrast, monocyte CD64 and CD14 expression was unaltered in sepsis and was not associated with mortality risk. Our study demonstrates that unlike monocytes, neutrophil receptor expression is altered in patients with sepsis receiving intensive care. It is promising to apply a combination approach to diagnose sepsis especially in time-limited conditions.

Dysregulated activities of proline-specific enzymes in septic shock patients (sepsis-2)

The proline-specific enzymes dipeptidyl peptidase 4 (DPP4), prolylcarboxypeptidase (PRCP), fibroblast activation protein α (FAP) and prolyl oligopeptidase (PREP) are known for their involvement in the immune system and blood pressure regulation. Only very limited information is currently available on their enzymatic activity and possible involvement in patients with sepsis and septic-shock. The activity of the enzymes was measured in EDTA-plasma of patients admitted to the intensive care unit (ICU): 40 septic shock patients (sepsis-2) and 22 ICU control patients after major intracranial surgery. These data were used to generate receiver operating characteristic (ROC) curves. A survival analysis (at 90 days) and an association study with other parameters was performed. PRCP (day 1) and PREP (all days) enzymatic activities were higher in septic shock patients compared to controls. In contrast, FAP and DPP4 were lower in these patients on all studied time points. Since large differences were found, ROC curves were generated and these yielded area under the curve (AUC) values for PREP, FAP and DPP4 of 0.88 (CI: 0.80-0.96), 0.94 (CI: 0.89-0.99) and 0.86 (CI: 0.77-0.95), respectively. PRCP had a lower predicting value with an AUC of 0.71 (CI: 0.58-0.83). A nominally significant association was observed between survival and the DPP4 enzymatic activity at day 1 (p<0.05), with a higher DPP4 activity being associated with an increase in survival. All four enzymes were dysregulated in septic shock patients. DPP4, FAP and PREP are good in discriminating between septic shock patients and ICU controls and should be further explored to see whether they are already dysregulated in earlier stages, opening perspectives for their further investigation as biomarkers in sepsis. DPP4 also shows potential as a prognostic biomarker. Additionally, the associations found warrant further research.

National Performance on the Medicare SEP-1 Sepsis Quality Measure

OBJECTIVES

The Centers for Medicare and Medicaid Services requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. We used recently released data from this program to characterize national performance on the sepsis measure, known as SEP-1.

DESIGN

Cross-sectional study of United States hospitals participating in the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program linked to Centers for Medicare and Medicaid Services' Healthcare Cost Reporting Information System.

SETTING

General, short-stay, acute-care hospitals in the United States.

MEASUREMENTS AND MAIN RESULTS

We examined the hospital factors associated with reporting SEP-1 data, the hospital factors associated with performance on the SEP-1 measure, and the relationship between SEP-1 performance and performance on other quality measures related to time-sensitive medical conditions. A total of 3,283 hospitals were eligible for the analysis, of which 2,851 (86.8%) reported SEP-1 performance data. SEP-1 reporting was more common in larger, nonprofit hospitals. The most common reason for nonreporting was an inadequate case volume. Among hospitals reporting SEP-1 performance data, overall bundle compliance was generally low, but it varied widely across hospitals (mean and SD: 48.9% ± 19.4%). Compared with hospitals with worse SEP-1 performance, hospitals with better SEP-1 performance tended to be smaller, for-profit, nonteaching, and with intermediate-sized ICUs. Better hospital performance on SEP-1 was associated with higher rates of timely head CT interpretation for stroke patients (rho = 0.16; p < 0.001), more frequent aspirin administration for patients with chest pain or heart attacks (rho = 0.24; p < 0.001) and shorter median time to electrocardiogram for patients with chest pain (rho = -0.12; p < 0.001).

CONCLUSIONS

The majority of eligible hospitals reported SEP-1 data, and overall bundle compliance was highly variable. SEP-1 performance was associated with structural hospital characteristics and performance on other measures of hospital quality, providing preliminary support for SEP-1 performance as a marker of timely hospital sepsis care.

