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Surviving Sepsis in a Referral Neonatal Intensive Care Unit: Association between Time to Antibiotic Administration and In-Hospital Outcomes. J Pediatr 2020; 217:59-65.e1. [PMID: 31604632 DOI: 10.1016/j.jpeds.2019.08.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/25/2019] [Accepted: 08/09/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine if time to antibiotic administration is associated with mortality and in-hospital outcomes in a neonatal intensive care unit (NICU) population. STUDY DESIGN We conducted a prospective evaluation of infants with suspected sepsis between September 2014 and February 2018; sepsis was defined as clinical concern prompting blood culture collection and antibiotic administration. Time to antibiotic administration was calculated from time of sepsis identification, defined as the order time of either blood culture or an antibiotic, to time of first antibiotic administration. We used linear models with generalized estimating equations to determine the association between time to antibiotic administration and mortality, ventilator-free and inotrope-free days, and NICU length of stay in patients with culture-proven sepsis. RESULTS Among 1946 sepsis evaluations, we identified 128 episodes of culture-proven sepsis in 113 infants. Among them, prolonged time to antibiotic administration was associated with significantly increased risk of mortality at 14 days (OR, 1.47; 95% CI, 1.15-1.87) and 30 days (OR, 1.47; 95% CI, 1.11-1.94) as well as fewer inotrope-free days (incidence rate ratio, 0.91; 95% CI, 0.84-0.98). No significant associations with ventilator-free days or NICU length of stay were demonstrated. CONCLUSIONS Among infants with sepsis, delayed time to antibiotic administration was an independent risk factor for death and prolonged cardiovascular dysfunction. Further study is needed to define optimal timing of antimicrobial administration in high-risk NICU populations.
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102
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Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J Telemed Telecare 2020; 27:518-526. [PMID: 31903840 DOI: 10.1177/1357633x19896667] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Sepsis is a life-threatening emergency. Together, early recognition and intervention decreases mortality. Protocol-based resuscitation in the emergency department (ED) has improved survival in sepsis patients, but guideline-adherent care is less common in low-volume EDs. This study examined the association between provider-to-provider telemedicine and adherence with sepsis bundle components in rural community hospitals. METHODS This is a prospective cohort study of adults presenting with sepsis or septic shock in community EDs participating in rural telemedicine networks. The primary outcome was adherence to four sepsis bundle requirements: lactate measurement within 3 hours, blood culture before antibiotics, broad-spectrum antibiotics, and adequate fluid resuscitation. Multivariable generalized estimating equations estimated the association between telemedicine and adherence. RESULTS In this cohort (n = 655), 5.6% of subjects received ED telemedicine consults. The telemedicine group was more likely to be male and have a higher severity of illness. After adjusting for severity and chief complaint, total sepsis bundle adherence was higher in the telemedicine group compared with the non-telemedicine group (aOR 17.27 [95%CI 6.64-44.90], p < 0.001). Telemedicine consultation was associated with higher adherence with three of the individual bundle components: lactate, antibiotics, and fluid resuscitation. DISCUSSION Telemedicine patients were more likely to receive initial blood lactate measurement, timely broad-spectrum antibiotics, and adequate fluid resuscitation. In rural, community EDs, telemedicine may improve sepsis care and potentially reduce disparities in sepsis outcomes at low-volume facilities. Future work should identify specific components of telemedicine-augmented care that improve performance with sepsis quality indicators.
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Affiliation(s)
- Nicholas M Mohr
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA.,Department of Anesthesia Division of Critical Care, College of Medicine, University of Iowa, Iowa City, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, USA
| | - Kalyn D Campbell
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, College of Medicine, University of Iowa, Iowa City, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, USA
| | - Fred Ullrich
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Kimberly A Merchant
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Marcia M Ward
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
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103
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Lambden S, Laterre PF, Levy MM, Francois B. The SOFA score-development, utility and challenges of accurate assessment in clinical trials. Crit Care 2019; 23:374. [PMID: 31775846 PMCID: PMC6880479 DOI: 10.1186/s13054-019-2663-7] [Citation(s) in RCA: 399] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/29/2019] [Indexed: 12/29/2022] Open
Abstract
The Sequential Organ Failure Assessment or SOFA score was developed to assess the acute morbidity of critical illness at a population level and has been widely validated as a tool for this purpose across a range of healthcare settings and environments.In recent years, the SOFA score has become extensively used in a range of other applications. A change in the SOFA score of 2 or more is now a defining characteristic of the sepsis syndrome, and the European Medicines Agency has accepted that a change in the SOFA score is an acceptable surrogate marker of efficacy in exploratory trials of novel therapeutic agents in sepsis. The requirement to detect modest serial changes in a patients' SOFA score therefore means that increased clarity on how the score should be assessed in different circumstances is required.This review explores the development of the SOFA score, its applications and the challenges associated with measurement. In addition, it proposes guidance designed to facilitate the consistent and valid assessment of the score in multicentre sepsis trials involving novel therapeutic agents or interventions.ConclusionThe SOFA score is an increasingly important tool in defining both the clinical condition of the individual patient and the response to therapies in the context of clinical trials. Standardisation between different assessors in widespread centres is key to detecting response to treatment if the SOFA score is to be used as an outcome in sepsis clinical trials.
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Affiliation(s)
- Simon Lambden
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB20Q, UK
| | - Pierre Francois Laterre
- St Luc University Hospital, Université Catholique de Louvain, Avenue Hippocrate 12, 1200, Brussels, Belgium
| | - Mitchell M Levy
- Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI, USA
| | - Bruno Francois
- Intensive care unit & Inserm CIC 1435 & Inserm UMR 1092, Dupuytren University Hospital, Limoges, France.
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104
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Liu Z, Tan K, Bu L, Bo L, Ni W, Fei M, Chen F, Deng X, Li J. Tim4 regulates NALP3 inflammasome expression and activity during monocyte/macrophage dysfunction in septic shock patients. Burns 2019; 46:652-662. [PMID: 31676250 DOI: 10.1016/j.burns.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 10/25/2022]
Abstract
Sepsis is the leading cause of death in burn patients. Monocytes/macrophages rapidly exhibit impaired production of proinflammatory cytokines and an elevated generation of anti-inflammatory cytokines in septic patients with immunosuppression. However, the expression patterns of Tim4 and Nod-like receptor protein 3 (NALP3) inflammasome and their roles during immunosuppression in septic shock patients are not well understood. Tim4 and NALP3 inflammasome expression in monocytes were downregulated in immunosuppressive patients with sepsis compared with healthy volunteers. Meanwhile, NALP3 inflammasome expression was upregulated by Tim4 overexpression in murine bone marrow-derived macrophages (BMDMs) and J774A.1 macrophages. Tim4 overexpression improved the ability of BMDMs and J774A.1 macrophages to produce proinflammatory cytokines and increased the expression of cleaved-caspase-1 (p10) after LPS/ATP stimulation. In addition, overexpression of Tim4 enhanced phagocytosis of apoptotic polymorphonuclear neutrophils (PMNs) by BMDMs and J774A.1 macrophages, while depletion of NALP3 in Tim4 overexpressing BMDMs and J774A.1 macrophages decreased phagocytosis of apoptotic PMNs. In summary, the expression of Tim4 and NALP3 inflammasome in monocytes/macrophages was downregulated in septic shock patients, and diminished expression of Tim4 and NALP3 inflammasome in monocytes/macrophages might play a critical role in sepsis-elicited immunosuppression.
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Affiliation(s)
- Zheng Liu
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Kezhe Tan
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Lan Bu
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Lulong Bo
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Wen Ni
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Miaomiao Fei
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Fang Chen
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China
| | - Xiaoming Deng
- Faculty of Anesthesiology, Changhai Hospital, Second Military Medical University, 200433, Shanghai, China.
| | - Jinbao Li
- Department of Anesthesiology, Shanghai First People's Hospital, Jiaotong University, 200081, Shanghai, China.
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105
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Association of negative fluid balance during the de-escalation phase of sepsis management with mortality: A cohort study. J Crit Care 2019; 55:16-21. [PMID: 31670149 DOI: 10.1016/j.jcrc.2019.09.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE We aimed to evaluate the impact of negative fluid balance during the fluid de-escalation phase of sepsis management. MATERIAL AND METHODS This is a historical cohort study of adult intensive care units (ICU) patients with septic shock and severe sepsis in a quaternary medical center, from January 2007 through December 2009. We used regression modeling to assess the impact of negative volume balance on mortality after adjustments for age, comorbidities, and illness severity. RESULTS Among 633 enrolled patients, 387 patients reached negative fluid balance who in comparison with others had a lower 90-day mortality rate (36% vs. 44%; P = .048), despite higher severity of illness. Each 1-L negative daily fluid balance was associated with reduced ICU, hospital, 90-day and 1-year mortality (hazard ratio [HR] 0.39 [95%CI, 0.28-0.57], 0.76 [95%CI, 0.63-0.94], 0.69 [95%CI, 0.59-0.81], 0.67 [0.58-0.78], respectively; P < .05). This protective effect of negative volume balance was maintained when cumulative ICU fluid balance was utilized. CONCLUSIONS There is not only a significant association between outcomes of patients who were resuscitated for sepsis and achieving negative fluid balance, but also the amount of daily or cumulative negative fluid balance is associated with lower mortality of these patients. Prospective clinical trials are needed to validate this finding.
