201
|
Multicentre observational study of adherence to Sepsis Six guidelines in emergency general surgery. Br J Surg 2017; 104:e165-e171. [PMID: 28121038 DOI: 10.1002/bjs.10432] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/01/2016] [Accepted: 10/25/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency. METHODS Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days). RESULTS Of a total of 5067 patients from 97 hospitals across the UK, 911 (18·0 per cent) fulfilled the criteria for sepsis, 165 (3·3 per cent) for severe sepsis and 24 (0·5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17·6-94·5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19·8 (i.q.r. 10·0-35·4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality. CONCLUSION Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent.
Collapse
|
202
|
|
203
|
Rothman M, Levy M, Dellinger RP, Jones SL, Fogerty RL, Voelker KG, Gross B, Marchetti A, Beals J. Sepsis as 2 problems: Identifying sepsis at admission and predicting onset in the hospital using an electronic medical record–based acuity score. J Crit Care 2017; 38:237-244. [DOI: 10.1016/j.jcrc.2016.11.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/08/2016] [Accepted: 11/23/2016] [Indexed: 12/14/2022]
|
204
|
Erbs GC, Mastroeni MF, Pinho MSL, Koenig Á, Sperotto G, Ekwaru JP, Westphal GA. Comorbidities Might Condition the Recovery of Quality of Life in Survivors of Sepsis. J Intensive Care Med 2017; 34:337-343. [PMID: 28359215 DOI: 10.1177/0885066617699360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE: To assess how preexisting disabling comorbidities (DC) affect the recovery rate of quality of life (QOL) over time in sepsis survivors. METHODS: A prospective study was conducted on sepsis survivors who answered the 36-Item Short Form Health Survey (SF-36) 7 days after discharge from the intensive care unit. Subsequent interviews were held at 3, 6, and 12 months. The results of the physical component score (PCS) and mental component score (MCS) of the SF-36 were evaluated. Patients were divided into 2 groups to compare patients with DC (DC group) and without DC (no-DC group). Quantile regression was used to model changes in PCS and MCS between different time points. RESULTS: Seventy-nine sepsis survivors were enrolled. After controlling for baseline age and QOL, the QOL scores were lower among patients with DC than in no-DC patients. The QOL of DC group got worse when compared to no-DC group. Recovery rate of PCS and MCS was higher in the DC group than in the no-DC group (PCS: 20.51 vs 16.96, P < .01; MCS: 19.24 vs 9.66, P < .01). Their baseline QOL was recovered only by 6 months after the sepsis episode. CONCLUSION: Quality-of-life impairment and its recovery rhythm in patients with sepsis appear to be conditioned by coexisting DC.
Collapse
Affiliation(s)
- Gislene C Erbs
- 1 University of the Region of Joinville, Joinville, Santa Catarina, Brazil
| | - Marco F Mastroeni
- 1 University of the Region of Joinville, Joinville, Santa Catarina, Brazil
| | - Mauro S L Pinho
- 1 University of the Region of Joinville, Joinville, Santa Catarina, Brazil
| | - Álvaro Koenig
- 2 Unimed Hospital Center of Joinville, Santa Catarina, Brazil
| | | | | | - Glauco A Westphal
- 1 University of the Region of Joinville, Joinville, Santa Catarina, Brazil.,2 Unimed Hospital Center of Joinville, Santa Catarina, Brazil
| |
Collapse
|
205
|
Impact of Delayed Admission to the Intensive Care Unit from the Emergency Department upon Sepsis Outcomes and Sepsis Protocol Compliance. Crit Care Res Pract 2017; 2017:9616545. [PMID: 28409028 PMCID: PMC5376419 DOI: 10.1155/2017/9616545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/11/2017] [Accepted: 02/21/2017] [Indexed: 12/31/2022] Open
Abstract
Rationale. The impact of emergency department length of stay (EDLOS) upon sepsis outcomes needs clarification. We sought to better understand the relationship between EDLOS and both outcomes and protocol compliance in sepsis. Methods. We performed a retrospective observational study of septic patients admitted to the ICU from the ED between January 2012 and December 2015 in a single tertiary care teaching hospital. 287 patients with severe sepsis and septic shock were included. Study population was divided into patients with EDLOS < 6 hrs (early admission) versus ≥6 hours (delayed admission). We assessed the impact of EDLOS on hospital mortality, compliance with sepsis protocol, and resuscitation. Statistical significance was determined by chi-square test. Results. Of the 287 septic ED patients, 137 (47%) were admitted to the ICU in <6 hours. There was no significant in-hospital mortality difference between early and delayed admissions (p = 0.68). Both groups have similar compliance with the 3-hour protocol (p = 0.77). There was no significant difference in achieving optimal resuscitation within 12 hours (p = 0.35). Conclusion. We found that clinical outcomes were not significantly different between early and delayed ICU admissions. Additionally, EDLOS did not impact compliance with the sepsis protocol with the exception of repeat lactate draw.
Collapse
|
206
|
|
207
|
|
208
|
Building Systemwide Improvement Capability: Does an Organization's Strategy for Quality Improvement Matter? Qual Manag Health Care 2017; 25:92-101. [PMID: 27031358 DOI: 10.1097/qmh.0000000000000089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning. METHODS Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results. RESULTS We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success. CONCLUSIONS This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.
Collapse
|
209
|
Cioară AP, Flonta M, Binder A, Pop A, Siladi V, Todor N, Cristea V, Lupse M. Can we find accessible and relevant markers for sepsis outcome? REV ROMANA MED LAB 2017. [DOI: 10.1515/rrlm-2017-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background and Aim: Sepsis is a life-threatening disease with high mortality, therefore establishing early diagnostic and finding reliable prognostic biomarkers is vital. We aimed to investigate the prognostic role, as a single value, of serum procalcitonin, C-reactive protein, serum lactate, platelets number and serum glucose level in septic patients, all measured in the first 24 hours after hospital admittance.
Materials and methods: This retrospective study included 241 adult patients with sepsis, severe sepsis or septic shock. We use data from patients observation sheets. Data that were collected include: demographic parameters, comorbidities, necessity of mechanical ventilation and laboratory variables. We performed the statistical analysis with the chi square test for nonparametric data and to analyse the accuracy of prediction we used the receiver - operator curves with the level of significance set at p < 0.05.
Results: From 241 patients with a median age of 68 years, 127 (52.69%) were male.113 patients had severe sepsis. 89 patients (36.9%) died and male had an increase mortality rate. Most cases were respiratory sepsis (45.20%). The highest mortality rate was in septic shock (51.2%). Procalcitonin, C-reactive protein and glucose serum level at admittance were not correlated with mortality. The serum levels of creatinine >1.67 mg/dL and serum lactate >1.9 mmol/L at admittance were correlated with mortality (p < 0.01). The cutoff value of 121×103/uL platelets number was also correlated with mortality (p < 0.01).
Conclusions: Our findings suggest that serum creatinine, serum lactate and the platelets number could be used as prognostic markers in septic patients at admittance.
Collapse
Affiliation(s)
| | - Mirela Flonta
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Astrid Binder
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Andreea Pop
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Violeta Siladi
- Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania
| | - Nicolae Todor
- ”Prof. Dr. Ion Chiricuța” Institute of Oncology, Cluj-Napoca, Romania
| | - Victor Cristea
- University of Medicine and Pharmacy „Iuliu Hațieganu”, Cluj-Napoca, Romania
| | - Mihaela Lupse
- University of Medicine and Pharmacy „Iuliu Hațieganu”, Cluj-Napoca, Romania
| |
Collapse
|
210
|
Jozwiak M, Monnet X, Teboul JL. Early goal-directed therapy et choc septique — 15 ans après la Rivers’ study, ARISE, ProCESS et ProMISe. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1261-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
211
|
Meier B, Staton C. Sepsis Resuscitation in Resource-Limited Settings. Emerg Med Clin North Am 2017; 35:159-173. [DOI: 10.1016/j.emc.2016.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
212
|
Abstract
Sepsis is a heterogeneous clinical syndrome that encompasses infections of many different types and severity. Not surprisingly, it has confounded most attempts to apply a single definition, which has also limited the ability to develop a set of reliable diagnostic criteria. It is perhaps best defined as the different clinical syndromes produced by an immune response to infection that causes harm to the body beyond that of the local effects of the infection.
Collapse
Affiliation(s)
- Michael C Scott
- Adult Intensive Care Unit, Saint Agnes Hospital, 900 S. Caton Ave, Baltimore, MD 21229, USA.
| |
Collapse
|
213
|
Pulia MS, Redwood R, Sharp B. Antimicrobial Stewardship in the Management of Sepsis. Emerg Med Clin North Am 2017; 35:199-217. [PMID: 27908334 DOI: 10.1016/j.emc.2016.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sepsis represents a unique clinical dilemma with regard to antimicrobial stewardship. The standard approach to suspected sepsis in the emergency department centers on fluid resuscitation and timely broad-spectrum antimicrobials. The lack of gold standard diagnostics and evolving definitions for sepsis introduce a significant degree of diagnostic uncertainty that may raise the potential for inappropriate antimicrobial prescribing. Intervention bundles that combine traditional quality improvement strategies with emerging electronic health record-based clinical decision support tools and rapid molecular diagnostics represent the most promising approach to enhancing antimicrobial stewardship in the management of suspected sepsis in the emergency department.