Is Lactic Acidosis After Lung Transplantation Associated With Worse Outcomes?

BACKGROUND

Elevated lactate levels may be caused by increased production suggestive of tissue ischemia; however, they may also occur without evidence of ischemia, by catecholamine activation of beta receptors. The purpose of this study was to determine the factors associated with increased lactate levels during and after lung transplantation and to evaluate whether lactate levels were associated with increased time to extubation and postoperative complications.

METHODS

This was a retrospective study of patients who underwent lung transplantation between January 2015 and May 2017 at the University of Michigan, Ann Arbor, MI. Multivariable linear regression was used to determine the factors associated with peak lactate levels and to find the associations between lactate levels and outcomes of nitric oxide time, intubation time, length of stay, and creatinine level. Logistic regression was used to determine the associations between lactate levels and acute kidney injury and atrial fibrillation.

RESULTS

A total of 86 patients underwent single-lung transplantation (n = 17; 20%) or double-lung transplantation (n = 69; 80%). All patients initially had normal lactate levels. On univariate analysis, lactate levels at several time points were correlated with subsequent acute kidney injury, increased time to extubation, and increased nitric oxide time. After adjustment, the study found that higher peak intensive care unit lactate levels (regression coefficient B = 0.046; interquartile range, 0.006, 0.086; P = .025) were associated with longer length of stay.

CONCLUSIONS

Cardiopulmonary bypass time, total ischemic time, and catecholamine use were associated with higher lactate levels, whereas nitric oxide and higher pulmonary artery pressures were associated with lower levels. Increased lactate levels were independently associated with longer intubation times, postoperative acute kidney injury, and longer length of stay.

Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis

BACKGROUND

Optimal timing for the start of vasopressors (VP) in septic shock has not been widely studied since it is assumed that fluids must be administered in advance. We sought to evaluate whether a very early start of VP, even without completing the initial fluid loading, might impact clinical outcomes in septic shock.

METHODS

A total of 337 patients with sepsis requiring VP support for at least 6 h were initially selected from a prospectively collected database in a 90-bed mixed-ICU during a 24-month period. They were classified into very-early (VE-VPs) or delayed vasopressor start (D-VPs) categories according to whether norepinephrine was initiated or not within/before the next hour of the first resuscitative fluid load. Then, VE-VPs (n = 93) patients were 1:1 propensity matched to D-VPs (n = 93) based on age; source of admission (emergency room, general wards, intensive care unit); chronic and acute comorbidities; and lactate, heart rate, systolic, and diastolic pressure at vasopressor start. A risk-adjusted Cox proportional hazard model was fitted to assess the association between VE-VPs and day 28 mortality. Finally, a sensitivity analysis was performed also including those patients requiring VP support for less than 6 h.

RESULTS

Patients subjected to VE-VPs received significantly less resuscitation fluids at vasopressor starting (0[0-510] vs. 1500[650-2300] mL, p < 0.001) and during the first 8 h of resuscitation (1100[500-1900] vs. 2600[1600-3800] mL, p < 0.001), with no significant increase in acute renal failure and/or renal replacement therapy requirements. VE-VPs was related with significant lower net fluid balances 8 and 24 h after VPs. VE-VPs was also associated with a significant reduction in the risk of death compared to D-VPs (HR 0.31, CI95% 0.17-0.57, p < 0.001) at day 28. Such association was maintained after including patients receiving vasopressors for < 6 h.

CONCLUSION

A very early start of vasopressor support seems to be safe, might limit the amount of fluids to resuscitate septic shock, and could lead to better clinical outcomes.

Sepsis trends: increasing incidence and decreasing mortality, or changing denominator?