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Hunter JG, Pritchett C, Pandya D, Cripps A, Langford R. Sim-sepsis: improving sepsis treatment in the emergency department? BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2019; 5:232-233. [PMID: 35521495 DOI: 10.1136/bmjstel-2018-000307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Jeremy G Hunter
- Department of Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Dhruti Pandya
- Department of Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Alex Cripps
- University of Exeter Medical School, Exeter, UK
| | - Roger Langford
- Department of Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, UK
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107
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Britton GW, Babcock C, Colombo CJ. All Organ Dysfunctions Are Equal…But Some Are More Equal Than Others. Crit Care Med 2019; 46:818-819. [PMID: 29652709 DOI: 10.1097/ccm.0000000000003042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Garrett W Britton
- Department of Medicine, Critical Care Section, Walter Reed National Military Medical Center, Bethesda, MD Department of Medicine, Critical Care Section, Dwight David Eisenhower Army Medical Center, Fort Gordon, GA
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108
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Predictive Factors Associated With In-Hospital Mortality for Patients Across the Sepsis Spectrum. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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109
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Olander A, Andersson H, Sundler AJ, Bremer A, Ljungström L, Andersson Hagiwara M. Prehospital characteristics among patients with sepsis: a comparison between patients with or without adverse outcome. BMC Emerg Med 2019; 19:43. [PMID: 31387528 PMCID: PMC6685242 DOI: 10.1186/s12873-019-0255-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/19/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The prehospital care of patients with sepsis are commonly performed by the emergency medical services. These patients may be critically ill and have high in-hospital mortality rates. Unfortunately, few patients with sepsis are identified by the emergency medical services, which can lead to delayed treatment and a worse prognosis. Therefore, early identification of patients with sepsis is important, and more information about the prehospital characteristics that can be used to identify these patients is needed. Based on this lack of information, the objectives of this study were to investigate the prehospital characteristics that are identified while patients with sepsis are being transported to the hospital by the emergency medical services, and to compare these values to those of the patients with and without adverse outcomes during their hospital stays. METHODS This was a retrospective observational study. The patients' electronic health records were reviewed and selected consecutively based on the following: retrospectively diagnosed with sepsis and transported to an emergency department by the emergency medical services. Data were collected on demographics, prehospital characteristics and adverse outcomes, defined as the in-hospital mortality or treatment in the intensive care unit, and analysed by independent sample t-test and chi-square. Sensitivity, specificity and likelihood ratio, of prehospital characteristics for predicting or development of adverse outcome were analysed. RESULTS In total, 327 patients were included. Of these, 50 patients had adverse outcomes. When comparing patients with or without an adverse outcome, decreased oxygen saturation and body temperature, increased serum glucose level and altered mental status during prehospital care were found to be associated with an adverse outcome. CONCLUSIONS The findings suggests that patients having a decreased oxygen saturation and body temperature, increased serum glucose level and altered mental status during prehospital care are at risk of a poorer patient prognosis and adverse outcome. Recognizing these prehospital characteristics may help to identify patients with sepsis early and improve their long-term outcomes. However further research is required to predict limit values of saturation and serum glucose and to validate the use of prehospital characteristics for adverse outcome in patients with sepsis.
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Affiliation(s)
- Agnes Olander
- PreHospen - Centre for Prehospital Research, University of Borås, Allégatan 1, SE- 405 30, Borås, Sweden. .,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
| | - Henrik Andersson
- PreHospen - Centre for Prehospital Research, University of Borås, Allégatan 1, SE- 405 30, Borås, Sweden.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Annelie J Sundler
- PreHospen - Centre for Prehospital Research, University of Borås, Allégatan 1, SE- 405 30, Borås, Sweden
| | - Anders Bremer
- PreHospen - Centre for Prehospital Research, University of Borås, Allégatan 1, SE- 405 30, Borås, Sweden.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.,Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Lars Ljungström
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Skaraborg Hospital, RegionVästra Götaland, Skövde, Sweden
| | - Magnus Andersson Hagiwara
- PreHospen - Centre for Prehospital Research, University of Borås, Allégatan 1, SE- 405 30, Borås, Sweden.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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110
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Shock Index Predicts Outcome in Patients with Suspected Sepsis or Community-Acquired Pneumonia: A Systematic Review. J Clin Med 2019; 8:jcm8081144. [PMID: 31370356 PMCID: PMC6723191 DOI: 10.3390/jcm8081144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/29/2022] Open
Abstract
Background: To improve outcomes for patients who present to hospital with suspected sepsis, it is necessary to accurately identify those at high risk of adverse outcomes as early and swiftly as possible. To assess the prognostic accuracy of shock index (heart rate divided by systolic blood pressure) and its modifications in patients with sepsis or community-acquired pneumonia. Methods: An electronic search of MEDLINE, EMBASE, Allie and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (WHO ITRP) was conducted from conception to 26th March 2019. Eligible studies were required to assess the prognostic accuracy of shock index or its modifications for outcomes of death or requirement for organ support either in sepsis or pneumonia. The methodological appraisal was carried out using the Downs and Black checklist. Evidence was synthesised using a narrative approach due to heterogeneity. Results: Of 759 records screened, 15 studies (8697 patients) were included in this review. Shock index ≥ 1 at time of hospital presentation was a moderately accurate predictor of mortality in patients with sepsis or community-acquired pneumonia, with high specificity and low sensitivity. Only one study reported outcomes related to organ support. Conclusions: Elevated shock index at time of hospital presentation predicts mortality in sepsis with high specificity. Shock index may offer benefits over existing sepsis scoring systems due to its simplicity.
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111
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Dzobo K, Adotey S, Thomford NE, Dzobo W. Integrating Artificial and Human Intelligence: A Partnership for Responsible Innovation in Biomedical Engineering and Medicine. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2019; 24:247-263. [PMID: 31313972 DOI: 10.1089/omi.2019.0038] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Historically, the term "artificial intelligence" dates to 1956 when it was first used in a conference at Dartmouth College in the US. Since then, the development of artificial intelligence has in part been shaped by the field of neuroscience. By understanding the human brain, scientists have attempted to build new intelligent machines capable of performing complex tasks akin to humans. Indeed, future research into artificial intelligence will continue to benefit from the study of the human brain. While the development of artificial intelligence algorithms has been fast paced, the actual use of most artificial intelligence (AI) algorithms in biomedical engineering and clinical practice is still markedly below its conceivably broader potentials. This is partly because for any algorithm to be incorporated into existing workflows it has to stand the test of scientific validation, clinical and personal utility, application context, and is equitable as well. In this context, there is much to be gained by combining AI and human intelligence (HI). Harnessing Big Data, computing power and storage capacities, and addressing societal issues emergent from algorithm applications, demand deploying HI in tandem with AI. Very few countries, even economically developed states, lack adequate and critical governance frames to best understand and steer the AI innovation trajectories in health care. Drug discovery and translational pharmaceutical research stand to gain from AI technology provided they are also informed by HI. In this expert review, we analyze the ways in which AI applications are likely to traverse the continuum of life from birth to death, and encompassing not only humans but also all animal, plant, and other living organisms that are increasingly touched by AI. Examples of AI applications include digital health, diagnosis of diseases in newborns, remote monitoring of health by smart devices, real-time Big Data analytics for prompt diagnosis of heart attacks, and facial analysis software with consequences on civil liberties. While we underscore the need for integration of AI and HI, we note that AI technology does not have to replace medical specialists or scientists and rather, is in need of such expert HI. Altogether, AI and HI offer synergy for responsible innovation and veritable prospects for improving health care from prevention to diagnosis to therapeutics while unintended consequences of automation emergent from AI and algorithms should be borne in mind on scientific cultures, work force, and society at large.
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Affiliation(s)
- Kevin Dzobo
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Wernher and Beit Building (South), UCT Medical Campus, Anzio Road, Observatory 7925, Cape Town, South Africa.,Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sampson Adotey
- International Development Innovation Network, D-Lab, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Nicholas E Thomford
- Pharmacogenetics Research Group, Division of Human Genetics, Department of Pathology and Institute of Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Witness Dzobo
- Pathology and Immunology Department, University Hospital Southampton, Mail Point B, Tremona Road, Southampton, UK.,University of Portsmouth, Faculty of Science, St Michael's Building, White Swan Road, Portsmouth, UK
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112
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Kahn JM, Davis BS, Yabes JG, Chang CCH, Chong DH, Hershey TB, Martsolf GR, Angus DC. Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis. JAMA 2019; 322:240-250. [PMID: 31310298 PMCID: PMC6635905 DOI: 10.1001/jama.2019.9021] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown. OBJECTIVE To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach. EXPOSURES Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay. RESULTS The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, -1.7% to 7.2%], P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, -0.47 to 1.47 days], P = .31), a significant relative decrease in the C difficile infection rate (P < .001) (10th quarter adjusted difference, -1.8% [95% CI, -2.6% to -1.0%], P < .001), and a significant relative increase in central venous catheter use (P = .02) (10th quarter adjusted difference, 4.8% [95% CI, 2.3% to 7.4%], P < .001). CONCLUSIONS AND RELEVANCE In New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.