Collapse
Affiliation(s)
- Michael S Pulia
- Emergency Medicine Antimicrobial Stewardship Program, BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 310, Madison, WI 53705, USA.
| | - Robert Redwood
- Antibiotic Stewardship Committee, Divine Savior Healthcare, 2817 New Pinery Road, Portage, WI 53901, USA
| | - Brian Sharp
- The American Center, BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 310, Madison, WI 53705, USA
| |
Collapse
|
214
|
Westra BL, Landman S, Yadav P, Steinbach M. Secondary Analysis of an Electronic Surveillance System Combined with Multi-focal Interventions for Early Detection of Sepsis. Appl Clin Inform 2017; 8:47-66. [PMID: 28097288 DOI: 10.4338/aci-2016-07-ra-0112] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/11/2016] [Indexed: 01/20/2023] Open
Abstract
To conduct an independent secondary analysis of a multi-focal intervention for early detection of sepsis that included implementation of change management strategies, electronic surveillance for sepsis, and evidence based point of care alerting using the POC AdvisorTM application. METHODS Propensity score matching was used to select subsets of the cohorts with balanced covariates. Bootstrapping was performed to build distributions of the measured difference in rates/means. The effect of the sepsis intervention was evaluated for all patients, and High and Low Risk subgroups for illness severity. A separate analysis was performed patients on the intervention and non-intervention units (without the electronic surveillance). Sensitivity, specificity, and the positive predictive values were calculated to evaluate the accuracy of the alerting system for detecting sepsis or severe sepsis/ septic shock. RESULTS There was positive effect on the intervention units with sepsis electronic surveillance with an adjusted mortality rate of -6.6%. Mortality rates for non-intervention units also improved, but at a lower rate of -2.9%. Additional outcomes improved for patients on both intervention and non-intervention units for home discharge (7.5% vs 1.1%), total length of hospital stay (-0.9% vs -0.3%), and 30 day readmissions (-6.6% vs -1.6%). Patients on the intervention units showed better outcomes compared with non-intervention unit patients, and even more so for High Risk patients. The sensitivity was 95.2%, specificity of 82.0% and PPV of 50.6% for the electronic surveillance alerts. CONCLUSION There was improvement over time across the hospital for patients on the intervention and non-intervention units with more improvement for sicker patients. Patients on intervention units with electronic surveillance have better outcomes; however, due to differences in exclusion criteria and types of units, further study is needed to draw a direct relationship between the electronic surveillance system and outcomes.
Collapse
Affiliation(s)
- Bonnie L Westra
- Bonnie L. Westra, PhD, RN, FAAN, FACMI, University of Minnesota, School of Nursing, 308 Harvard St SE, WDH 5-140, Minneapolis, MN, USA 55455,
| | | | | | | |
Collapse
|
215
|
Kleinpell R. Promoting early identification of sepsis in hospitalized patients with nurse-led protocols. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:10. [PMID: 28073375 PMCID: PMC5225612 DOI: 10.1186/s13054-016-1590-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
216
|
Castellanos-Ortega Á, Suberviola B. Has the Surviving Sepsis Campaign been successful in Spain? Med Intensiva 2017; 41:1-2. [DOI: 10.1016/j.medin.2016.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 01/20/2023]
|
217
|
Sánchez B, Ferrer R, Suarez D, Romay E, Piacentini E, Gomà G, Martínez M, Artigas A. Declining mortality due to severe sepsis and septic shock in Spanish intensive care units: A two-cohort study in 2005 and 2011. Med Intensiva 2017; 41:28-37. [DOI: 10.1016/j.medin.2016.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/04/2016] [Accepted: 09/07/2016] [Indexed: 01/08/2023]
|
218
|
Liu Y, Hou JH, Li Q, Chen KJ, Wang SN, Wang JM. Biomarkers for diagnosis of sepsis in patients with systemic inflammatory response syndrome: a systematic review and meta-analysis. SPRINGERPLUS 2016; 5:2091. [PMID: 28028489 PMCID: PMC5153391 DOI: 10.1186/s40064-016-3591-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 10/20/2016] [Indexed: 12/25/2022]
Abstract
Background Sepsis is one of the most common diseases that seriously threaten human health. Although a large number of markers related to sepsis have been reported in the last two decades, the diagnostic accuracy of these biomarkers remains unclear due to the lack of similar baselines among studies. Therefore, we conducted a large systematic review and meta-analysis to evaluate the diagnostic value of biomarkers from studies that included non-infectious systemic inflammatory response syndrome patients as a control group. Methods We searched Medline, Embase and the reference lists of identified studies beginning in April 2014. The last retrieval was updated in September 2016. Results Ultimately, 86 articles fulfilled the inclusion criteria. Sixty biomarkers and 10,438 subjects entered the final analysis. The areas under the receiver operating characteristic curves for the 7 most common biomarkers, including procalcitonin, C-reactive protein, interleukin 6, soluble triggering receptor expressed on myeloid cells-1, presepsin, lipopolysaccharide binding protein and CD64, were 0.85, 0.77, 0.79, 0.85, 0.88, 0.71 and 0.96, respectively. The remaining 53 biomarkers exhibited obvious variances in diagnostic value and methodological quality. Conclusions Although some biomarkers displayed moderate or above moderate diagnostic value for sepsis, the limitations of the methodological quality and sample size may weaken these findings. Currently, we still lack an ideal biomarker to aid in the diagnosis of sepsis. In the future, biomarkers with better diagnostic value as well as a combined diagnosis using multiple biomarkers are expected to solve the challenge of the diagnosis of sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s40064-016-3591-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yong Liu
- Intensive Care Unit, Suining Central Hospital, Deshengxi Road 127, Chuanshan District, Suining, 629000 Sichuan People's Republic of China
| | - Jun-Huan Hou
- Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 People's Republic of China.,State Key Laboratory of Trauma, Burn and Combined Injury, Trauma Center, Chongqing, 400042 People's Republic of China
| | - Qing Li
- Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 People's Republic of China.,State Key Laboratory of Trauma, Burn and Combined Injury, Trauma Center, Chongqing, 400042 People's Republic of China
| | - Kui-Jun Chen
- Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 People's Republic of China.,State Key Laboratory of Trauma, Burn and Combined Injury, Trauma Center, Chongqing, 400042 People's Republic of China
| | - Shu-Nan Wang
- Department of Radiology, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Jian-Min Wang
- Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, 400042 People's Republic of China.,State Key Laboratory of Trauma, Burn and Combined Injury, Trauma Center, Chongqing, 400042 People's Republic of China
| |
Collapse
|
219
|
Abstract
The history of the first commercial antibiotics is briefly reviewed, together with data from the US and WHO, showing the decrease in death due to infectious diseases over the 20th century, from just under half of all deaths, to less than 10%. The second half of the 20th century saw the new use of antibiotics as growth promoters for food animals in the human diet, and the end of the 20th century and beginning of the 21st saw the beginning and rapid rise of advanced microbial resistance to antibiotics.
Collapse
|
220
|
Pulmonary Infection Is an Independent Risk Factor for Long-Term Mortality and Quality of Life for Sepsis Patients. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4213712. [PMID: 28050557 PMCID: PMC5165149 DOI: 10.1155/2016/4213712] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/31/2016] [Accepted: 10/26/2016] [Indexed: 02/05/2023]
Abstract
Background. Long-term outcomes (mortality and health-related quality of life) of sepsis have risen as important indicators for health care. Pulmonary infection and abdominal infection are the leading causes of sepsis. However, few researches about long-term outcomes focused on the origin of sepsis. Here we aim to study the clinical differences between pulmonary-sepsis and abdominal-sepsis and to investigate whether different infection foci were associated with long-term outcomes. Methods. Patients who survived after hospital discharge were followed up by telephone interview. Quality of life (QoL) was assessed using the EuroQol 5-dimension (EQ5D) questionnaire. Results. Four hundred and eighty-three sepsis patients were included, 272 (56.3%) had pulmonary-sepsis, and 180 (37.3%) had abdominal-sepsis. The overall ICU and one-year mortality rates of the cohort were 17.8% and 36.1%, respectively. Compared with abdominal-sepsis, pulmonary-sepsis patients had older age, higher APACHE II, higher ICU mortality (31.7% versus 12.6%), and one-year mortality (45.4% versus 24.4%), together with worse QoL. Age, septic shock, acute renal failure, fungus infection, anion gap, and pulmonary infection were predictors for one-year mortality and pulmonary infection was a risk factor for poor QoL. Conclusions. Pulmonary-sepsis showed worse outcome than abdominal-sepsis. Pulmonary infection is a risk factor for one-year mortality and QoL after sepsis.
