Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012

OBJECTIVE

To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.

DESIGN

A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.

METHODS

The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.

RESULTS

Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).

CONCLUSIONS

Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

New insights into fluid resuscitation

Recent high-quality randomised-controlled trials comparing the effects of hydroxyethyl starch (HES) preparations and crystalloids for fluid resuscitation in critically ill patients have demonstrated an increased risk of death and use of renal replacement therapy (RRT). Consequently, a number of systematic reviews incorporating these new results have been published that have consistently demonstrated an increased risk of death and use of RRT associated with HES solutions, regardless of type of HES and dose administered, both in general intensive care patients and in those with severe sepsis. These effects become apparent in the post-resuscitation period and may relate to increased tissue accumulation associated with HES. These results question the clinical role of semi-synthetic colloids for fluid resuscitation and mandate a reappraisal about how these fluids are administered to critically ill patients, specifically considering the potential for toxicity.

Prevalence of adenomas and sessile serrated adenomas in Chinese compared with Caucasians

BACKGROUND AND AIMS

Colonic adenomas and sessile serrated adenomas (SSA) are the most common premalignant polyps identified at colonoscopy. This study compares the prevalence of neoplastic polyps in Chinese and Caucasians in a general gastroenterology outpatient practice in Australia.

METHODS

This study included consecutive unselected colonoscopies performed for standard clinical indications by a single endoscopist (JMH). All polyps detected were measured, resected, and sent for histopathology. The prevalence of adenomas, advanced adenomas, SSA, and cancer in the Chinese and Caucasian cohorts were compared. Advanced adenomas were defined as adenomas > 10 mm, villous histology, or high-grade dysplasia.

RESULTS

The study included 346 Chinese and 654 Caucasians. There was no significant difference in the baseline characteristics including age, gender, and indications of colonoscopy, although Chinese were more likely to present with rectal bleeding (22.8% vs 15.9%, P = 0.01). The prevalence of adenomatous polyps was similar in both Caucasians (34.3%) and Chinese (35.3%). However, advanced adenomas were more significantly common in Caucasians (11.3%) compared with Chinese (4.6%) (P < 0.001). SSA was rare in Chinese (2%) but present more frequently in Caucasians (7%) (P = 0.001). Multivariate analysis showed that Caucasian ethnicity (odds ratio 2.4, 95% confidence interval 1.6-3.6) and the presence of SSA (odds ratio 4.4, 95% confidence interval 2.3-8.6) were independent predictors for the detection of an advanced adenoma.

CONCLUSIONS

The prevalence of significant colorectal lesions, including advanced adenomas, large adenomas, and SSA, were lower in Chinese compared with Caucasians. These findings may influence the guidelines for colonic cancer screening in Chinese populations.

Interprofessional education: effects on professional practice and healthcare outcomes (update)

BACKGROUND

The delivery of effective, high-quality patient care is a complex activity. It demands health and social care professionals collaborate in an effective manner. Research continues to suggest that collaboration between these professionals can be problematic. Interprofessional education (IPE) offers a possible way to improve interprofessional collaboration and patient care.

OBJECTIVES

To assess the effectiveness of IPE interventions compared to separate, profession-specific education interventions; and to assess the effectiveness of IPE interventions compared to no education intervention.

SEARCH METHODS

For this update we searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for the years 2006 to 2011. We also handsearched the Journal of Interprofessional Care (2006 to 2011), reference lists of all included studies, the proceedings of leading IPE conferences, and websites of IPE organisations.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE interventions that reported objectively measured or self reported (validated instrument) patient/client or healthcare process outcomes.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the eligibility of potentially relevant studies. For included studies, at least two review authors extracted data and assessed study quality. A meta-analysis of study outcomes was not possible due to heterogeneity in study designs and outcome measures. Consequently, the results are presented in a narrative format.

MAIN RESULTS

This update located nine new studies, which were added to the six studies from our last update in 2008. This review now includes 15 studies (eight RCTs, five CBA and two ITS studies). All of these studies measured the effectiveness of IPE interventions compared to no educational intervention. Seven studies indicated that IPE produced positive outcomes in the following areas: diabetes care, emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical error rates for emergency department teams; collaborative team behaviour in operating rooms; management of care delivered in cases of domestic violence; and mental health practitioner competencies related to the delivery of patient care. In addition, four of the studies reported mixed outcomes (positive and neutral) and four studies reported that the IPE interventions had no impact on either professional practice or patient care.