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Affiliation(s)
- Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Billie S. Davis
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chung-Chou H. Chang
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David H. Chong
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Tina Batra Hershey
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- CRISMA Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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113
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Custodero C, Wu Q, Ghita GL, Anton SD, Brakenridge SC, Brumback BA, Efron PA, Gardner AK, Leeuwenburgh C, Moldawer LL, Petersen JW, Moore FA, Mankowski RT. Prognostic value of NT-proBNP levels in the acute phase of sepsis on lower long-term physical function and muscle strength in sepsis survivors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:230. [PMID: 31234943 PMCID: PMC6589880 DOI: 10.1186/s13054-019-2505-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/04/2019] [Indexed: 12/29/2022]
Abstract
Background Sepsis survivors often develop chronic critical illness (CCI) and demonstrate the persistent inflammation, immunosuppression, and catabolism syndrome predisposing them to long-term functional limitations and higher mortality. There is a need to identify biomarkers that can predict long-term worsening of physical function to be able to act early and prevent mobility loss. N-terminal pro-brain natriuretic peptide (NT-proBNP) is a well-accepted biomarker of cardiac overload, but it has also been shown to be associated with long-term physical function decline. We explored whether NT-proBNP blood levels in the acute phase of sepsis are associated with physical function and muscle strength impairment at 6 and 12 months after sepsis onset. Methods This is a retrospective analysis conducted in 196 sepsis patients (aged 18–86 years old) as part of the University of Florida (UF) Sepsis and Critical Illness Research Center (SCIRC) who consented to participate in the 12-month follow-up study. NT-proBNP was measured at 24 h after sepsis onset. Patients were followed to determine physical function by short physical performance battery (SPPB) test score (scale 0 to12—higher score corresponds with better physical function) and upper limb muscle strength by hand grip strength test (kilograms) at 6 and 12 months. We used a multivariate linear regression model to test an association between NT-proBNP levels, SPPB, and hand grip strength scores. Missing follow-up data or absence due to death was accounted for by using inverse probability weighting based on concurrent health performance status scores. Statistical significance was set at p ≤ 0.05. Results After adjusting for covariates (age, gender, race, Charlson comorbidity index, APACHE II score, and presence of CCI condition), higher levels of NT-proBNP at 24 h after sepsis onset were associated with lower SPPB scores at 12 months (p < 0.05) and lower hand grip strength at 6-month (p < 0.001) and 12-month follow-up (p < 0.05). Conclusions NT-proBNP levels during the acute phase of sepsis may be a useful indicator of higher risk of long-term impairments in physical function and muscle strength in sepsis survivors.
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Affiliation(s)
- Carlo Custodero
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL, 32611, USA.,Dipartimento Interdisciplinare di Medicina, Clinica Medica Cesare Frugoni, University of Bari Aldo Moro, Bari, Italy
| | - Quran Wu
- Department of Surgery, University of Florida, Gainesville, FL, USA.,Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Gabriela L Ghita
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Stephen D Anton
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL, 32611, USA
| | | | - Babette A Brumback
- Department of Surgery, University of Florida, Gainesville, FL, USA.,Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Anna K Gardner
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL, 32611, USA.,Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL, 32611, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - John W Petersen
- Department of Cardiology, University of Florida, Gainesville, FL, USA
| | | | - Robert T Mankowski
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL, 32611, USA.
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Nedeva C, Menassa J, Puthalakath H. Sepsis: Inflammation Is a Necessary Evil. Front Cell Dev Biol 2019; 7:108. [PMID: 31281814 PMCID: PMC6596337 DOI: 10.3389/fcell.2019.00108] [Citation(s) in RCA: 175] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/29/2019] [Indexed: 12/12/2022] Open
Abstract
Sepsis is one of the leading causes of deaths world-wide and yet there are no therapies available other than ICU treatment. The patient outcome is determined by a complex interplay between the pro and anti-inflammatory responses of the body i.e., a homeostatic balance between these two competing events to be achieved for the patient’s recovery. The initial attempts on drug development mainly focused on controlling inflammation, however, without any tangible outcome. This was despite most deaths occurring during the immune paralysis stage of this biphasic disease. Recently, the focus has been shifting to understand immune paralysis (caused by apoptosis and by anti-inflammatory cytokines) to develop therapeutic drugs. In this review we put forth an argument for a proper understanding of the molecular basis of inflammation as well as apoptosis for developing an effective therapy.
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Affiliation(s)
- Christina Nedeva
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Menassa
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Hamsa Puthalakath
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
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Huang HB, Xu B, Liu GY, Du B. N-terminal pro-B-type natriuretic peptide for predicting fluid challenge in patients with septic shock. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:264. [PMID: 31355231 DOI: 10.21037/atm.2019.05.60] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background The aim of this study is to examine whether plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration could predict fluid responsiveness in septic shock patients following fluid challenge (FC). Methods We reviewed prospectively collected data from 79 septic shock patients who received invasive cardiac output (CO) monitoring following a 500 mL FC. Haemodynamics were recorded, and blood sampling for NT-proBNP values was performed. Patients were divided into responders and non-responders according to fluid responsiveness, which was defined as cardiac index (CI) increase ≥10% induced by FC. The NT-proBNP and the CI changes were analysed using Pearson correlation. The area under the curve (AUC) for NT-proBNP was used to test its ability to distinguish responders and non-responders. Subgroup analyses were also explored. Results Among 79 patients, there were 55 responders. High NT-proBNP values were common in the study cohort. Baseline NT-proBNP values were comparable between responders and non-responders. In general, NT-proBNP values were not significantly correlated with CI changes after FC (r=-0.104, P=0.361). Similarly, the NT-proBNP baseline values could not identify responders to FC with an AUC of 0.508 (95% confidence interval, 0.369-0.647). This result was further confirmed in the subgroup analyses. Conclusions Baseline NT-proBNP concentration value may not serve as an indicator of fluid responsiveness in patients with septic shock and should not be an indicator to withhold fluid loading.
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Affiliation(s)
- Hui-Bin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China.,Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, Fuzhou 350001, China
| | - Biao Xu
- Critical Care Medicine Center, the PLA 302 Hospital, Beijing 100039, China
| | - Guang-Yun Liu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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Worapratya P, Wuthisuthimethawee P. Septic shock in the ER: diagnostic and management challenges. OPEN ACCESS EMERGENCY MEDICINE 2019; 11:77-86. [PMID: 31114401 PMCID: PMC6489668 DOI: 10.2147/oaem.s166086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/21/2019] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient's volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.
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Affiliation(s)
- Panita Worapratya
- Department of Emergency Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Prasit Wuthisuthimethawee
- Department of Emergency Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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Nannan Panday RS, Lammers EMJ, Alam N, Nanayakkara PWB. An overview of positive cultures and clinical outcomes in septic patients: a sub-analysis of the Prehospital Antibiotics Against Sepsis (PHANTASi) trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:182. [PMID: 31113475 PMCID: PMC6530106 DOI: 10.1186/s13054-019-2431-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/10/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sepsis remains one of the most important causes of morbidity and mortality worldwide. In approximately 30-50% of cases of suspected sepsis, no pathogen is isolated, disabling the clinician to treat the patient with targeted antimicrobial therapy. Studies investigating the differences in the patient outcomes between culture-positive and culture-negative sepsis patients have only been conducted in subgroups of sepsis patients and results are ambiguous. METHODS This is a sub-analysis of the PHANTASi (Prehospital Antibiotics Against Sepsis trial), a randomized controlled trial that focused on the effect of prehospital antibiotics in sepsis patients. We evaluated the outcome of cultures from different sources and determined what the clinical implications of having a positive culture compared to negative cultures were for patient outcomes. Furthermore, we looked at the effect of antibiotics on culture outcomes. RESULTS 1133 patients (42.6%) with culture-positive sepsis were identified, compared to 1526 (56.4%) patients with culture-negative sepsis. 28-day mortality (RR 1.43 [95% CI 1.11-1.83]) and 90-day mortality (RR 1.41 [95% CI 1.15-1.71]) were significantly higher in culture-positive patients compared to culture-negative patients. Culture-positive sepsis was also associated with ≥ 3 organ systems affected during the sepsis episode (RR 4.27 [95% CI 2.78-6.60]). Patients who received antibiotics at home more often had negative blood cultures (85.9% vs. 78%) than those who did not (p < 0.001). CONCLUSIONS Our results show that culture-positive sepsis is associated with a higher mortality rate and culture-positive patients more often have multiple organ systems affected during the sepsis episode. TRIAL REGISTRATION The PHANTASi trial is registered at ClinicalTrials.gov, number NCT01988428 . Date of registration: November 20, 2013.
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Affiliation(s)
- Rishi S Nannan Panday
- Section Acute Medicine, Department of Internal Medicine Amsterdam UMC, University Medical Centers, Location VU University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Eline M J Lammers
- Section Acute Medicine, Department of Internal Medicine Amsterdam UMC, University Medical Centers, Location VU University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
| | - Nadia Alam
- Section Acute Medicine, Department of Internal Medicine Amsterdam UMC, University Medical Centers, Location VU University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine Amsterdam UMC, University Medical Centers, Location VU University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands.
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Abdullah SMOB, Grand J, Sijapati A, Puri PR, Nielsen FE. qSOFA is a useful prognostic factor for 30-day mortality in infected patients fulfilling the SIRS criteria for sepsis. Am J Emerg Med 2019; 38:512-516. [PMID: 31171438 DOI: 10.1016/j.ajem.2019.05.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/09/2019] [Accepted: 05/19/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The "quick Sequential Organ Failure Assessment" (qSOFA) score is a bedside risk-stratification tool to predict the likelihood of organ dysfunction. This study evaluated the qSOFA score as a prognostic factor for 30-day mortality in emergency department (ED) patients with sepsis identified by the Systemic Inflammatory Response Syndrome (SIRS) criteria. METHODS A historical cohort study was conducted reviewing patients admitted to a single-center ED from November 1, 2013, to October 31, 2014. All patients with suspected or proven infections who fulfilled two or more SIRS criteria were included. Data of SIRS, qSOFA and baseline clinical data were obtained from triage forms and patient records. RESULTS A total of 434 patients with sepsis of any severity were included. A total of 73 (16.8%) had a qSOFA score of ≥2 and were more frequently transferred to the intensive care unit (ICU) (26.0 vs. 6.7%; 95% confidence interval (CI) of the difference 8.9-29.7%) and had increased 30-day mortality (32.9 vs. 9.1%, 95% CI of the difference 12.6-35.0%) compared to patients with a qSOFA score of <2. In an adjusted logistic regression model, a qSOFA score of ≥2 was independently associated with 30-day mortality (odds ratio 4.83; 95% CI 2.11-11.02). CONCLUSION Almost one third of the patients with a qSOFA score of ≥2 had died within 30 days and a qSOFA score of ≥2 was independently associated with mortality. This study indicated that qSOFA score of at least two could provide useful prognostic information for septic patients defined by the SIRS criteria.