Collapse
|
221
|
McLymont N, Glover GW. Scoring systems for the characterization of sepsis and associated outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:527. [PMID: 28149888 DOI: 10.21037/atm.2016.12.53] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Sepsis is responsible for the utilisation of a significant proportion of healthcare resources and has high mortality rates. Early diagnosis and prompt interventions are associated with better outcomes but is impeded by a lack of diagnostic tools and the heterogeneous and enigmatic nature of sepsis. The recently updated definitions of sepsis have moved away from the centrality of inflammation and the systemic inflammatory response syndrome (SIRS) criteria which have been shown to be non-specific. Sepsis is now defined as a "life-threatening organ dysfunction caused by a dysregulated host response to infection". The Quick (q) Sequential (Sepsis-related) Organ Failure Assessment (SOFA) score is proposed as a surrogate for organ dysfunction and may act as a risk predictor for patients with known or suspected infection, as well as being a prompt for clinicians to consider the diagnosis of sepsis. Early warning scores (EWS) are track and trigger physiological monitoring systems that have become integrated within many healthcare systems for the detection of acutely deteriorating patients. The recent study by Churpek and colleagues sought to compare qSOFA to more established alerting criteria in a population of patients with presumed infection, and compared the ability to predict death or unplanned intensive care unit (ICU) admission. This perspective paper discusses recent advances in the diagnostic criteria for sepsis and how qSOFA may fit into the pre-existing models of acute care and sepsis quality improvement.
Collapse
Affiliation(s)
- Natalie McLymont
- Department of Intensive Care, Guy's and St Thomas' Hospital, King's College London, London, UK
| | - Guy W Glover
- Department of Intensive Care, Guy's and St Thomas' Hospital, King's College London, London, UK
| |
Collapse
|
222
|
|
223
|
McCulloch P, Morgan L, Flynn L, Rivero-Arias O, Martin G, Collins G, New S. Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BackgroundHigh rates of iatrogenic harm have been confirmed in observational studies of surgery. Most interventions designed to reduce this have been targeted at either workplace culture or operational systems. We hypothesised that an integrated intervention addressing both culture and system might be more effective than either approach alone.ObjectiveTo evaluate interventions designed to improve surgical team performance by impacting culture or systems in isolation or combination.DesignFive controlled intervention experiments, addressing system, culture or both, were performed in operating theatres. A final whole-system intervention study integrated approaches that showed benefit in these experiments. The five linked studies were subjected to a pre-planned pooled analysis to identify the effects of interventions, combinations and confounders. A qualitative interview study provided explanatory data on the mechanisms of intervention success and failure. An economic analysis was conducted.SettingOperating theatres in five hospitals, performing orthopaedic, trauma, vascular and plastic surgery were used for the linked studies. The final study occurred in a tertiary referral neurosurgery unit.ParticipantsThe main study subjects were clinical staff. Patient outcomes, both clinical and patient reported, were collected as secondary outcome measures.InterventionsThe interventions tested were (1) teamwork training (TT) based on the aviation crew resource management model, (2) the development of a set of standard operating procedures (SOPs), (3) a safety improvement programme based on lean principles, (4) TT plus SOPs and (5) TT plus lean. The final intervention used elements of all three strategies.Main outcome measuresPrimary outcomes were team non-technical skills [as measured by the Oxford Non-Technical Skills (NOTECHS) II scale score] and team technical performance (via the ‘glitch count’). Secondary outcomes were compliance with the World Health Organization (WHO)’s checklist procedures, patient length of stay, readmissions, 30-day mortality, complications and patient-reported outcome measures [as measured by the European Quality of Life-5 Dimensions (EQ-5D)]. A qualitative interview study provided explanatory data on the mechanisms of intervention success and failure. An economic analysis was conducted.Data sourcesDirect observation of whole operations, clinical records, hospital information systems and EQ-5D questionnaires. The qualitative study used semistructured interviews.Statistical methodsIndividual studies were analysed using two-way analysis of variance, and an overall individual patient pooled analysis was performed. Methods validation studies and other analyses used chi-squared test, correlation and regression methods as appropriate.ResultsWe studied 453 operations. The results of single interventions were inconsistent. TT alone improved non-technical skills and WHO compliance (p < 0.001) but not technical performance, whereas the systems interventions (lean and SOP) improved non-technical skills and technical performance (p < 0.001), but were less effective in improving WHO compliance. The integrated intervention approaches improved all aspects of team performance except time-out attempt rate, whereas the single approaches were significantly poorer at improving checklist compliance (p < 0.001) and failed to improve glitch rate. Combining all three strategies did not increase the percentage of successful projects. The qualitative analysis confirmed that integrated interventions better addressed the breadth of challenges that face surgical safety but also indicated that differences in implementation between integrated- and single-intervention studies amplified their differential effect.ConclusionsA combination of TT plus systems improvement training appears more effective in improving team performance than either approach alone. An implementation strategy based on an understanding of the barriers to change in hospitals is important for success.Future workMore work is required to understand and measure barriers to safety improvement. Implementation strategies need to be tested empirically. Methods for delivering integrated interventions on a larger scale need development. A cluster randomised trial of the integrated-systems/culture-improvement approach is warranted.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
Collapse
Affiliation(s)
- Peter McCulloch
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Lauren Morgan
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Lorna Flynn
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Graham Martin
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Gary Collins
- Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Steve New
- Saïd Business School, University of Oxford, Oxford, UK
| |
Collapse
|
224
|
Tarrant C, O’Donnell B, Martin G, Bion J, Hunter A, Rooney KD. A complex endeavour: an ethnographic study of the implementation of the Sepsis Six clinical care bundle. Implement Sci 2016; 11:149. [PMID: 27852320 PMCID: PMC5112724 DOI: 10.1186/s13012-016-0518-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 10/30/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Implementation of the 'Sepsis Six' clinical care bundle within an hour of recognition of sepsis is recommended as an approach to reduce mortality in patients with sepsis, but achieving reliable delivery of the bundle has proved challenging. There remains little understanding of the barriers to reliable implementation of bundle components. We examined frontline clinical practice in implementing the Sepsis Six. METHODS We conducted an ethnographic study in six hospitals participating in the Scottish Patient Safety Programme Sepsis collaborative. We conducted around 300 h of non-participant observation in emergency departments, acute medical receiving units and medical and surgical wards. We interviewed a purposive sample of 43 members of hospital staff. Data were analysed using a constant comparative approach. RESULTS Implementation strategies to promote reliable use of the Sepsis Six primarily focused on education, engaging and motivating staff, and providing prompts for behaviour, along with efforts to ensure that equipment required was readily available. Although these strategies were successful in raising staff awareness of sepsis and engagement with implementation, our study identified that completing the bundle within an hour was not straightforward. Our emergent theory suggested that rather than being an apparently simple sequence of six steps, the Sepsis Six actually involved a complex trajectory comprising multiple interdependent tasks that required prioritisation and scheduling, and which was prone to problems of coordination and operational failures. Interventions that involved allocating specific roles and responsibilities for completing the Sepsis Six in ways that reduced the need for coordination and task switching, and the use of process mapping to identify system failures along the trajectory, could help mitigate against some of these problems. CONCLUSIONS Implementation efforts that focus on individual behaviour change to improve uptake of the Sepsis Six should be supplemented by an understanding of the bundle as a complex trajectory of work in which improving reliability requires attention to coordination of workflow, as well as addressing the mundane problems of interruptions and operational failures that obstruct task completion.
Collapse
Affiliation(s)
- Carolyn Tarrant
- SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Barbara O’Donnell
- Institute of Healthcare Policy and Practice, School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
| | - Graham Martin
- SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Julian Bion
- University Department of Anaesthesia and Critical Care, University of Birmingham, Birmingham, UK
| | | | - Kevin D. Rooney
- Institute of Healthcare Policy and Practice, School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
- Department of Anaesthesia and Intensive Care Medicine, Royal Alexandra Hospital, Paisley, UK
| |
Collapse
|
225
|
Bendjelid K. Cardiac output-Scvo 2 relationship during sepsis: A subtle association. J Crit Care 2016; 38:351-352. [PMID: 27836261 DOI: 10.1016/j.jcrc.2016.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Karim Bendjelid
- Intensive Care Service, Geneva University Hospitals, CH, -1211, Geneva 14, Switzerland.
| |
Collapse
|
226
|
|
227
|
Schorr C, Odden A, Evans L, Escobar GJ, Gandhi S, Townsend S, Levy M. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards. J Hosp Med 2016; 11 Suppl 1:S32-S39. [PMID: 27805796 DOI: 10.1002/jhm.2656] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 08/26/2016] [Accepted: 08/31/2016] [Indexed: 11/07/2022]
Abstract
Sepsis is a leading cause of in-hospital death, and evidence suggests a higher mortality in patients presenting with sepsis on the ward compared to those presenting to the emergency department. Ward patients who develop severe sepsis may have poor outcomes for a variety of reasons, including delayed diagnosis, lack of readily available staffing, and delayed treatment. We report on a multihospital quality improvement program for early detection and treatment of sepsis on general medical-surgical wards. We describe a multipronged approach to improve severe sepsis outcomes using the Institute for Healthcare Improvement's Plan-Do-Study-Act model. Sixty sites engaged in a collaborative implementation process that aligned people, process, and technology. Based on our experience, we recommend a stepwise approach to implement such a program: (1) both administrative and clinical leadership commit to a common goal; (2) appoint clinical champions and give them authority to engage other clinicians to improve timeliness of interventions; (3) map workflows and processes to rely heavily on the nursing staff's ability to evaluate and report severe sepsis screening results; (4) if available, design and deploy technology with the assistance of clinical informaticians (eg, to enable electronic health records-based continuous screening); (5) to determine success, consider tracking screening compliance and process, and outcome measures such as length of stay and mortality. Journal of Hospital Medicine 2016;S11:32-S39. © 2016 Society of Hospital Medicine.