AUTHORS' CONCLUSIONS

This updated review reports on 15 studies that met the inclusion criteria (nine studies from this update and six studies from the 2008 update). Although these studies reported some positive outcomes, due to the small number of studies and the heterogeneity of interventions and outcome measures, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. To improve the quality of evidence relating to IPE and patient outcomes or healthcare process outcomes, the following three gaps will need to be filled: first, studies that assess the effectiveness of IPE interventions compared to separate, profession-specific interventions; second, RCT, CBA or ITS studies with qualitative strands examining processes relating to the IPE and practice changes; third, cost-benefit analyses.

Randomized clinical trial of zoledronic acid in multiple myeloma patients undergoing high-dose chemotherapy and stem-cell transplantation

BACKGROUND

A growing body of evidence is demonstrating that the nitrogen-containing bisphosphonate zoledronic acid (zol) improves clinical outcomes in various cancer settings, including multiple myeloma. Those findings provided the rationale for conducting an open-label randomized controlled phase iii trial to evaluate the effect of zol on overall survival (os) and progression-free survival (pfs) in patients with previously untreated high-risk multiple myeloma.

METHODS

The trial randomly assigned 308 adult patients less than 65 years of age with previously untreated symptomatic multiple myeloma (1:1) to receive zol 4 mg intravenously once every 28 days for 24 months (n = 151) or no zol (n = 157). Before autologous stem-cell transplantation (asct), all patients received a high-dose noncytotoxic induction regimen of dexamethasone, all-trans-retinoic acid, and interferon alpha 2b.

RESULTS

After a median follow-up of 69.8 months (range: 36.5-96 months), the 10-year pfs (66% vs. 52%, p < 0.001) and os (67% vs. 48%, p < 0.001) rates were significantly higher in treated patients than in control patients. Overall response (77% zol vs. 75% control), complete response (52% vs. 46%), and very good partial response (25% vs. 29%) rates were similar between the groups. Treatment was generally well tolerated, with no reports of renal impairment or osteonecrosis of the jaw.

CONCLUSIONS

In symptomatic previously untreated multiple myeloma patients, zol combined with high-dose therapy followed by asct improved os and pfs without appreciable toxicity. These findings provide additional evidence of the meaningful anticancer activity of zol in this patient population.

Causes of death after fluid bolus resuscitation: new insights from FEAST

The Fluid Expansion as Supportive Therapy (FEAST study) was an extremely well conducted study that gave unexpected results. The investigators had reported that febrile children with impaired perfusion treated in low-income countries without access to intensive care are more likely to die if they receive bolus resuscitation with albumin or saline compared with no bolus resuscitation at all. In a secondary analysis of the trial, published in BMC Medicine, the authors found that increased mortality was evident in patients who presented with clinical features of severe shock in isolation or in conjunction with features of respiratory or neurological failure. The cause of excess deaths was primarily refractory shock and not fluid overload. These features are consistent with a potential cardiotoxic or ischemia-reperfusion injury following resuscitation with boluses of intravenous fluid. Although these effects may have been amplified by the absence of invasive monitoring, mechanical ventilation or vasopressors, the results provide compelling insights into the effects of intravenous fluid resuscitation and potential adverse effects that extend beyond the initial resuscitation period. These data add to the increasing body of literature about the safety and efficacy of intravenous resuscitation fluids, which may be applicable to management of other populations of critically ill patients.

Hydroxyethyl starch in severe sepsis: end of starch era?

Expanded abstract

Rational fluid management in today's ICU practice

Intravenous fluid therapy has evolved significantly over time. From the initial report of the first intravenous administration of sodium-chloride-based solution to the development of goal-directed fluid therapy using novel dynamic indices, efforts have focused on improving patient outcomes. The goal of this review is to provide a brief overview of current concepts for intravenous fluid administration in the ICU. Results of recently published clinical trials suggesting harmful effects of starch-based solutions on critically ill patients are discussed. Concepts for goal-directed fluid therapy and new modalities for the assessment of fluid status as well as for the prediction of responsiveness to different interventions will continue to emerge. Advances in technology will have to be critically evaluated for their ability to improve outcomes in different clinical scenarios.