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Affiliation(s)
| | - Johannes Grand
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Astha Sijapati
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Pushpa Raj Puri
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Finn Erland Nielsen
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark; Department of Emergency Medicine, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
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Kennedy JL, Haberling DL, Huang CC, Lessa FC, Lucero DE, Daskalakis DC, Vora NM. Infectious Disease Hospitalizations: United States, 2001 to 2014. Chest 2019; 156:255-268. [PMID: 31047954 DOI: 10.1016/j.chest.2019.04.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Infectious disease epidemiology has changed over time, reflecting improved clinical interventions and emergence of threats such as antimicrobial resistance. This study investigated infectious disease hospitalizations in the United States from 2001 to 2014. METHODS Estimated rates of infectious disease hospitalizations were calculated by using the National (Nationwide) Inpatient Sample. Infectious disease hospitalizations were defined as hospitalizations with a principal discharge diagnosis of an infectious disease. Diagnoses according to site of infection and sepsis were examined, as was occurrence of in-hospital death. The leading nonsepsis infectious disease secondary diagnoses for hospitalizations with a principal diagnosis of sepsis were identified. RESULTS The mean annual age-adjusted infectious disease hospitalization rate was 1,468.2 (95% CI, 1,459.9-1,476.4) per 100,000 population; in-hospital death occurred in 4.22% (95% CI, 4.18-4.25) of infectious disease hospitalizations. The mean annual age-adjusted infectious disease hospitalization rate increased from 2001-2003 to 2012-2014 (rate ratio, 1.05; 95% CI, 1.01-1.09), as did the percentage of in-hospital death (4.21% [95% CI, 4.13-4.29] to 4.30% [95% CI, 4.26-4.35]; P = .049). The diagnoses with the highest hospitalization rates among all sites of infection and sepsis diagnoses were the lower respiratory tract followed by sepsis. The most common nonsepsis infectious disease secondary diagnoses among sepsis hospitalizations were "urinary tract infection," "pneumonia, organism unspecified," and "intestinal infection due to Clostridium [Clostridioides] difficile." CONCLUSIONS Although hospital discharge data are subject to limitations, particularly for tracking sepsis, lower respiratory tract infections and sepsis seem to be important contributors to infectious disease hospitalizations. Prevention of infections that lead to sepsis and improvements in sepsis management would decrease the burden of infectious disease hospitalizations and improve outcomes, respectively.
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Affiliation(s)
- Jordan L Kennedy
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Dana L Haberling
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA
| | - Chaorui C Huang
- New York City Department of Health and Mental Hygiene, New York, NY
| | - Fernanda C Lessa
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - David E Lucero
- New York City Department of Health and Mental Hygiene, New York, NY
| | | | - Neil M Vora
- New York City Department of Health and Mental Hygiene, New York, NY; Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, New York, NY
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120
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Liu R, Greenstein JL, Granite SJ, Fackler JC, Bembea MM, Sarma SV, Winslow RL. Data-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU. Sci Rep 2019; 9:6145. [PMID: 30992534 PMCID: PMC6467982 DOI: 10.1038/s41598-019-42637-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 03/26/2019] [Indexed: 02/02/2023] Open
Abstract
Septic shock is a life-threatening condition in which timely treatment substantially reduces mortality. Reliable identification of patients with sepsis who are at elevated risk of developing septic shock therefore has the potential to save lives by opening an early window of intervention. We hypothesize the existence of a novel clinical state of sepsis referred to as the "pre-shock" state, and that patients with sepsis who enter this state are highly likely to develop septic shock at some future time. We apply three different machine learning techniques to the electronic health record data of 15,930 patients in the MIMIC-III database to test this hypothesis. This novel paradigm yields improved performance in identifying patients with sepsis who will progress to septic shock, as defined by Sepsis- 3 criteria, with the best method achieving a 0.93 area under the receiver operating curve, 88% sensitivity, 84% specificity, and median early warning time of 7 hours. Additionally, we introduce the notion of patient-specific positive predictive value, assigning confidence to individual predictions, and achieving values as high as 91%. This study demonstrates that early prediction of impending septic shock, and thus early intervention, is possible many hours in advance.
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Affiliation(s)
- Ran Liu
- Institute for Computational Medicine, The Johns Hopkins University, Maryland, USA
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Maryland, USA
| | - Joseph L Greenstein
- Institute for Computational Medicine, The Johns Hopkins University, Maryland, USA
| | - Stephen J Granite
- Institute for Computational Medicine, The Johns Hopkins University, Maryland, USA
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
| | - Sridevi V Sarma
- Institute for Computational Medicine, The Johns Hopkins University, Maryland, USA.
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Maryland, USA.
| | - Raimond L Winslow
- Institute for Computational Medicine, The Johns Hopkins University, Maryland, USA.
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Maryland, USA.
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Bond WF, Barker LT, Cooley KL, Svendsen JD, Tillis WP, Vincent AL, Vozenilek JA, Powell ES. A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation. Simul Healthc 2019; 14:129-136. [PMID: 30730469 PMCID: PMC6787919 DOI: 10.1097/sih.0000000000000357] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU. METHODS The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1-10 Likert scale, with 10 "completely confident"). Pre-post responses were compared by two-tailed paired t test. RESULTS We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05). CONCLUSIONS We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.
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Affiliation(s)
- William F Bond
- From Jump Simulation (W.F.B., L.T.B., K.L.C., J.D.S., J.A.V.), an OSF HealthCare and University of Illinois College of Medicine at Peoria Collaboration; Department of Emergency Medicine (W.F.B., L.T.B., A.L.V., J.A.V.), Division of Pulmonary and Critical Care Medicine (W.P.T), and OSF ConstantCare (W.P.T.), OSF HealthCare; Departments of Emergency Medicine (W.F.B., L.T.B., A.L.V., J.A.V.), and Internal Medicine (W.P.T.), University of Illinois College of Medicine at Peoria; and Department of Emergency Medicine (E.S.P.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
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Critical Illness Needs Better Science, Not Clinical "Precision". Crit Care Med 2019; 45:e245. [PMID: 28098658 DOI: 10.1097/ccm.0000000000002157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Delay of appropriate antibiotic treatment is associated with high mortality in patients with community-onset sepsis in a Swedish setting. Eur J Clin Microbiol Infect Dis 2019; 38:1223-1234. [PMID: 30911928 PMCID: PMC6570779 DOI: 10.1007/s10096-019-03529-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
Abstract
Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important. Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock. A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012–2013. The criterion “early appropriate antibiotic treatment” was defined as administration of the first dose of adequate antibiotics within 1 h, and the second dose given with less than 25% delay after the recommended dose interval. A high-risk patient was defined as a septic patient with either shock within 24 h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality. Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment. Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.
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Benchmarking clinical outcomes and the immunocatabolic phenotype of chronic critical illness after sepsis in surgical intensive care unit patients. J Trauma Acute Care Surg 2019; 84:342-349. [PMID: 29251709 DOI: 10.1097/ta.0000000000001758] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A growing number of patients survive sepsis but remain chronically critically ill. We sought to define clinical outcomes and incidence of chronic critical illness (CCI) after sepsis and to determine whether selected biomarkers of inflammation, immunosuppression, and catabolism differ between these patients and those that rapidly recover (RAP). METHODS This 3-year prospective observational cohort study (NCT02276417) evaluated 145 surgical intensive care unit patients with sepsis for the development of CCI (≥14 days of intensive care unit resource utilization with persistent organ dysfunction). Patient clinical demographics, outcomes, and serial serum/urine samples were collected for plasma protein and urinary metabolite analyses. RESULTS Of 145 sepsis patients enrolled, 19 (13%) died during their hospitalization and 71 (49%) developed CCI. The CCI patients were significantly older (mean, 63 ± 15 vs. 58 ± 13 years, p = 0.006) and more likely to be discharged to long-term acute care facilities (32% vs. 3%, p < 0.0001), whereas those with RAP were more often discharged to home or a rehabilitation facility. Six-month mortality was significantly higher in CCI as compared with RAP cohort (37% vs. 2%; p < 0.01). Multivariate logistic regression modeling revealed delayed onset sepsis (>48 hours after admission; odds ratio [OR], 10.93; 95% confidence interval [CI], 4.15-28.82]), interfacility transfer (OR, 3.58; 95% CI, 1.43-8.96), vasopressor-dependent septic shock (OR, 3.75; 95% CI, 1.47-9.54), and Sequential Organ Failure Assessment score of 5 or greater at 72 hours (OR, 5.03; 95% CI, 2.00-12.62) as independent risk factors for the development of CCI. The CCI patients also demonstrated greater elevations in inflammatory cytokines (IL-6, IL-8, IL-10), and biomarker profiles are consistent with persistent immunosuppression (absolute lymphocyte count and soluble programmed death ligand 1) and catabolism (plasma insulin-like growth factor binding protein 3 and urinary 3-methylhistidine excretion). CONCLUSION The development of CCI has become the predominant clinical trajectory in critically ill surgical patients with sepsis. These patients exhibit biomarker profiles consistent with an immunocatabolic phenotype of persistent inflammation, immunosuppression, and catabolism. LEVEL OF EVIDENCE Prognostic, level II.