Collapse
Affiliation(s)
- Christa Schorr
- Cooper Research Institute-Critical Care, Cooper University Hospital, Camden, New Jersey.
| | - Andrew Odden
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, New York
| | - Gabriel J Escobar
- Systems Research Initiative, Kaiser Permanente Division of Research, Kaiser Permanente, Oakland, California
| | - Snehal Gandhi
- Division of Hospital Medicine, Medical Informatics and Care Delivery Innovation, Cooper University Hospital, Camden, New Jersey
| | - Sean Townsend
- Department of Quality and Safety, California Pacific Medical Center, San Francisco, California
| | - Mitchell Levy
- Department of Pulmonary, Critical Care, and Sleep Medicine, Rhode Island Hospital, Providence, Rhode Island
| |
Collapse
|
228
|
Machado FR, Levy MM, Rhodes A. Fixed minimum volume resuscitation: Pro. Intensive Care Med 2016; 43:1678-1680. [PMID: 27798737 DOI: 10.1007/s00134-016-4590-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 10/07/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil. .,Latin America Sepsis Institute, Sao Paulo, Brazil.
| | - Mitchell M Levy
- Department of Pulmonary and Critical Care, Alpert Medical School at Brown University, Providence, RI, USA
| | - Andrew Rhodes
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
229
|
Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:323. [PMID: 27724931 PMCID: PMC5057215 DOI: 10.1186/s13054-016-1484-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 09/13/2016] [Indexed: 01/07/2023]
Abstract
Background The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. Reducing the loss of transplantable organs from deceased potential donors as a function of cardiac arrest (CA) may contribute to an increase in organ donations. Our purpose was to test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential brain-dead donors (PBDDs) due to CA. Methods The quality improvement project included 27 hospitals that reported deceased donors prospectively to the Transplant Center of the State of Santa Catarina, Brazil. All deceased donors reported prospectively between May 2012 and April 2014 were analyzed. Hospitals were encouraged to use the VIP approach checklist during the management of PBDDs. The checklist was composed of the following goals: protocol duration 12–24 hours, temperature > 35 °C, mean arterial pressure ≥ 65 mmHg, diuresis 1–4 ml/kg/h, corticosteroids, vasopressin, tidal volume 6–8 ml/kg, positive end-expiratory pressure 8–10 cmH2O, sodium < 150 mEq/L, and glycemia < 180 mg/dl. A logistic regression model was used to identify predictors of CA. Results There were 726 PBDD notifications, of which 324 (44.6) were actual donors, 141 (19.4 %) CAs, 226 (31.1 %) family refusals, and 35 (4.8 %) contraindications. Factors associated with CA reduction included use of the checklist (odds ratio (OR) 0.43, p < 0.001), maintenance performed inside the ICU (OR 0.49, p = 0.013), and vasopressin administration (OR 0.56, p = 0.04). More than three interventions had association with less CAs (OR 0.19, p < 0.001). After 24 months, CAs decreased from 27.3 % to 14.6 % (p = 0.002), reaching 12.1 % in the following two 4-month periods (p < 0.001). Simultaneous increases in organ recovered per donor and in actual donors were observed. Conclusions A quality improvement program based on education and the use of a goal checklist for the management of potential donors inside the ICU is strongly associated with a decrease in donor losses and an increase in organs recovered per donor. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1484-1) contains supplementary material, which is available to authorized users.
Collapse
|
230
|
Lief L, Arbo J, Berlin DA. The Physiology of Early Goal-Directed Therapy for Sepsis. J Intensive Care Med 2016; 32:567-573. [PMID: 27708007 DOI: 10.1177/0885066616671705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2001, Rivers and colleagues published a randomized controlled trial of early goal-directed therapy (EGDT) for the treatment of sepsis. More than a decade later, it remains a landmark achievement. The study proved the benefits of early aggressive treatment of sepsis. However, many questions remain about specific aspects of the complex EGDT algorithm. Recently, 3 large trials attempted to replicate these results. None of the studies demonstrated a benefit of an EGDT protocol for sepsis. This review explores the physiologic basis of goal-directed therapy, including the hemodynamic targets and the therapeutic interventions. An understanding of the physiologic basis of EGDT helps reconcile the results of the clinical trials.
Collapse
Affiliation(s)
- Lindsay Lief
- 1 Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - John Arbo
- 2 Division of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - David A Berlin
- 1 Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
231
|
Aaronson EL, Filbin MR, Brown DFM, Tobin K, Mort EA. New Mandated Centers for Medicare and Medicaid Services Requirements for Sepsis Reporting: Caution from the Field. J Emerg Med 2016; 52:109-116. [PMID: 27720289 DOI: 10.1016/j.jemermed.2016.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/05/2016] [Accepted: 08/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The release of the Center for Medicare and Medicaid Service's (CMS) latest quality measure, Severe Sepsis/Septic Shock Early Management Bundle (SEP-1), has intensified the long-standing debate over optimal care for severe sepsis and septic shock. Although the last decade of research has demonstrated the importance of comprehensive bundled care in conjunction with compliance mechanisms to reduce patient mortality, it is not clear that SEP-1 achieves this aim. The heterogeneous and often cryptic presentation of severe sepsis and septic shock, along with the multifaceted criteria for the definition of this clinical syndrome, pose a particular challenge for fitting requirements to this disease, and implementation could have unintended consequences. OBJECTIVE Following a simulated reporting exercise, in which 50 charts underwent expert review, we aimed to detail the challenges of, and offer suggestions on how to rethink, measuring performance in severe sepsis and septic shock care. DISCUSSION There were several challenges associated with the design and implementation of this measure. The ambiguous definition of severe sepsis and septic shock, prescriptive fluid volume requirements, rigid reassessment, and complex abstraction logic all raise significant concern. CONCLUSIONS Although SEP-1 represents an important first step in requiring hospitals to improve outcomes for patients with severe sepsis and septic shock, the current approach must be revisited. The volume and complexity of the currently required SEP-1 reporting elements deserve serious consideration and revision before they are used as measures of accountability and tied to reimbursement.
Collapse
Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathy Tobin
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Elizabeth A Mort
- Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
232
|
Jozwiak M, Monnet X, Teboul JL. Implementing sepsis bundles. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:332. [PMID: 27713890 DOI: 10.21037/atm.2016.08.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis bundles represent key elements of care regarding the diagnosis and treatment of patients with septic shock and allow ones to convert complex guidelines into meaningful changes in behavior. Sepsis bundles endorsed the early goal-directed therapy (EGDT) and their implementation resulted in an improved outcome of septic shock patients. They induced more consistent and timely application of evidence-based care and reduced practice variability. These benefits mainly depend on the compliance with sepsis bundles, highlighting the importance of dedicated performance improvement initiatives, such as multifaceted educational programs. Nevertheless, the interest of early goal directed therapy in septic shock patients compared to usual care has recently been questioned, leading to an update of sepsis bundles in 2015. These new sepsis bundles may also exhibit, as the previous bundles, some limits and pitfalls and the effects of their implementation still needs to be evaluated.
Collapse
Affiliation(s)
- Mathieu Jozwiak
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| |
Collapse
|
233
|
Zhang Z, Smischney NJ, Zhang H, Van Poucke S, Tsirigotis P, Rello J, Honore PM, Sen Kuan W, Ray JJ, Zhou J, Shang Y, Yu Y, Jung C, Robba C, Taccone FS, Caironi P, Grimaldi D, Hofer S, Dimopoulos G, Leone M, Hong SB, Bahloul M, Argaud L, Kim WY, Spapen HD, Rocco JR. AME evidence series 001-The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital. J Thorac Dis 2016; 8:2654-2665. [PMID: 27747021 PMCID: PMC5059246 DOI: 10.21037/jtd.2016.08.03] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sepsis is a heterogeneous disease caused by an infection stimulus that triggers several complex local and systemic immuno-inflammatory reactions, which results in multiple organ dysfunction and significant morbidity and mortality. The diagnosis of sepsis is challenging because there is no gold standard for diagnosis. As a result, the clinical diagnosis of sepsis is ever changing to meet the clinical and research requirements. Moreover, although there are many novel biomarkers and screening tools for predicting the risk of sepsis, the diagnostic performance and effectiveness of these measures are less than satisfactory, and there is insufficient evidence to recommend clinical use of these new techniques. As a consequence, diagnostic criteria for sepsis need regular revision to cope with emerging evidence. This review aims to present the most updated information on diagnosis and early recognition of sepsis. Recommendations for clinical use of different diagnostic tools rely on the Grades of Recommendation Assessment, Development and Evaluation (GRADE) framework. Because most of the studies were observational and did not allow a reliable assessment of these tools, a two-step inference approach was employed. Future trials need to confirm or refute a particular index test and should directly explore relevant patient outcome parameters.