Numerous studies suggest that the incidence of sepsis has been steadily increasing over the past several decades while mortality rates are falling. However, reliably assessing trends in sepsis epidemiology is challenging due to changing diagnosis and coding practices over time. Ongoing efforts by clinicians, administrators, policy makers, and patient advocates to increase sepsis awareness, screening, and recognition are leading to more patients being labeled with sepsis. Subjective clinical definitions and heterogeneous presentations also allow for wide discretion in diagnosing sepsis rather than specific infections alone or non-specific syndromes. These factors create a potential ascertainment bias whereby the inclusion of less severely ill patients in sepsis case counts over time leads to a perceived increase in sepsis incidence and decrease in sepsis mortality rates. Analyses that rely on administrative data alone are further confounded by changing coding practices in response to new policies, financial incentives, and efforts to improve documentation. An alternate strategy for measuring sepsis incidence, outcomes, and trends is to use objective and consistent clinical criteria rather than administrative codes or registries to identify sepsis. This is feasible using data routinely found in electronic health record systems, such as blood culture draws and sustained courses of antibiotics to identify infection and laboratory values, vasopressors, and mechanical ventilation to measure acute organ dysfunction. Recent surveillance studies using this approach suggest that sepsis incidence and mortality rates have been essentially stable over the past decade. In this review, we summarize the major epidemiologic studies of sepsis trends, potential biases in these analyses, and the recent change in the surveillance paradigm toward using objective clinical data from electronic health records to more accurately characterize sepsis trends.

Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach

Sepsis and septic shock are medical emergencies, with high associated mortality. The Surviving Sepsis Campaign has developed definitions and management guidelines, emphasizing the use of hour-1 care bundle. Anesthesiologists frequently encounter sepsis when source control is required. The authors summarize expected manifestations of organ dysfunction and state-of-the-art management of patients with sepsis and septic shock. They highlight an increasingly vital role point-of-care ultrasound examination in the recognition and management of hemodynamic derangements in this patient population. Supporting the role of anesthesiologists as perioperative physicians, the authors provide a framework for transitions of care between operating room and intensive care units.

Long-term survival after intensive care: A retrospective cohort study

Background Limited data exist on long-term survival of patients requiring admission to intensive care units (ICUs). The aim of this study was to investigate long-term survival of ICU patients in Iceland and assess changes over a 15-year period. Methods Data were collected on age, gender, admission cause, length of stay, comorbidities, mechanical ventilation and survival of patients 18 years and older admitted to the ICUs in Landspitali during 2002-2016. Long-term survival of patients surviving more than 30 days from admission was estimated and its predictors assessed with Cox regression analysis. Long-term survival was compared to the survival of an age- and gender-matched reference group from the general population. Results Of 15 832 ICU admissions, 55% was medical, 38% was surgical and 7% was due to trauma. The 5-year survival of medical, surgical and trauma patients was 66%, 76% and 92% respectively. Significant survival differences were found between admission subgroups. Higher age and comorbidity burden was related to decreased survival in all patient groups. After correcting for age, gender, comorbidities, length of ICU stay and mechanical ventilation, patient survival improved during the study period only for patients admitted for infections. There was a high variability in the estimated time point where the ICU admission had no residual effect on survival. Conclusions Long-term survival of ICU patients is substantially decreased compared to the general population, but varies based on admission causes. Improved long-term survival of patients admitted with infections could be explained by earlier detection and improved treatment of septic shock.

Korean Registry for Improving Sepsis Survival (KISS): Protocol for a Multicenter Cohort of Adult Patients with Sepsis or Septic Shock

Sepsis is one of the significant causes of morbidity and mortality. The burden caused by sepsis has continued to increase in recent years in the Korea, highlighting the urgent need for the implementation of strategies to improve sepsis treatment outcomes. We therefore designed a web-based sepsis registry system (“Korean Registry for Improving Sepsis Survival” [KISS]) protocol to be used in hospitals in the Korea for evaluation of the epidemiology and clinical characteristics of patients with sepsis, via an analysis of outcome predictors. The inclusion criteria of this registry are as follows: adult patients ≥18 years admitted to the participating hospitals who are diagnosed with sepsis or septic shock. Demographic and clinical information data of the patients will be collected from hospital medical records and will be recorded in a case report form, which will be entered into a web-based data management system. The analysis of the collected data will be performed as follows: (1) epidemiological and clinical characteristics of sepsis and septic shock, (2) application of sepsis bundles and antibiotic stewardship, and (3) audit and feedback. In conclusion, we aim to build the comprehensive web-based sepsis registry in the Korea through a nation-wide network of participating hospitals. Information collected and analyzed through the KISS can be used for further improvements in the clinical management of sepsis. Furthermore, the KISS will facilitate research leading to the formulation of public health policies regarding sepsis bundle and antibiotic stewardship strategies in the Korea.