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CE: A Review of the Revised Sepsis Care Bundles. Am J Nurs 2019; 118:40-49. [PMID: 30004905 DOI: 10.1097/01.naj.0000544139.63510.b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
: Sepsis is an extreme response to infection that can cause tissue damage, organ failure, and death if not treated promptly and appropriately. Each year in the United States, sepsis affects more than 1.5 million people and kills roughly 250,000. Prompt recognition and treatment of sepsis are essential to saving lives, and nurses play a critical role in the early detection of sepsis, as they are often first to recognize the signs and symptoms of infection. Here, the authors review recent revisions to the sepsis care bundles and discuss screening and assessment tools nurses can use to identify sepsis in the ICU, in the ED, on the medical-surgical unit, and outside the hospital.
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Hassan EA, Abdel Rehim AS, Ahmed AO, Abdullahtif H, Attia A. Clinical Value of Presepsin in Comparison to hsCRP as a Monitoring and Early Prognostic Marker for Sepsis in Critically Ill Patients. ACTA ACUST UNITED AC 2019; 55:medicina55020036. [PMID: 30717340 PMCID: PMC6409617 DOI: 10.3390/medicina55020036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/24/2019] [Accepted: 01/30/2019] [Indexed: 01/01/2023]
Abstract
Background and objectives: Sepsis carries a poor prognosis for critically ill patients, even withintensive management. We aimed to determined early predictors of sepsis-related in-hospital mortality and to monitor levels of presepsin and high sensitivity C reactive protein (hsCRP) during admission relative to the applied treatment and the development of complications. Materials and Methods: An observational study was conducted on 68 intensive care unit (ICU) patients with sepsis. Blood samples from each patient were collected at admission (day 0) for measuring presepsin, hsCRP, biochemical examination, complete blood picture and microbiological culture and at the third day (day 3) for measuring presepsin and hsCRP. Predictors of sepsis-related in-hospital mortality were assessed using regression analysis. Predictive abilities of presepsin and hsCRP were compared using the area under a receiver operating characteristic curve. The Kaplan–Meier method was used to estimate the overall survival rate. Results: Results showed that the sepsis-related in-hospital mortality was 64.6%. The day 0 presepsin and SOFA scores were associated with this mortality. Presepsin levels were significantly higher at days 0 and 3 in non-survivors vs. survivors (p = 0.03 and p < 0.001 respectively) and it decreased over the three days in survivors. Presepsin had a higher prognostic accuracy than hsCRP at all the evaluated times. Conclusions: Overall, in comparison with hsCRP, presepsin was an early predictor of sepsis-related in-hospital mortality in ICU patients. Changes in presepsin concentrations over time may be useful for sepsis monitoring, which in turn could be useful for stratifying high-risk patients on ICU admission that benefit from intensive treatment.
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Affiliation(s)
- Elham A Hassan
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut 71111, Egypt.
| | - Abeer S Abdel Rehim
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut 71111, Egypt.
| | - Asmaa O Ahmed
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut 71111, Egypt.
| | - Hanan Abdullahtif
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut 71111, Egypt.
| | - Alaa Attia
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut 71111, Egypt.
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129
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Greenwood-Ericksen MB, Rothenberg C, Mohr N, Andrea SD, Slesinger T, Osborn T, Whittle J, Goyal P, Tarrant N, Schuur JD, Yealy DM, Venkatesh A. Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States. J Rural Health 2018; 35:490-497. [PMID: 30488590 DOI: 10.1111/jrh.12339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs. METHODS We analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. FINDINGS Rural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤ .001; 91% urban vs 84% rural; P ≤ .001, respectively). CONCLUSIONS Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.
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Affiliation(s)
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Nicholas Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Todd Slesinger
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Tiffany Osborn
- Department of Surgery, Acute and Critical Care Surgery and Department of Medicine, Emergency Medicine, Washington University, St. Louis, Missouri
| | - Jessica Whittle
- Department of Emergency Medicine, UT Chattanooga/Erlanger Health Systems, Chattanooga, Tennessee
| | - Pawan Goyal
- American College of Emergency Physicians, Washington, DC
| | - Nalani Tarrant
- American College of Emergency Physicians, Washington, DC
| | - Jeremiah D Schuur
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut
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Abstract
Despite efforts in prevention and intensive care, trauma and subsequent sepsis are still associated with a high mortality rate. Traumatic injury remains the main cause of death in people younger than 45 years and is thus a source of immense social and economic burden. In recent years, the knowledge concerning gender medicine has continuously increased. A number of studies have reported gender dimorphism in terms of response to trauma, shock and sepsis. However, the advantageous outcome following trauma-hemorrhage in females is not due only to sex. Rather, it is due to the prevailing hormonal milieu of the victim. In this respect, various experimental and clinical studies have demonstrated beneficial effects of estrogen for the central nervous system, the cardiopulmonary system, the liver, the kidneys, the immune system, and for the overall survival of the host. Nonetheless, there remains a gap between the bench and the bedside. This is most likely because clinical studies have not accounted for the estrus cycle. This review attempts to provide an overview of the current level of knowledge and highlights the most important organ systems responding to trauma, shock and sepsis. There continues to be a need for clinical studies on the prevailing hormonal milieu following trauma, shock and sepsis.
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Affiliation(s)
- Florian Bösch
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilians-University Munich, 81377, Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilians-University Munich, 81377, Munich, Germany
| | - Irshad H Chaudry
- Center for Surgical Research and Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, 35294, USA.
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Shave K, Ali S, Scott SD, Hartling L. Procedural pain in children: a qualitative study of caregiver experiences and information needs. BMC Pediatr 2018; 18:324. [PMID: 30316301 PMCID: PMC6186099 DOI: 10.1186/s12887-018-1300-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/01/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Children experience multiple painful procedures when being cared for in emergency departments (EDs). Unfortunately, evidence-based interventions to manage such pain and distress are under-utilized across EDs. Caregivers are uniquely positioned and invested to advocate for the adaptation of such evidence into practice. Our objective was to gather information from caregivers of children experiencing procedural pain in the ED to inform the development of a novel, caregiver-focused knowledge translation (KT) tool. METHODS The study design was qualitative description. Caregivers of children who underwent intravenous (IV) insertion or venipuncture in the pediatric ED at an urban tertiary care centre were interviewed. Thematic analysis was applied to the data. The TRanslating Emergency Knowledge for Kids (TREKK) Parent Advisory Group continuously informed this study, and provided input on interview guide development and piloting, data collection, analysis of the data, interpretation of the results, and development of next steps. RESULTS Interviews revealed four major themes: 1) source of healthcare information; 2) delivering healthcare information; 3) communication with caregivers; and 4) procedure-related anxiety and long-term effects. Caregivers most valued receiving information directly from their healthcare provider. They also expressed that healthcare providers should direct information about the procedure to their child and identified strategies to involve children in their care. Caregivers wanted to be empowered to ask informed questions of their healthcare providers. Finally, caregivers reported negative experiences with procedures for their children, occurring mainly at non-pediatric centres. CONCLUSIONS We have identified core information needs for caregivers whose children are experiencing IV insertion or venipuncture. These results will form the foundation for the development of a KT tool that may empower caregivers to actively participate in their child's healthcare.
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Affiliation(s)
- Kassi Shave
- Alberta Research Centre for Health Evidence (ARCHE), University of Alberta, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
- Department of Pediatrics, University of Alberta, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Samina Ali
- Department of Pediatrics, University of Alberta, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
- Women and Children’s Health Research Institute, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Shannon D. Scott
- Women and Children’s Health Research Institute, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
- Faculty of Nursing, University of Alberta, Edmonton, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence (ARCHE), University of Alberta, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
- Department of Pediatrics, University of Alberta, ECHA 4-472, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
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McNab D, Freestone J, Black C, Carson-Stevens A, Bowie P. Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method. BMC Med 2018; 16:174. [PMID: 30305088 PMCID: PMC6180427 DOI: 10.1186/s12916-018-1164-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 09/03/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Ensuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management. METHODS In a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis. RESULTS Fourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed. CONCLUSIONS Traditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.
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Affiliation(s)
- Duncan McNab
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, G3 8BW, UK. .,NHS Ayrshire and Arran, Ayr, UK. .,Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | | | - Chris Black
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, G3 8BW, UK.,NHS Ayrshire and Arran, Ayr, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.,Department of Family Practice, University of British Columbia, Vancouver, Canada.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Paul Bowie
- NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, G3 8BW, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Harmankaya M, Oreskov JO, Burcharth J, Gögenur I. The impact of timing of antibiotics on in-hospital outcomes after major emergency abdominal surgery. Eur J Trauma Emerg Surg 2018; 46:221-227. [PMID: 30310958 DOI: 10.1007/s00068-018-1026-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/06/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients undergoing major open emergency abdominal surgery experience high morbidity and mortality rates and often have sepsis at admission. The purpose of this study was to evaluate the association between antibiotic timing and in-hospital outcomes such as complications, need for reoperation, length of stay, and 30-day mortality. METHODS This retrospective observational cohort study was conducted between January 2010 and December 2015 including patients that were triaged through the emergency department for subsequent major open abdominal surgery. All relevant perioperative data were extracted from medical records. The outcomes of interest were development of in-hospital postoperative complications, reoperations, length of stay, and 30-day mortality, all in association with antibiotic timing, categorized according to 0-6, 6-12, or > 12 h from triage. Multivariate logistic regression was performed to evaluate adjusted outcomes associated with antibiotic timing. RESULTS A total of 408 patients were included, of whom 107 (26.2%) underwent at least one reoperation and 55.4% had at least one postoperative complication. These complications consisted of 26% surgical complications and 74% medical complications. Of the surgical complications, 73% were Clavien-Dindo ≥ 3. The median length of stay was 9 days and the overall 30-day mortality was 17.9%. The data showed that the development of complications, need for reoperation, 30-day mortality, and the length of stay were significantly correlated to delayed antibiotic administration of more than 12 h from admission. CONCLUSIONS Antibiotic administration more than 12 h from triage was associated with a significantly increased risk of postoperative complications, need for reoperation, 30-day mortality, and a prolonged length of stay, when compared to patients that received antibiotic treatment 0-6 h and 6-12 h after triage. Our data suggest that prophylactic antibiotics should be administered to all patients undergoing major open emergency abdominal surgery; however, the dose and duration cannot be concluded on the basis of our data and should be further examined.