Collapse
Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- Department of Critical Care Medicine, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | | | - Haibo Zhang
- Keenan Research Center for Biomedical Science of St. Michael’s Hospital, Departments of Anesthesia and Physiology, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Sven Van Poucke
- Departments of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Panagiotis Tsirigotis
- 2nd Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jordi Rello
- CIBERES, Vall d’Hebron Institut of Research, Universitat Autonoma de Barcelona, Spain
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore and the Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Juliet June Ray
- DeWitt Daughtry Family Department of Surgery, Jackson Memorial Hospital, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Jiancang Zhou
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical Collegue, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200001, China
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - David Grimaldi
- Intensive Care Department, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Herbert D. Spapen
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Jose Rodolfo Rocco
- Department of Internal Medicine and Post-graduated Program, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
234
|
Suarez De La Rica A, Gilsanz F, Maseda E. Epidemiologic trends of sepsis in western countries. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:325. [PMID: 27713883 DOI: 10.21037/atm.2016.08.59] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Since the American College of Chest Physicians (ACCP) and the Society of Critical care Medicine (SCCM) published the first consensus definition of syndromes related to sepsis in 1992, the knowledge of epidemiology of sepsis has clearly improved, although no prospective studies have been performed to analyse the incidence of sepsis in general population. There are differences in epidemiologic trends in sepsis between western countries and low-income and middle-income countries. In the United States (US), most of epidemiologic studies have been based on large, administrative databases, reporting an increase in the incidence of severe sepsis over years. In general, studies describing epidemiology of sepsis outside the US use clinical definitions and intensive care unit (ICU) observational cohort designs instead of administrative databases and definitions. Incidence of sepsis has increased over years, probably due to progressive aging of population, the existence of more comorbidities and maybe the liberal use of sepsis codification, by including patients with less severity. Notwithstanding, mortality due to sepsis is clearly decreasing over years, probably to improvement in ICU care, although absolute mortality is growing on account of the raise in incidence. Risk factors for sepsis are the two ends of life, male sex, US black race, presence of comorbidities and certain genetic variants. Respiratory tract infections are the most common source of sepsis, and, nowadays, Gram-positive infections are more frequent that Gram-negative sepsis in most prospective studies.
Collapse
Affiliation(s)
- Alejandro Suarez De La Rica
- Department of Anesthesiology and Surgical Critical Care, Surgical Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesiology and Surgical Critical Care, Surgical Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Emilio Maseda
- Department of Anesthesiology and Surgical Critical Care, Surgical Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| |
Collapse
|
235
|
Clinician Perception of the Effectiveness of an Automated Early Warning and Response System for Sepsis in an Academic Medical Center. Ann Am Thorac Soc 2016; 12:1514-9. [PMID: 26288388 DOI: 10.1513/annalsats.201503-129oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE We implemented an electronic early warning and response system (EWRS) to improve detection of and response to severe sepsis. Sustainability of such a system requires stakeholder acceptance. We hypothesized that clinicians receiving such alerts perceive them to be useful and effective. OBJECTIVES To survey clinicians after EWRS notification about perceptions of the system. METHODS For a 6-week study period 1 month after EWRS implementation in a large tertiary referral medical center, bedside clinicians, including providers (physicians, advanced practice providers) and registered nurses (RNs), were surveyed confidentially within 2 hours of an alert. MEASUREMENTS AND MAIN RESULTS For the 247 alerts that triggered, 127 providers (51%) and 105 RNs (43%) completed the survey. Clinicians perceived most patients as stable before and after the alert. Approximately half (39% providers, 48% RNs) felt the alert provided new information, and about half (44% providers, 56% RNs) reported changes in management as a result of the alert, including closer monitoring and additional interventions. Over half (54% providers, 65% RNs) felt the alert was appropriately timed. Approximately one-third found the alert helpful (33% providers, 40% RNs) and fewer felt it improved patient care (24% providers, 35% RNs). CONCLUSIONS A minority of responders perceived the EWRS to be useful, likely related to the perception that most patients identified were stable. However, management was altered half the time after an alert. These results suggest further improvements to the system are needed to enhance clinician perception of the system's utility.
Collapse
|
236
|
Bigelow MEG, Jamieson BG, Chui CO, Mao Y, Shin KS, Huang TJ, Huang PH, Ren L, Adhikari B, Chen J, Iturriaga E. Point-of-Care Technologies for the Advancement of Precision Medicine in Heart, Lung, Blood, and Sleep Disorders. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2016; 4:2800510. [PMID: 27602308 PMCID: PMC5003165 DOI: 10.1109/jtehm.2016.2593920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/30/2016] [Accepted: 04/05/2016] [Indexed: 12/26/2022]
Abstract
The commercialization of new point of care technologies holds great potential in facilitating and advancing precision medicine in heart, lung, blood, and sleep (HLBS) disorders. The delivery of individually tailored health care to a patient depends on how well that patient's health condition can be interrogated and monitored. Point of care technologies may enable access to rapid and cost-effective interrogation of a patient's health condition in near real time. Currently, physiological data are largely limited to single-time-point collection at the hospital or clinic, whereas critical information on some conditions must be collected in the home, when symptoms occur, or at regular intervals over time. A variety of HLBS disorders are highly dependent on transient variables, such as patient activity level, environment, time of day, and so on. Consequently, the National Heart Lung and Blood Institute sponsored a request for applications to support the development and commercialization of novel point-of-care technologies through small businesses (RFA-HL-14-011 and RFA-HL-14-017). Three of the supported research projects are described to highlight particular point-of-care needs for HLBS disorders and the breadth of emerging technologies. While significant obstacles remain to the commercialization of such technologies, these advancements will be required to achieve precision medicine.
Collapse
Affiliation(s)
| | | | - Chi On Chui
- Electrical Engineering and Bioengineering DepartmentsUniversity of California at Los AngelesLos AngelesCA90095USA
| | - Yufei Mao
- Electrical Engineering and Bioengineering DepartmentsUniversity of California at Los AngelesLos AngelesCA90095USA
| | - Kyeong-Sik Shin
- Electrical Engineering and Bioengineering DepartmentsUniversity of California at Los AngelesLos AngelesCA90095USA
| | - Tony Jun Huang
- Bioengineering Science and Mechanics DepartmentThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | - Po-Hsun Huang
- Bioengineering Science and Mechanics DepartmentThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | - Liqiang Ren
- Bioengineering Science and Mechanics DepartmentThe Pennsylvania State UniversityUniversity ParkPA16802USA
| | | | - Jue Chen
- National Heart, Lung, and Blood InstituteBethesdaMD20892USA
| | - Erin Iturriaga
- National Heart, Lung, and Blood InstituteBethesdaMD20892USA
| |
Collapse
|
237
|
Boland LL, Hokanson JS, Fernstrom KM, Kinzy TG, Lick CJ, Satterlee PA, LaCroix BK. Prehospital Lactate Measurement by Emergency Medical Services in Patients Meeting Sepsis Criteria. West J Emerg Med 2016; 17:648-55. [PMID: 27625735 PMCID: PMC5017855 DOI: 10.5811/westjem.2016.6.30233] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/24/2016] [Accepted: 06/06/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction We aimed to pilot test the delivery of sepsis education to emergency medical services (EMS) providers and the feasibility of equipping them with temporal artery thermometers (TATs) and handheld lactate meters to aid in the prehospital recognition of sepsis. Methods This study used a convenience sample of prehospital patients meeting established criteria for sepsis. Paramedics received education on systemic inflammatory response syndrome (SIRS) criteria, were trained in the use of TATs and hand-held lactate meters, and enrolled patients who had a recent history of infection, met ≥ 2 SIRS criteria, and were being transported to a participating hospital. Blood lactate was measured by paramedics in the prehospital setting and again in the emergency department (ED) via usual care. Paramedics entered data using an online database accessible at the point of care. Results Prehospital lactate values obtained by paramedics ranged from 0.8 to 9.8 mmol/L, and an elevated lactate (i.e. ≥ 4.0) was documented in 13 of 112 enrolled patients (12%). The unadjusted correlation of prehospital and ED lactate values was 0.57 (p< 0.001). The median interval between paramedic assessment of blood lactate and the electronic posting of the ED-measured lactate value in the hospital record was 111 minutes. Overall, 91 patients (81%) were hospitalized after ED evaluation, 27 (24%) were ultimately diagnosed with sepsis, and 3 (3%) died during hospitalization. Subjects with elevated prehospital lactate were somewhat more likely to have been admitted to the intensive care unit (23% vs 15%) and to have been diagnosed with sepsis (38% vs 22%) than those with normal lactate levels, but these differences were not statistically significant. Conclusion In this pilot, EMS use of a combination of objective SIRS criteria, subjective assessment of infection, and blood lactate measurements did not achieve a level of diagnostic accuracy for sepsis that would warrant hospital prenotification and committed resources at a receiving hospital based on EMS assessment alone. Nevertheless, this work provides an early model for increasing EMS awareness and the implementation of novel devices that may enhance the prehospital assessment for sepsis. Additional translational research studies with larger numbers of patients and more robust methods are needed.