Arterial blood pressure correlates with 90-day mortality in sepsis patients: a retrospective multicenter derivation and validation study using high-frequency continuous data

OBJECTIVE

To identify the outcome of patients with sepsis using high-frequency blood pressure data.

MATERIALS AND METHODS

This retrospective observational study was conducted at a university hospital ICU (derivation study) and at two urban hospitals (validation study) with data from adult sepsis patients who visited the centers during the same period. The area under the curve (AUC) of blood pressure falling below threshold was calculated. The predictive 90-day mortality (primary endpoint) area under threshold (AUT) and critical blood pressure were calculated as the maximum area under the curve of the receiver operating characteristic curve (AUCROC) and the threshold minus average AUT (derivation study), respectively. For the validation study, the derived 90-day mortality AUCROC (using critical blood pressure) was compared with Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and APACHE III.

RESULTS

Derivation cohort (N = 137): the drop area from the mean blood pressure of 70 mmHg at 24-48 hours most accurately predicted 90-day mortality [critical blood pressure, 67.8 mmHg; AUCROC, 0.763; 95% confidence interval (CI), 0.653-0.890]. Validation cohort (N = 141): the 90-day mortality AUCROC (0.776) compared with the AUCROC for SOFA (0.711), SAPSII (0.771), APACHE II (0.745), and APACHE III (0.710) was not significantly different from the critical blood pressure 67.8 mmHg (P = 0.420).

CONCLUSION

High-frequency arterial blood pressure data of the period and extent of blood pressure depression can be useful in predicting the clinical outcomes of patients with sepsis.

Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process

Objective

To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.

Design

Modified Delphi process.

Setting

Participants from 34 countries.

Population

Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.

Methods

We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.

Main outcome measure

Consensus on bundle items.

Results

Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.

Conclusion

A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.

Tweetable abstract

A maternal sepsis bundle for low resource settings has been developed by international consensus.

A maternal sepsis bundle for low resource settings has been developed by international consensus.

The prognostic value of serum procalcitonin measurements in critically injured patients: a systematic review

Background

Major trauma is associated with high incidence of septic complications and multiple organ dysfunction (MOD), which markedly influence the outcome of injured patients. Early identification of patients at risk of developing posttraumatic complications is crucial to provide early treatment and improve outcomes. We sought to evaluate the prognostic value of serum procalcitonin (PCT) levels after trauma as related to severity of injury, sepsis, organ dysfunction, and mortality.

Methods

We searched PubMed, MEDLINE, EMBASE, the Cochrane Database, and references of included articles. Two investigators independently identified eligible studies and extracted data. We included original studies that assessed the prognostic value of serum PCT levels in predicting severity of injury, sepsis, organ dysfunction, and mortality among critically injured adult patients.

Results

Among 2015 citations, 19 studies (17 prospective; 2 retrospective) met inclusion criteria. Methodological quality of included studies was moderate. All studies showed a strong correlation between initial PCT levels and Injury Severity Score (ISS). Twelve out of 16 studies demonstrated significant elevation of initial PCT levels in patients who later developed sepsis after trauma. PCT level appeared a strong predictor of MOD in seven out of nine studies. While two studies did not show association between PCT levels and mortality, four studies demonstrated significant elevation of PCT levels in non-survivors versus survivors. One study reported that the PCT level of ≥ 5 ng/mL was associated with significantly increased mortality (OR 3.65; 95% CI 1.03–12.9; p = 0.04).

Conclusion

PCT appears promising as a surrogate biomarker for trauma. Initial peak PCT level may be used as an early predictor of sepsis, MOD, and mortality in trauma population.