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Affiliation(s)
- Mücahit Harmankaya
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark.
| | - Jakob Ohm Oreskov
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark
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Carneiro AH, Póvoa P, Gomes JA. Dear Sepsis-3, we are sorry to say that we don't like you. Rev Bras Ter Intensiva 2018; 29:4-8. [PMID: 28444066 PMCID: PMC5385979 DOI: 10.5935/0103-507x.20170002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/11/2016] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Pedro Póvoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa - Lisboa, Portugal
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135
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Westphal GA, Pereira AB, Fachin SM, Sperotto G, Gonçalves M, Albino L, Bittencourt R, Franzini VDR, Koenig Á. An electronic warning system helps reduce the time to diagnosis of sepsis. Rev Bras Ter Intensiva 2018; 30:414-422. [PMID: 30570029 PMCID: PMC6334482 DOI: 10.5935/0103-507x.20180059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To describe the improvements of an early warning system for the identification of septic patients on the time to diagnosis, antibiotic delivery, and mortality. METHODS This was an observational cohort study that describes the successive improvements made over a period of 10 years using an early warning system to detect sepsis, including systematic active manual surveillance, electronic alerts via a telephonist, and alerts sent directly to the mobile devices of nurses. For all periods, after an alert was triggered, early treatment was instituted according to the institutional sepsis guidelines. RESULTS In total, 637 patients with sepsis were detected over the study period. The median triage-to-diagnosis time was reduced from 19:20 (9:10 - 38:15) hours to 12:40 (2:50 - 23:45) hours when the manual surveillance method was used (p = 0.14), to 2:10 (1:25 - 2:20) hours when the alert was sent automatically to the hospital telephone service (p = 0.014), and to 1:00 (0:30 - 1:10) hour when the alert was sent directly to the nurse's mobile phone (p = 0.016). The diagnosis-to-antibiotic time was reduced to 1:00 (0:55 - 1:30) hours when the alert was sent to the telephonist and to 0:45 (0:30 - 1:00) minutes when the alert was sent directly to the nurse's mobile phone (p = 0.02), with the maintenance of similar values over the following years. There was no difference in the time of treatment between survivors and non-survivors. CONCLUSION Electronic systems help reduce the triage-to-diagnosis time and diagnosis-to-antibiotic time in patients with sepsis.
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Williams JM, Keijzers G, Macdonald SP, Shetty A, Fraser JF. Review article: Sepsis in the emergency department - Part 3: Treatment. Emerg Med Australas 2018; 30:144-151. [PMID: 29569847 DOI: 10.1111/1742-6723.12951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 10/17/2022]
Abstract
Although comprehensive guidelines for treatment of sepsis exist, current research continues to refine and revise several aspects of management. Imperatives for rapid administration of broad-spectrum antibiotics for all patients with sepsis may not be supported by contemporary data. Many patients may be better served by a more judicious approach allowing consideration of investigation results and evidence-based guidelines. Conventional fluid therapy has been challenged with early evidence supporting balanced, restricted fluid and early vasopressor use. Albumin, vasopressin and hydrocortisone have each been shown to support blood pressure and reduce catecholamine requirements but without effect on mortality, and as such should be considered for ED patients with septic shock on a case-by-case basis. Measurement of quality care in sepsis should incorporate quality of blood cultures and guideline-appropriateness of antibiotics, as well as timeliness of therapy. Local audit is an essential and effective means to improve practice. Multicentre consolidation of data through agreed minimum sepsis data sets would provide baseline quality data, required for the design and evaluation of interventions.
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Affiliation(s)
- Julian M Williams
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Stephen Pj Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Amith Shetty
- Department of Emergency Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,NHMRC Centre for Research in Critical Infection, Westmead Millennium Institute, Sydney, New South Wales, Australia
| | - John F Fraser
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
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Abstract
The last two to three years provided several “big steps” regarding our understanding and management of sepsis. The increasing insight into pathomechanisms of post-infectious defense led to some new models of host response. Besides hyper-, hypo-, and anti-inflammation as the traditional approaches to sepsis pathophysiology, tolerance and resilience were described as natural ways that organisms react to microbes. In parallel, huge data analyses confirmed these research insights with a new way to define sepsis and septic shock (called “Sepsis-3”), which led to discussions within the scientific community. In addition to these advances in understanding and defining the disease, follow-up protocols of the initial “sepsis bundles” from the Surviving Sepsis Campaign were created; some of them were part of quality management studies by clinicians, and some were in the form of mandatory procedures. As a result, new “bundles” were initiated with the goal of enabling standardized management of sepsis and septic shock, especially in the very early phase. This short commentary provides a brief overview of these two major fields as recent hallmarks of sepsis research.
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Affiliation(s)
- Daniela Berg
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Berlin, Germany
| | - Herwig Gerlach
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Berlin, Germany
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Rhee C, Dantes RB, Epstein L, Klompas M. Using objective clinical data to track progress on preventing and treating sepsis: CDC's new 'Adult Sepsis Event' surveillance strategy. BMJ Qual Saf 2018; 28:305-309. [PMID: 30254095 DOI: 10.1136/bmjqs-2018-008331] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA .,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymund Barretto Dantes
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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139
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Antibiotic therapy in the critically ill - expert opinion of the Intensive Care Medicine Scientific Subcommittee of the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 34:215-220. [PMID: 28248705 DOI: 10.1097/eja.0000000000000595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.
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140
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Chang S, Kim YH, Kim YJ, Kim YW, Moon S, Lee YY, Jung JS, Kim Y, Jung HE, Kim TJ, Cheong TC, Moon HJ, Cho JA, Kim HR, Han D, Na Y, Seok SH, Cho NH, Lee HC, Nam EH, Cho H, Choi M, Minato N, Seong SY. Taurodeoxycholate Increases the Number of Myeloid-Derived Suppressor Cells That Ameliorate Sepsis in Mice. Front Immunol 2018; 9:1984. [PMID: 30279688 PMCID: PMC6153344 DOI: 10.3389/fimmu.2018.01984] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 08/13/2018] [Indexed: 01/01/2023] Open
Abstract
Bile acids (BAs) control metabolism and inflammation by interacting with several receptors. Here, we report that intravenous infusion of taurodeoxycholate (TDCA) decreases serum pro-inflammatory cytokines, normalizes hypotension, protects against renal injury, and prolongs mouse survival during sepsis. TDCA increases the number of granulocytic myeloid-derived suppressor cells (MDSCLT) distinctive from MDSCs obtained without TDCA treatment (MDSCL) in the spleen of septic mice. FACS-sorted MDSCLT cells suppress T-cell proliferation and confer protection against sepsis when adoptively transferred better than MDSCL. Proteogenomic analysis indicated that TDCA controls chromatin silencing, alternative splicing, and translation of the immune proteome of MDSCLT, which increases the expression of anti-inflammatory molecules such as oncostatin, lactoferrin and CD244. TDCA also decreases the expression of pro-inflammatory molecules such as neutrophil elastase. These findings suggest that TDCA globally edits the proteome to increase the number of MDSCLT cells and affect their immune-regulatory functions to resolve systemic inflammation during sepsis.
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Affiliation(s)
- Sooghee Chang
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
| | - Youn-Hee Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Young-Joo Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Young-Woo Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Sungyoon Moon
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Yong Yook Lee
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Jin Sun Jung
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Youngsoo Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Hi-Eun Jung
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae-Joo Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Taek-Chin Cheong
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Hye-Jung Moon
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Ah Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Hang-Rae Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
- Department of Anatomy, Seoul National University College of Medicine, Seoul, South Korea
| | - Dohyun Han
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Yirang Na
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Seung-Hyeok Seok
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Nam-Hyuk Cho
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Hai-Chon Lee
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Eun-Hee Nam
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
| | - Hyosuk Cho
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Murim Choi
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Nagahiro Minato
- Department of Immunology and Cell Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seung-Yong Seong
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
- Wide River Institute of Immunology, Seoul National University, Seoul, South Korea
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141
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The Early Recognition and Management of Sepsis in Sub-Saharan African Adults: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15092017. [PMID: 30223556 PMCID: PMC6164025 DOI: 10.3390/ijerph15092017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/09/2018] [Accepted: 09/13/2018] [Indexed: 12/16/2022]
Abstract
Sepsis is a common cause of morbidity and mortality in sub-Saharan African adults. Standardised management pathways have been documented to improve the survival of adults with sepsis from high-resource settings. Our aim was to assess the current evidence base for early sepsis interventions (recognition, empirical antibiotics, and resuscitation) in resource-poor settings of sub-Saharan Africa. We searched MEDLINE, EMBASE and CINHAL Plus databases to identify interventional studies for the early recognition and management of sepsis in sub-Saharan Africa (1 January 2000 to 1 August 2018) using a protocol-driven search strategy: adults, protocolised care pathway, and sub-Saharan Africa. We identified 725 publications of which three met criteria for final selection. Meta-analysis from two randomised controlled trials demonstrated that mortality was increased by 'early goal-directed therapy' interventions that increased fluid resuscitation (R.R. 1.26, 95% C.I. 1.00⁻1.58, p = 0.045; I² 53%). The third observational cohort study demonstrated improved survival after implementation of protocolised management for sepsis (mortality 33.0% vs. 45.7%, p = 0.005). No study incorporated standardised protocols for empirical antibiotic administration. High rates of pneumonia and mycobacteraemia were reported. There has been little research into the early recognition and management of sepsis in sub-Saharan Africa. Interventional trials of early goal-directed therapy have, to date, increased mortality. There is an urgent need to develop effective strategies to improve outcomes for adults with sepsis in sub-Saharan Africa.