Collapse
Affiliation(s)
- Lori L Boland
- Allina Health, Division of Applied Research, Minneapolis, Minnesota; Allina Health, Emergency Medical Services, St. Paul, Minnesota
| | - Jonathan S Hokanson
- Abbott Northwestern Hospital, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Karl M Fernstrom
- Allina Health, Division of Applied Research, Minneapolis, Minnesota
| | - Tyler G Kinzy
- Allina Health, Division of Applied Research, Minneapolis, Minnesota
| | - Charles J Lick
- Allina Health, Emergency Medical Services, St. Paul, Minnesota
| | - Paul A Satterlee
- Allina Health, Emergency Medical Services, St. Paul, Minnesota; Abbott Northwestern Hospital, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Brian K LaCroix
- Allina Health, Emergency Medical Services, St. Paul, Minnesota
| |
Collapse
|
238
|
van den Hengel LC, Visseren T, Meima-Cramer PE, Rood PPM, Schuit SCE. Knowledge about systemic inflammatory response syndrome and sepsis: a survey among Dutch emergency department nurses. Int J Emerg Med 2016; 9:19. [PMID: 27416936 PMCID: PMC4945519 DOI: 10.1186/s12245-016-0119-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 06/30/2016] [Indexed: 11/10/2022] Open
Abstract
Background Sepsis has a high mortality. Early recognition and timely treatment are essential for patient survival. The aim of this study is to examine the factors that influence the knowledge and recognition of systemic inflammatory response syndrome (SIRS) criteria and sepsis by emergency department (ED) nurses. Methods A prospective, multi-center study including 216 ED nurses from 11 hospitals and academic medical centers in The Netherlands was conducted in 2013. A validated questionnaire was used to evaluate ED nurses’ knowledge about SIRS and sepsis. Questions about demographic characteristics were also included, to investigate factors that may contribute to the knowledge about SIRS and sepsis. Results The mean total score was 15.9 points, with a maximum possible score of 29 points. ED nurses employed at hospitals with a level 3 intensive care unit (ICU) scored significantly higher than their colleagues employed at hospitals with a level 1 or 2 ICU. Recently completed education in sepsis was associated with a higher score. The employees in low ICU level hospitals who reported recent education did not score significantly lower than their ICU level 3 colleagues. ED nurses over the age of 50 scored significantly lower than their younger colleagues. Conclusions The knowledge of ED nurses concerning SIRS and sepsis rises proportionally with the level of ICU in hospitals. Recent education in sepsis raises knowledge level as well. We recommend that when there is a low exposure rate to SIRS and sepsis, more emphasis should be placed on regular education.
Collapse
Affiliation(s)
- L C van den Hengel
- Department of Emergency Medicine, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - T Visseren
- Department of Emergency Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - P E Meima-Cramer
- Erasmus MC Zorgacademie: Training Center for Health Professionals, Erasmus Medical Center, Rotterdam, The Netherlands
| | - P P M Rood
- Department of Emergency Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - S C E Schuit
- Department of Emergency Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
239
|
Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, Jahan R, Tan JCK, Harvey SE, Bell D, Bion JF, Coats TJ, Singer M, Young JD, Rowan KM. Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock. Health Technol Assess 2016; 19:i-xxv, 1-150. [PMID: 26597979 DOI: 10.3310/hta19970] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Early goal-directed therapy (EGDT) is recommended in international guidance for the resuscitation of patients presenting with early septic shock. However, adoption has been limited and uncertainty remains over its clinical effectiveness and cost-effectiveness. OBJECTIVES The primary objective was to estimate the effect of EGDT compared with usual resuscitation on mortality at 90 days following randomisation and on incremental cost-effectiveness at 1 year. The secondary objectives were to compare EGDT with usual resuscitation for requirement for, and duration of, critical care unit organ support; length of stay in the emergency department (ED), critical care unit and acute hospital; health-related quality of life, resource use and costs at 90 days and at 1 year; all-cause mortality at 28 days, at acute hospital discharge and at 1 year; and estimated lifetime incremental cost-effectiveness. DESIGN A pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation. SETTING Fifty-six NHS hospitals in England. PARTICIPANTS A total of 1260 patients who presented at EDs with septic shock. INTERVENTIONS EGDT (n = 630) or usual resuscitation (n = 630). Patients were randomly allocated 1 : 1. MAIN OUTCOME MEASURES All-cause mortality at 90 days after randomisation and incremental net benefit (at £20,000 per quality-adjusted life-year) at 1 year. RESULTS Following withdrawals, data on 1243 (EGDT, n = 623; usual resuscitation, n = 620) patients were included in the analysis. By 90 days, 184 (29.5%) in the EGDT and 181 (29.2%) patients in the usual-resuscitation group had died [p = 0.90; absolute risk reduction -0.3%, 95% confidence interval (CI) -5.4 to 4.7; relative risk 1.01, 95% CI 0.85 to 1.20]. Treatment intensity was greater for the EGDT group, indicated by the increased use of intravenous fluids, vasoactive drugs and red blood cell transfusions. Increased treatment intensity was reflected by significantly higher Sequential Organ Failure Assessment scores and more advanced cardiovascular support days in critical care for the EGDT group. At 1 year, the incremental net benefit for EGDT versus usual resuscitation was negative at -£725 (95% CI -£3000 to £1550). The probability that EGDT was more cost-effective than usual resuscitation was below 30%. There were no significant differences in any other secondary outcomes, including health-related quality of life, or adverse events. LIMITATIONS Recruitment was lower at weekends and out of hours. The intervention could not be blinded. CONCLUSIONS There was no significant difference in all-cause mortality at 90 days for EGDT compared with usual resuscitation among adults identified with early septic shock presenting to EDs in England. On average, costs were higher in the EGDT group than in the usual-resuscitation group while quality-adjusted life-years were similar in both groups; the probability that it is cost-effective is < 30%. FUTURE WORK The ProMISe (Protocolised Management In Sepsis) trial completes the planned trio of evaluations of EGDT across the USA, Australasia and England; all have indicated that EGDT is not superior to usual resuscitation. Recognising that each of the three individual, large trials has limited power for evaluating potentially important subgroups, the harmonised approach adopted provides the opportunity to conduct an individual patient data meta-analysis, enhancing both knowledge and generalisability. TRIAL REGISTRATION Current Controlled Trials ISRCTN36307479. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 97. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Tiffany M Osborn
- Departments of Surgery and Emergency Medicine, Washington University, St Louis, MO, USA
| | - G Sarah Power
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rahi Jahan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Jermaine C K Tan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Sheila E Harvey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Derek Bell
- Faculty of Medicine, Imperial College London, London, UK.,Department of Acute Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Julian F Bion
- Department of Intensive Care Medicine, University of Birmingham, Birmingham, UK
| | - Timothy J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - J Duncan Young
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| |
Collapse
|
240
|
Joynes EL, Martin J, Ross M. Management of Septic Shock in the Remote Prehospital Setting. Air Med J 2016; 35:235-238. [PMID: 27393760 DOI: 10.1016/j.amj.2016.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/20/2016] [Accepted: 04/02/2016] [Indexed: 06/06/2023]
Abstract
This study aims to assess the management of septic shock by air medical retrieval teams in the remote setting. A retrospective observational study was performed over 36 months. Sixty-seven adult patients who met the criteria for septic shock were included. Respiratory sepsis was the working diagnosis for 53% of patients; this was confirmed on intensive care unit (ICU) discharge in 39% of patients. Intravenous antibiotics and oxygen were delivered in over 90% of patients. Central and arterial line insertions were performed in 48% and 40% of patients, respectively, and 79% of patients were catheterized. Thirty-three percent of patients required intubation, and 80% of patients received an initial crystalloid fluid bolus of 20 mL/kg. Vasopressors were started in 89% of patients. Upon reaching definitive care, 91% of patients were admitted to a high-dependency or ICU setting, with a median length of ICU stay of 4 days and a 30-day mortality of 13%. Of those admitted to the ICU, intubation was required in 48%, new renal support in 20%, and blood pressure support in 84% of patients, respectively. Septic shock was recognized early and managed aggressively by remote retrieval teams, which may have contributed to the low mortality rate observed.
Collapse
Affiliation(s)
- Emma Lucy Joynes
- Careflight Darwin, Darwin Airport, Northern Territory, Australia.
| | - Jodie Martin
- Careflight Darwin, Darwin Airport, Northern Territory, Australia
| | - Mark Ross
- Careflight Darwin, Darwin Airport, Northern Territory, Australia
| |
Collapse
|
241
|
Rolnick J, Downing NL, Shepard J, Chu W, Tam J, Wessels A, Li R, Dietrich B, Rudy M, Castaneda L, Shieh L. Validation of Test Performance and Clinical Time Zero for an Electronic Health Record Embedded Severe Sepsis Alert. Appl Clin Inform 2016; 7:560-72. [PMID: 27437061 DOI: 10.4338/aci-2015-11-ra-0159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 04/10/2016] [Indexed: 11/23/2022] Open
Abstract
BACHGROUND Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management. OBJECTIVE To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR. METHODS The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis. RESULTS Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen. CONCLUSION We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Ron Li
- Stanford Hospital & Clinics
| | | | | | | | | |
Collapse
|
242
|
[Value of blood lactic acid in evaluating disease severity and prognosis in children with sepsis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18. [PMID: 27324538 PMCID: PMC7389082 DOI: 10.7499/j.issn.1008-8830.2016.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To investigate the value of blood lactic acid (BLA) in evaluating disease severity and prognosis in children with sepsis. METHODS A total of 484 children with sepsis were enrolled and divided into common sepsis group (n=310), severe sepsis group (n=105), and septic shock group (n=69). BLA level was measured before treatment, and the results of BLA re-examination after early fluid resuscitation were collected for children with septic shock and a BLA level of >2 mmol/L. RESULTS The BLA level increased with the increasing severity of sepsis. The analysis of the receiver operating characteristic curve showed that the cut-off value of BLA for the diagnosis of septic shock was 2.25 mmol/L, with a sensitivity of 82.6% and a specificity of 79.8%. The fatality rates in the BLA ≤1 mmol/L, BLA 1.1-2 mmol/L, BLA 2.1-4 mmol/L, and BLA >4 mmol/L groups were 8.5%, 9.4%, 27.2%, and 67.6%, respectively, and the risk of death in the BLA >4 mmol/L group was 22.4 times that in the BLA ≤1 mmol/L group. In children with septic shock who had a BLA level of >2 mmol/L before treatment and whose BLA levels were ≤2 mmol/L or >2 mmol/L after resuscitation, the fatality rates were 33.3% and 69.2%, respectively. CONCLUSIONS BLA can be used to evaluate disease severity and prognosis in children with sepsis, and a BLA level of 2.25 mmol/L has a high value in diagnosing septic shock. Early resuscitation helps BLA level return to normal and can improve the prognosis of children with septic shock.
Collapse
|
243
|
Yan HP, Lu XL, Qiu J, Liu PP, Zuo C, Zhu YM. [Value of blood lactic acid in evaluating disease severity and prognosis in children with sepsis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:506-10. [PMID: 27324538 PMCID: PMC7389082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/29/2016] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To investigate the value of blood lactic acid (BLA) in evaluating disease severity and prognosis in children with sepsis. METHODS A total of 484 children with sepsis were enrolled and divided into common sepsis group (n=310), severe sepsis group (n=105), and septic shock group (n=69). BLA level was measured before treatment, and the results of BLA re-examination after early fluid resuscitation were collected for children with septic shock and a BLA level of >2 mmol/L. RESULTS The BLA level increased with the increasing severity of sepsis. The analysis of the receiver operating characteristic curve showed that the cut-off value of BLA for the diagnosis of septic shock was 2.25 mmol/L, with a sensitivity of 82.6% and a specificity of 79.8%. The fatality rates in the BLA ≤1 mmol/L, BLA 1.1-2 mmol/L, BLA 2.1-4 mmol/L, and BLA >4 mmol/L groups were 8.5%, 9.4%, 27.2%, and 67.6%, respectively, and the risk of death in the BLA >4 mmol/L group was 22.4 times that in the BLA ≤1 mmol/L group. In children with septic shock who had a BLA level of >2 mmol/L before treatment and whose BLA levels were ≤2 mmol/L or >2 mmol/L after resuscitation, the fatality rates were 33.3% and 69.2%, respectively. CONCLUSIONS BLA can be used to evaluate disease severity and prognosis in children with sepsis, and a BLA level of 2.25 mmol/L has a high value in diagnosing septic shock. Early resuscitation helps BLA level return to normal and can improve the prognosis of children with septic shock.
Collapse
Affiliation(s)
- Hai-Peng Yan
- Academy of Pediatrics, University of South China/Emergency Center, Hunan Children's Hospital, Changsha 410007, China.
| | | | | | | | | | | |
Collapse
|
244
|
Tuuri RE, Gehrig MG, Busch CE, Ebeling M, Morella K, Hunt L, Russell WS. "Beat the Shock Clock": An Interprofessional Team Improves Pediatric Septic Shock Care. Clin Pediatr (Phila) 2016; 55:626-38. [PMID: 26307185 DOI: 10.1177/0009922815601984] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Ideal care for septic shock (SS) is difficult. This interprofessional quality improvement intervention in a mid-volume pediatric emergency department aimed to reduce time to vascular access, fluid resuscitation, and antibiotics for SS. Intensive education, a care pathway, and an order set were applied. Outcome measures for patients with criteria for SS before and after intervention were compared. There were 43 patients pre-intervention (January 2009 to June 2011) and 63 post-intervention (June 2012 to June 2013). Median time to vascular access decreased from 37 minutes pre-intervention to 24 minutes post-intervention (p = 0.05). Median time to first fluid bolus decreased from 35 to 26 minutes (p = 0.08). Percentage of boluses delivered rapidly by pressure method increased from 21% to 74% (p < 0.0001). Median time to antibiotics decreased from 92 to 55 minutes (p = 0.02). In conclusion, a multimodal, interprofessional quality improvement intervention in a mid-sized pediatric emergency department improved the time to critical interventions for SS.
Collapse
Affiliation(s)
- Rachel E Tuuri
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Madeline G Gehrig
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Carrie E Busch
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Myla Ebeling
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Kristen Morella
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Lisa Hunt
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - W Scott Russell
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| |
Collapse
|
245
|
Probiotics and Synbiotics Decrease Postoperative Sepsis in Elective Gastrointestinal Surgical Patients: a Meta-Analysis. J Gastrointest Surg 2016; 20:1123-31. [PMID: 27073082 DOI: 10.1007/s11605-016-3142-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The health benefits of probiotics and synbiotics are well established in healthy adults, but their role in preventing postoperative sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotics on the incidence of postoperative sepsis in gastrointestinal (GI) surgical patients. METHODS A comprehensive literature search of all published randomized control trials (RCTs) was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Inclusion criteria included RCTs comparing the use of any strain or dose of a specified probiotic/synbiotic with placebo or a "no treatment" control group. The incidence of postoperative sepsis (within 1 month of surgery) and postoperative mortality were analyzed. RESULTS Fifteen RCTs involving 1201 patients (192 receiving probiotics, 413 receiving synbiotics, and 596 receiving placebo) were analyzed. Overall, probiotic and synbiotic uses significantly reduced the risk of developing postoperative sepsis by 38 % (relative risk (RR) = 0.62, 95 % confidence interval (CI) 0.52-0.74, p < 0.001). CONCLUSIONS The use of probiotic/synbiotic supplementation is associated with a significant reduction in the risk of developing postoperative sepsis in patients undergoing elective GI surgery. Probiotic/synbiotic supplementation is a valuable adjunct in the care of patients undergoing GI surgery. Additional studies are required to determine the optimal dose and strain of probiotic/synbiotic.
Collapse
|
246
|
Neri M, Riezzo I, Pomara C, Schiavone S, Turillazzi E. Oxidative-Nitrosative Stress and Myocardial Dysfunctions in Sepsis: Evidence from the Literature and Postmortem Observations. Mediators Inflamm 2016; 2016:3423450. [PMID: 27274621 PMCID: PMC4870364 DOI: 10.1155/2016/3423450] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/11/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Myocardial depression in sepsis is common, and it is associated with higher mortality. In recent years, the hypothesis that the myocardial dysfunction during sepsis could be mediated by ischemia related to decreased coronary blood flow waned and a complex mechanism was invoked to explain cardiac dysfunction in sepsis. Oxidative stress unbalance is thought to play a critical role in the pathogenesis of cardiac impairment in septic patients. AIM In this paper, we review the current literature regarding the pathophysiology of cardiac dysfunction in sepsis, focusing on the possible role of oxidative-nitrosative stress unbalance and mitochondria dysfunction. We discuss these mechanisms within the broad scenario of cardiac involvement in sepsis. CONCLUSIONS Findings from the current literature broaden our understanding of the role of oxidative and nitrosative stress unbalance in the pathophysiology of cardiac dysfunction in sepsis, thus contributing to the establishment of a relationship between these settings and the occurrence of oxidative stress. The complex pathogenesis of septic cardiac failure may explain why, despite the therapeutic strategies, sepsis remains a big clinical challenge for effectively managing the disease to minimize mortality, leading to consideration of the potential therapeutic effects of antioxidant agents.
Collapse
Affiliation(s)
- M. Neri
- Institute of Forensic Pathology, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D'Avanzo, Viale degli Aviatori 1, 71100 Foggia, Italy
| | - I. Riezzo
- Institute of Forensic Pathology, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D'Avanzo, Viale degli Aviatori 1, 71100 Foggia, Italy
| | - C. Pomara
- Institute of Forensic Pathology, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D'Avanzo, Viale degli Aviatori 1, 71100 Foggia, Italy
| | - S. Schiavone
- Institute of Pharmacology, Department of Clinical and Experimental Medicine, University of Foggia, Via L. Pinto 1, 71100 Foggia, Italy
| | - E. Turillazzi
- Institute of Forensic Pathology, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D'Avanzo, Viale degli Aviatori 1, 71100 Foggia, Italy
| |
Collapse
|
247
|
Happ MB, Sereika SM, Houze MP, Seaman JB, Tate JA, Nilsen ML, van Panhuis J, Scuilli A, Baumann BM, George E, Angus DC, Barnato AE. Quality of care and resource use among mechanically ventilated patients before and after an intervention to assist nurse-nonvocal patient communication. Heart Lung 2016; 44:408-415.e2. [PMID: 26354859 DOI: 10.1016/j.hrtlng.2015.07.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 07/01/2015] [Accepted: 07/04/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Implement and test unit-wide patient-nurse assisted communication strategies (SPEACS). BACKGROUND SPEACS improved nurse-patient communication outcomes; effects on patient care quality and resource use are unknown. METHODS Prospective, randomized stepped-wedge pragmatic trial of 1440 adults ventilated ≥2 days and awake for at least one shift in 6 ICUs at 2 teaching hospitals 2009-2011 with blinded retrospective medical record abstraction. MAIN RESULTS 323/383 (84%) nurses completed training; their communication knowledge (p < .001) and satisfaction and comfort (p < .001) increased. ICU days with physical restraint use (p = .44), heavy sedation (p = .73), pain score documentation (p = .97), presence of ICU-acquired pressure ulcers (p = .78), coma-free days (p = .76), ventilator-free days (p = .83), ICU length of stay (p = .77), hospital length of stay (p = .22), and median costs (p = .07) did not change. CONCLUSIONS SPEACS improved ICU nurses' knowledge, satisfaction and comfort in communicating with nonvocal MV patients but did not impact patient care quality or resource use.