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Dummitt B, Zeringue A, Palagiri A, Veremakis C, Burch B, Yount B. Using survival analysis to predict septic shock onset in ICU patients. J Crit Care 2018; 48:339-344. [PMID: 30290359 DOI: 10.1016/j.jcrc.2018.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the efficacy of survival analysis for predicting septic shock onset in ICU patients. MATERIALS AND METHODS We performed a retrospective analysis on ICU cases from Mercy Hospital St. Louis from 2012 to 2016. As part of the procedure for inclusion in the Apache Outcomes database, each case is reviewed by critical care clinicians to identify septic shock patients as well as the time of septic shock onset. We used survival analysis to predict septic shock onset in these cases and employed lagging to compensate for uncertainties in septic shock onset time. RESULTS Survival analysis was highly effective at predicting septic shock onset, producing AUC values of >0.87. The methodology was robust to lag times as well as the specific method of survival analysis used. CONCLUSIONS This methodology has the potential to be implemented in the ICU for real time prediction and can be used as a building block to expand the approach to other hospital wards or care environments.
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Affiliation(s)
- Benjamin Dummitt
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
| | - Angelique Zeringue
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
| | - Ashok Palagiri
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
| | | | - Benjamin Burch
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA; Department of Data Science, Maryville University, 650 Maryville University Drive, St. Louis, MO 63141, USA
| | - Byron Yount
- Mercy Virtual Care Center, 15740 S. Outer Forty, Chesterfield, MO 63017, USA.
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143
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Bennett S, Grawe E, Jones C, Josephs SA, Mechlin M, Hurford WE. Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction? Curr Opin Anaesthesiol 2018; 31:165-171. [PMID: 29341963 DOI: 10.1097/aco.0000000000000560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. RECENT FINDINGS Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value. SUMMARY Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes.
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Affiliation(s)
- Suzanne Bennett
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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144
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Rubens M, Saxena A, Ramamoorthy V, Das S, Khera R, Hong J, Armaignac D, Veledar E, Nasir K, Gidel L. Increasing Sepsis Rates in the United States: Results From National Inpatient Sample, 2005 to 2014. J Intensive Care Med 2018; 35:858-868. [DOI: 10.1177/0885066618794136] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives:To examine the trends in hospitalization rates, mortality, and costs for sepsis during the years 2005 to 2014.Methods:This was a retrospective serial cross-sectional analysis of patients ≥18 years admitted for sepsis in National Inpatient Sample. Trends in sepsis hospitalizations were estimated, and age- and sex-adjusted rates were calculated for the years 2005 to 2014.Results:There were 541 694 sepsis admissions in 2005 and increased to 1 338 905 in 2014. Sepsis rates increased significantly from 1.2% to 2.7% during the years 2005 to 2014 (relative increase: 123.8%; Ptrend< .001). However, the relative increase changed by 105.8% ( Ptrend< .001) after adjusting for age and sex and maintained significance. Although total cost of hospitalization due to sepsis increased significantly from US$22.2 to US$38.1 billion ( Ptrend< .001), the mean hospitalization cost decreased significantly from US$46,470 to US$29,290 ( Ptrend< .001).Conclusions:Hospitalizations for sepsis increased during the years 2005 to 2014. Our study paradoxically found declining rates of in-hospital mortality, length of stay, and mean hospitalization cost for sepsis. These findings could be due to biases introduced by International Classification of Diseases, Ninth Revision, Clinical Modification coding rules and increased readmission rates or alternatively due to increased awareness and surveillance and changing disposition status. Standardized epidemiologic registries should be developed to overcome these biases.
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Affiliation(s)
- Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Anshul Saxena
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
| | | | - Sankalp Das
- Employee Health and Wellness Advantage, Baptist Health South Florida, Miami, FL, USA
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Hong
- Division of Cardiovascular Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Donna Armaignac
- Teleheath Center of Excellence, Baptist Health South Florida, Miami, FL, USA
| | - Emir Veledar
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
| | - Khurram Nasir
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD, USA
| | - Louis Gidel
- Teleheath Center of Excellence, Baptist Health South Florida, Miami, FL, USA
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145
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Londoño J, Niño C, Archila A, Valencia M, Cárdenas D, Perdomo M, Moncayo G, Vargas C, Vallejo CE, Hincapié C, Ascuntar J, León A, Jaimes F. Antibiotics has more impact on mortality than other early goal-directed therapy components in patients with sepsis: An instrumental variable analysis. J Crit Care 2018; 48:191-197. [PMID: 30218959 DOI: 10.1016/j.jcrc.2018.08.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/30/2018] [Accepted: 08/24/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To estimate the effect of each of the EGDT components, as well as of the antibiotics, on length-of-stay and mortality. METHODS Prospective cohort in three hospitals. Adult patients admitted by the Emergency Rooms (ER) with infection and any of systolic blood pressure < 90 mmHg or lactate >4 mmol/L. An instrumental analysis with hospital of admission as the instrumental variable was performed to estimate the effect of each intervention on hospital mortality and secondary outcomes. RESULTS Among 2587 patients evaluated 884 met inclusion criteria, with a hospital mortality rate of 17% (n = 150). In the instrumental analysis, the only intervention associated with an absolute reduction in mortality (21%) was the use of antibiotics in the first 3 h. In patients with lactate values ≥4 mmol/L in the ER, a non-decrease of at least 10% at six hours was independently associated with mortality (OR = 3.1; 95%CI = 1.5-6.2). CONCLUSIONS Among patients entering ER with infection and shock or hypoperfusion criteria, the use of appropriate antibiotics in the first 3 h is the measure that has the greatest impact on survival. In addition, among patients with hyperlactatemia >4 mmol/L, the clearance of >10% of lactate during resuscitation is associated with better outcomes.
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Affiliation(s)
- Jessica Londoño
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia; Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - César Niño
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia
| | - Andrea Archila
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Marta Valencia
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia; Medical division, IPS Universitaria León XIII, Medellín, Colombia
| | - Diana Cárdenas
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Mayla Perdomo
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Giovanny Moncayo
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - César Vargas
- Medical division, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Carlos E Vallejo
- Medical division, IPS Universitaria León XIII, Medellín, Colombia; GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Carolina Hincapié
- GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Johana Ascuntar
- GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Alba León
- GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Fabián Jaimes
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia; GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia; Research Direction, Hospital Universitario San Vicente Fundación, Medellín, Colombia.
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146
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Kato T, Matsuura K. Recombinant human soluble thrombomodulin improves mortality in patients with sepsis especially for severe coagulopathy: a retrospective study. Thromb J 2018; 16:19. [PMID: 30158838 PMCID: PMC6107946 DOI: 10.1186/s12959-018-0172-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 05/06/2018] [Indexed: 02/08/2023] Open
Abstract
Background Disseminated intravascular coagulation (DIC) is associated with high mortality in patients with sepsis. Several studies reporting that recombinant human soluble thrombomodulin (rhTM) reduced mortality in sepsis patients. This retrospective cohort study aimed to evaluate the efficacy of rhTM for patients with mild coagulopathy compared with those with severe coagulopathy. Methods We evaluated about 90-day mortality and SOFA score. SOFA score was also evaluated for the following components: respiratory, cardiovascular, hepatic, renal and coagulation. Results All 69 patients were diagnosed with sepsis, fulfilled Japanese Association for Acute Medicine criteria for DIC, and were treated with rhTM. Patients were assigned to either the mild coagulopathy group (did not fulfill the International Society on Thrombosis and Haemostasis overt DIC criteria) or the severe coagulopathy group (fulfilled overt DIC criteria). The 90-day mortality was significant lower in severe coagulopathy group than mild coagulopathy group (P = 0.029). Although the SOFA scores did not decrease in the mild coagulopathy group, SOFA scores decreased significantly in the severe coagulopathy group. Furthermore the respiratory component of the SOFA score significant decreased in severe coagulopathy group compared with mild coagulopathy group. Conclusions rhTM administration may reduce mortality by improving organ dysfunction especially for respiratory in septic patients with severe coagulopathy.
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Affiliation(s)
- Takahiro Kato
- 1Departments of Pharmacy, Aichi Medical University, 1 -1 Yazakokarimata, Nagakute, Aichi 480-1195 Japan
| | - Katsuhiko Matsuura
- 2Laboratory of Clinical Pharmacodynamics, Aichi Gakuin University School of Pharmacy, Nagakute, Japan
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147
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Milano PK, Desai SA, Eiting EA, Hofmann EF, Lam CN, Menchine M. Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock. West J Emerg Med 2018; 19:774-781. [PMID: 30202487 PMCID: PMC6123087 DOI: 10.5811/westjem.2018.7.37651] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/03/2018] [Accepted: 07/11/2018] [Indexed: 01/20/2023] Open
Abstract
Introduction There have been conflicting data regarding the relationship between sepsis-bundle adherence and mortality. Moreover, little is known about how this relationship may be moderated by the anatomic source of infection or the location of sepsis declaration. Methods This was a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock. The study included patients who presented to one of three Los Angeles County Department of Health Services (DHS) full-service hospitals January 2012 to December 2014. The primary outcome of interest was the association between sepsis-bundle adherence and in-hospital mortality. Secondary outcome measures included in-hospital mortality by source of infection, and the location of sepsis declaration. Results Among the 4,582 patients identified with sepsis, overall mortality was lower among those who received bundle-adherent care compared to those who did not (17.9% vs. 20.4%; p=0.035). Seventy-five percent (n=3,459) of patients first met sepsis criteria in the ED, 9.6% (n=444) in the intensive care unit (ICU) and 14.8% (n=678) on the ward. Bundle adherence was associated with lower mortality for those declaring in the ICU (23.0% adherent [95% confidence interval{CI} {16.8–30.5}] vs. 31.4% non-adherent [95% CI {26.4–37.0}]; p=0.063), but not for those declaring in the ED (17.2% adherent [95% CI {15.8–18.7}] vs. 15.1% non-adherent [95% CI {13.0–17.5}]; p=0.133) or on the ward (24.8% adherent [95% CI {18.6–32.4}] vs. 24.4% non-adherent [95% CI {20.9–28.3}]; p=0.908). Pneumonia was the most common source of sepsis (32.6%), and patients with pneumonia had the highest mortality of all other subsets receiving bundle non-adherent care (28.9%; 95% CI [25.3–32.9]). Although overall mortality was lower among those who received bundle-adherent care compared to those who did not, when divided into subgroups by suspected source of infection, a statistically significant mortality benefit to bundle-adherent sepsis care was only seen in patients with pneumonia. Conclusion In a large public healthcare system, adherence with severe sepsis/septic shock management bundles was found to be associated with improved survival. Bundle adherence seems to be most beneficial for patients with pneumonia. The overall improved survival in patients who received bundle-adherent care was driven by patients declaring in the ICU. Adherence was not associated with lower mortality in the large subset of patients who declared in the ED, nor in the smaller subset of patients who declared in the ward.