Collapse
Affiliation(s)
- Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH, USA; The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA.
| | - Susan M Sereika
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Martin P Houze
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jennifer B Seaman
- The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Judith A Tate
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - Marci L Nilsen
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jennifer van Panhuis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Andrea Scuilli
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Derek C Angus
- The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Amber E Barnato
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| |
Collapse
|
248
|
Friedrich-Rust M, Wanger B, Heupel F, Filmann N, Brodt R, Kempf VAJ, Kessel J, Wichelhaus TA, Herrmann E, Zeuzem S, Bojunga J. Influence of antibiotic-regimens on intensive-care unit-mortality and liver-cirrhosis as risk factor. World J Gastroenterol 2016; 22:4201-4210. [PMID: 27122670 PMCID: PMC4837437 DOI: 10.3748/wjg.v22.i16.4201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/09/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the rate of infection, appropriateness of antimicrobial-therapy and mortality on intensive care unit (ICU). Special focus was drawn on patients with liver cirrhosis.
METHODS: The study was approved by the local ethical committee. All patients admitted to the Internal Medicine-ICU between April 1, 2007 and December 31, 2009 were included. Data were extracted retrospectively from all patients using patient charts and electronic documentations on infection, microbiological laboratory reports, diagnosis and therapy. Due to the large hepatology department and liver transplantation center, special interest was on the subgroup of patients with liver cirrhosis. The primary statistical-endpoint was the evaluation of the influence of appropriate versus inappropriate antimicrobial-therapy on in-hospital-mortality.
RESULTS: Charts of 1979 patients were available. The overall infection-rate was 53%. Multiresistant-bacteria were present in 23% of patients with infection and were associated with increased mortality (P < 0.000001). Patients with infection had significantly increased in-hospital-mortality (34% vs 17%, P < 0.000001). Only 9% of patients with infection received inappropriate initial antimicrobial-therapy, no influence on mortality was observed. Independent risk-factors for in-hospital-mortality were the presence of septic-shock, prior chemotherapy for malignoma and infection with Pseudomonas spp. Infection and mortality-rate among 175 patients with liver-cirrhosis was significantly higher than in patients without liver-cirrhosis. Infection increased mortality 2.24-fold in patients with cirrhosis. Patients with liver cirrhosis were at an increased risk to receive inappropriate initial antimicrobial therapy.
CONCLUSION: The results of the present study report the successful implementation of early-goal-directed therapy. Liver cirrhosis patients are at increased risk of infection, mortality and to receive inappropriate therapy. Increasing burden are multiresistant-bacteria.
Collapse
|
249
|
Gonzalez C, Begot E, Dalmay F, Pichon N, François B, Fedou AL, Chapellas C, Galy A, Mancia C, Daix T, Vignon P. Prognostic impact of left ventricular diastolic function in patients with septic shock. Ann Intensive Care 2016; 6:36. [PMID: 27099042 PMCID: PMC4839020 DOI: 10.1186/s13613-016-0136-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/28/2016] [Indexed: 01/10/2023] Open
Abstract
Background Left ventricular (LV) diastolic dysfunction is highly prevalent in the general population and associated with a significant morbidity and mortality. Its prognostic role in patients sustaining septic shock in the intensive care unit (ICU) remains controversial. Accordingly, we investigated whether LV diastolic function was independently associated with ICU mortality in a cohort of septic shock patients assessed using critical care echocardiography. Methods Over a 5-year period, patients hospitalized in a Medical–Surgical ICU who underwent an echocardiographic assessment with digitally stored images during the initial management of a septic shock were included in this retrospective single-center study. Off-line echocardiographic measurements were independently performed by an expert in critical care echocardiography who was unaware of patients’ outcome. LV diastolic dysfunction was defined by the presence of a lateral E′ maximal velocity <10 cm/s. A multivariate analysis was performed to determine independent risk factors associated with ICU mortality. Results Among the 540 patients hospitalized in the ICU with septic shock during the study period, 223 were studied (140 men [63 %]; age 64 ± 13 years; SAPS II 55 ± 18; SOFA 10 ± 3; Charlson 3.5 ± 2.5) and 204 of them (91 %) were mechanically ventilated. ICU mortality was 35 %. LV diastolic dysfunction was observed in 31 % of patients. The proportion of LV diastolic dysfunction tended to be higher in non-survivors than in their counterparts (28/78 [36 %] vs. 41/145 [28 %]: p = 0.15). Inappropriate initial antibiotic therapy (OR 4.17 [CI 95 % 1.33–12.5]: p = 0.03), maximal dose of vasopressors (OR 1.38 [CI 95 % 1.16–1.63]: p = 0.01), SOFA score (OR 1.16 [CI 95 % 1.02–1.32]: p = 0.02) and lateral E′ maximal velocity (OR 1.12 [CI 95 % 1.01–1.24]: p = 0.02) were independently associated with ICU mortality. After adjusting for the SAPS II score, inappropriate initial antibiotic therapy and maximal dose of vasopressors remained independent factors for ICU mortality, whereas a trend was only observed for lateral E′ maximal velocity (OR 1.11 [CI 95 % 0.99–1.23]: p = 0.07). Conclusion The present study suggests that LV diastolic function might be associated with ICU mortality in patients with septic shock. A multicenter prospective study assessing a large cohort of patients using serial echocardiographic examinations remains required to confirm the prognostic value of LV diastolic dysfunction in septic shock.
Collapse
Affiliation(s)
- Céline Gonzalez
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
| | - Emmanuelle Begot
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - François Dalmay
- Department of Biostatistics, Dupuytren Teaching Hospital, Limoges, France
| | - Nicolas Pichon
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - Bruno François
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France.,UMR 1092, University of Limoges, Limoges, France
| | - Anne-Laure Fedou
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
| | | | - Antoine Galy
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
| | - Claire Mancia
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France
| | - Thomas Daix
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France.,Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - Philippe Vignon
- Medical-Surgical ICU, Dupuytren Teaching Hospital, Limoges, France. .,Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France. .,UMR 1092, University of Limoges, Limoges, France. .,Réanimation Polyvalente, CHU Dupuytren, 2 Ave. Martin Luther King, 87000, Limoges, France.
| |
Collapse
|
250
|
Wu Y, Zhou J, Bi L, Huang M, Han Y, Zhang Q, Zhu D, Zhou S. Effects of bone marrow mesenchymal stem cells on the cardiac function and immune system of mice with endotoxemia. Mol Med Rep 2016; 13:5317-25. [PMID: 27109149 DOI: 10.3892/mmr.2016.5151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 12/22/2015] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to investigate the effects of bone marrow mesenchymal stem cells (MSCs) on the cardiac function and immune system of mice with endotoxemia. The mice were divided into the following groups: Control group, endotoxemia group, lipopolysaccharide (LPS) treatment group, LPS and MSC treatment group (LPS + MSC group) and MSC group. Following treatment with LPS, the cardiac function of the mice was examined at after 2, 6 and 24 h, and on day 7. An enzyme‑linked immunofluorescent assay was used to analyze the serum and the levels of cytokines in the myocardium, and western blotting was used to investigate any changes in the levels of signaling proteins associated with the myocardium. A 3‑(4,5‑dimethyl‑2‑thiazolyl)‑2,5‑diphenyl‑2H‑tetrazolium bromide assay was used to investigate the growth rate of the splenic cells at after 24 h and on day 7, and the humoral immune function and phagocytosis of the macrophages in the mice were also examined. The cardiac function of the mice with endotoxemia declined, although this impairment was circumvented following treatment with MSCs. The levels of interleukin (IL)‑1β, IL‑6, tumor necrosis factor‑α and IL‑10 in the serum and the myocardium increased following stimulation by LPS, although these declined as a result of MSC treatment. The expression levels of Toll‑like receptor 4, p65‑nuclear factor‑κB and phosphorylated p38 in the mouse myocardium were enhanced following stimulation by LPS, which subsequently decreased as a result of MSC treatment. Compared with the control group, the growth rate of the splenic cells, humoral immune function and the level of phagocytosis of macrophages were all increased, although these parameters declined following treatment with MSCs. Taken together, the present study revealed that the MSCs inhibited the inflammatory reaction in the mice with endotoxemia, and improved cardiac function. By contrast, the cellular and humoral immunity were depressed, and phagocytosis of the macrophages, which were enhanced following simulation with LPS, were decreased following treatment with MSCs. However, no overexpression of the anti‑inflammatory factor, IL‑10, was observed. The present study hypothesized that MSCs exert a bifunctional role in endotoxemia, by inhibiting inflammatory factors, including IL‑1 and IL‑6, and inhibiting the compensatory expression of IL‑10 following LPS stimulation. This avoids the possibility of excessive inhibition of immunological function, as this results in immunosuppression, and a higher ratio of IL‑10 to TNF‑α is indicative of a poor prognosis in patients with sepsis.
Collapse
Affiliation(s)
- Yuanfan Wu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Jing Zhou
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Liqing Bi
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Min Huang
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yi Han
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Qian Zhang
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Dongmei Zhu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Suming Zhou
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| |
Collapse
|