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Affiliation(s)
- Peter K Milano
- LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Shoma A Desai
- LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Erick A Eiting
- LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Erik F Hofmann
- LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Chun N Lam
- LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Michael Menchine
- LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Department of Emergency Medicine, Los Angeles, California
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148
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Lai CC, Ho CH, Chang CL, Chen CM, Chiang SR, Chao CM, Wang JJ, Cheng KC. Critical care medicine in Taiwan from 1997 to 2013 under National Health Insurance. J Thorac Dis 2018; 10:4957-4965. [PMID: 30233870 DOI: 10.21037/jtd.2018.07.131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Monitoring of trends in the use of the intensive care unit (ICU) and the outcomes of ICU patients is essential for the assessment of the effective use of ICU. This study aims to investigate the incidence and outcome of critical care admissions in Taiwan from 1997 to 2013. Methods Patients >18 years who had ICU admission between January 1997 and December 2013 were identified from the National Health Insurance Research Database in Taiwan. The main outcomes including ICU mortality and ICU length of stay (LOS) were measured. Results A total of 3,451,157 patients with ICU admission were identified during the study period. The mean ICU LOS was 5.9±9.0 days and the overall ICU-mortality rate was 19.8%. The mean age of the patients was 65.4 years old, 58.0% were elderly (≥65 years old), 61.1% were male. Annual incidence of ICU admissions increased from 115,754 in 1997 (age-adjusted incidence: 1,130/100,000 population) to 244,820 in 2013 (incidence: 1,483/100,000 population) (P<0.0001). The admission rate was highest for patients 75-104 years old (8,074 per 100,000 population), and lowest for those 18-44 years old (298 per 100,000 population). Among ICU admission patients, the percentage of patients ≥75 years old significantly increased from 25.2% in 1997 to 38.3% in 2013 (P<0.0001). ICU LOS remained stable during the study period, but the annual mortality rate significantly decreased from 23.0% in 1997 to 16.3% in 2013. Conclusions ICU admissions significantly increased from 1997 to 2013, especially for elderly patients, in contrast, the mortality rate of ICU patients significantly declined with time. In addition, the ICU LOS did not change during the study period.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying
| | - Chung-Han Ho
- Departments of Medical Research, Chi Mei Medical Center, Tainan.,Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy & Science, Tainan
| | - Chia-Li Chang
- Departments of Medical Research, Chi Mei Medical Center, Tainan
| | - Chin-Ming Chen
- Departments of Intensive Care Medicine, Chi Mei Medical Center, Tainan.,Chia Nan University of Pharmacy & Science, Tainan
| | - Shyh-Ren Chiang
- Chia Nan University of Pharmacy & Science, Tainan.,Departments of Internal Medicine, Chi Mei Medical Center, Tainan
| | - Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying
| | - Jhi-Joung Wang
- Departments of Medical Research, Chi Mei Medical Center, Tainan
| | - Kuo-Chen Cheng
- Departments of Internal Medicine, Chi Mei Medical Center, Tainan.,Department of Safety Health and Environmental Engineering, Chung Hwa University of Medical Technology, Tainan
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149
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Zhang LN, Tian H, Zhou XL, Tian SC, Zhang XH, Wu TJ. Upregulation of microRNA-351 exerts protective effects during sepsis by ameliorating skeletal muscle wasting through the Tead-4-mediated blockade of the Hippo signaling pathway. FASEB J 2018; 32:fj201800151RR. [PMID: 30040486 DOI: 10.1096/fj.201800151rr] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sepsis-induced skeletal muscle wasting may lead to various severe clinical consequences. Understanding molecular mechanisms of the regulation of the loss of skeletal muscle mass in septic patients remains a significant clinical challenge. The current study was conducted to establish septic mice models to explore the relationship between microRNA (miR)-351 and the transcription element apical (TEA) domain transcription factor (Tead)-4 gene and to investigate its effects on the skeletal muscle through mediating the Hippo signaling pathway in mice with acute sepsis. A total of 60 mice were collected to establish mouse models of acute sepsis. The positive expression rate of Tead-4 and the apoptotic index (AI) were measured. A dual-luciferase reporter gene assay was conducted to verify the targeting relationship between miR-351 and Tead-4. Furthermore, the muscle fiber diameter (MFD) and area (MFA) and the content of 3-methylhistidine (3-MH) and tyrosine (Tyr) were assessed. The expression levels of miR-351, p38-MAPK, Yes-associated protein, Tead-4, B-cell lymphoma X protein (Bax), and Caspase-3 were determined with quantitative RT-PCR and Western blot analysis. Finally, cell viability, apoptosis, and levels of inflammatory factors, including IL-1β, IL-6, IGF-1, TNF-α, and monocyte chemoattractant protein-1 were detected by 3-(4,5-dimethylthiazol-2- yl)-2,5-diphenyltetrazolium bromide assay, flow cytometry, and ELISA. Initially, Tead-4 protein expression was higher in skeletal muscle tissues of mice with acute sepsis. Tead-4 was identified to negatively regulate miR-351. Upregulation of miR-351 increased MFA and MFD, muscle weight water content, Bcl-2 expression levels, and cell viability. Up-regulation of miR-351 reduced AI; 3-MH and Tyr content; positive expression of Tead-4 protein; the expression levels of p38-MAPK, Yap, Tead-4, Bax, and Caspase-3; apoptosis; and inflammatory responses. The current study demonstrated that up-regulation of miR-351 inhibits the degradation of skeletal muscle protein and the atrophy of skeletal muscle in mice with acute sepsis by targeting Tead-4 through suppression of the Hippo signaling pathway. Thus, miR-351 overexpression may be a future therapeutic strategy for acute sepsis.-Zhang, L.-N., Tian, H., Zhou, X.-L., Tian, S.-C., Zhang, X.-H., Wu, T.-J. Upregulation of microRNA-351 exerts protective effects during sepsis by ameliorating skeletal muscle wasting through the Tead-4-mediated blockade of the Hippo signaling pathway.
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Affiliation(s)
- Li-Na Zhang
- Intensive Care Unit, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, China
| | - Hui Tian
- Intensive Care Unit, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, China
| | - Xiu-Li Zhou
- Intensive Care Unit, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, China
| | - Suo-Chen Tian
- Intensive Care Unit, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, China
| | - Xi-Hong Zhang
- Intensive Care Unit, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, China
| | - Tie-Jun Wu
- Intensive Care Unit, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, China
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150
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Jung AD, Baker J, Droege CA, Nomellini V, Johannigman J, Holcomb JB, Goodman MD, Pritts TA. Sooner is better: use of a real-time automated bedside dashboard improves sepsis care. J Surg Res 2018; 231:373-379. [PMID: 30278956 DOI: 10.1016/j.jss.2018.05.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/04/2018] [Accepted: 05/31/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Minimizing the interval between diagnosis of sepsis and administration of antibiotics improves patient outcomes. We hypothesized that a commercially available bedside clinical surveillance visualization system (BSV) would hasten antibiotic administration and decrease length of stay (LOS) in surgical intensive care unit (SICU) patients. METHODS A BSV, integrated with the electronic medical record and displayed at bedside, was implemented in our SICU in July 2016. A visual sepsis screen score (SSS) was added in July 2017. All patients admitted to SICU beds with bedside displays equipped with a BSV were analyzed to determine mean SSS, maximum SSS, time from positive SSS to antibiotic administration, SICU LOS, and mortality. RESULTS During the study period, 232 patients were admitted to beds equipped with the clinical surveillance visualization system. Thirty patients demonstrated positive SSS followed by confirmed sepsis (23 Pre-SSS versus 7 Post-SSS). Mean and maximum SSS were similar. Time from positive SSS to antibiotic administration was decreased in patients with a visual SSS (55.3 ± 15.5 h versus 16.2 ± 9.2 h; P < 0.05). ICU and hospital LOS was also decreased (P < 0.01). CONCLUSIONS Implementation of a visual SSS into a BSV led to a decreased time interval between the positive SSS and administration of antibiotics and was associated with shorter SICU and hospital LOS. Integration of a visual decision support system may help providers adhere to Surviving Sepsis Guidelines.
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Affiliation(s)
- Andrew D Jung
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer Baker
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Cincinnati Ohio
| | | | - Jay Johannigman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center at Houston, Houston Texas
| | | | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
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