Perioperative treatment of patients with sepsis

PURPOSE OF REVIEW

Key elements in the initial resuscitation and stabilization of the patient with sepsis are fluid therapy, vasopressor or inotropic support, administration of adequate antibiotics and source control. This review will primarily discuss fluid, vasopressor and antibiotic therapy because these have been the subject of the recent large clinical trials.

RECENT FINDINGS

On the basis of the recent large randomized clinical trials, starch solutions should be avoided in patients with sepsis because there is no evidence of benefit and clear signals of harm including adverse effects on kidney and haemostatic function and increased mortality in one trial. Ongoing trials are investigating the efficacy and safety of albumin and red blood cell transfusion in patients with sepsis. Norepinephrine should be the first-line vasopressor agent because accumulating evidence shows more adverse events with the use of dopamine. Early initiation of adequate antibiotic therapy is recommended and etomidate should not be used in patients with sepsis.

SUMMARY

Recent high-quality trials in the intensive care setting have provided data to improve the treatment and thereby the outcome of patients with sepsis. These findings may be used in the perioperative setting to minimize the harmful effects of specific interventions.

Rapid-response systems as a patient safety strategy: a systematic review

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.

Physical and mental health in patients and spouses after intensive care of severe sepsis: a dyadic perspective on long-term sequelae testing the Actor-Partner Interdependence Model

OBJECTIVE

To examine the physical and mental long-term consequences of intensive care treatment for severe sepsis in patients and their spouses under consideration of a dyadic perspective using the Actor-Partner Interdependence Model.

DESIGN

Prospective study.

SETTING

Patients and spouses who had requested advice from the German Sepsis Aid's National Helpline were invited to participate.

SUBJECTS

We included 55 patients who survived severe sepsis and their spouses an average of 55 months after ICU discharge.

MEASUREMENTS AND MAIN RESULTS

The Hospital Anxiety and Depression Scale, the Short Form-12 Health Survey, the Posttraumatic Stress Scale-10, and the Giessen Subjective Complaints List-24 were used. The Actor-Partner Interdependence Model was tested using multilevel modeling with the actor effect representing the impact of a person's posttraumatic stress symptoms on his or her own mental health-related quality of life and the partner effect characterized by the impact of a person's posttraumatic stress symptoms on his or her partner's mental health-related quality of life. A significant proportion of patients and spouses (26%-42%) showed clinically relevant scores of anxiety and depression; approximately two thirds of both, patients and spouses, reported posttraumatic stress symptoms defined as clinically relevant. Compared with normative samples, patients reported greater anxiety, poorer mental and physical health-related quality of life, and greater exhaustion; spouses had an impaired mental health-related quality of life and increased anxiety. Testing the Actor-Partner Interdependence Model revealed that posttraumatic stress symptoms were related to patients' (β = -0.71, 95% confidence interval -0.88 to -0.54) and spouses' (β = -0.62, 95% confidence interval -0.79 to -0.46) own mental health-related quality of life. Posttraumatic stress symptoms further influenced the mental health-related quality of life of the respective other (β = -0.18, 95% confidence interval -0.35 to -0.003 for patients; β = -0.15, 95% confidence interval -0.32 to 0.02 for spouses).

CONCLUSIONS

Interventions to treat posttraumatic stress symptoms after critical illness to improve mental health-related quality of life should not only include patients, but also consider spouses.

Quality of life before intensive care using EQ-5D: patient versus proxy responses

OBJECTIVE

To compare patients' retrospectively reported baseline quality of life before intensive care hospitalization with population norms and proxy reports.

DESIGN

Prospective cohort study.

SETTING

Thirteen ICUs at four teaching hospitals in Baltimore, MD.

PATIENTS

One hundred forty acute lung injury survivors and their designated proxies.

INTERVENTIONS

Around the time of hospital discharge, both patients and proxies were asked to retrospectively estimate patients' baseline quality of life before hospital admission using the EQ-5D quality-of-life instrument.

MEASUREMENTS AND MAIN RESULTS

Mean patient-rated EQ-5D visual analog scale scores and utility scores were significantly lower than population norms but were significantly higher than proxy ratings. However, the magnitude of difference in average utility scores between patients and either population norms or proxies was not clinically important. For the five individual EQ-5D domains, κ statistics revealed slight to fair agreement between patients and proxies. Bland-Altman plots demonstrated that for both the visual analog scale and utility scores, proxies underestimated scores when patients reported high ratings and overestimated scores for low patient ratings.

CONCLUSIONS

Patients retrospectively reported worse baseline health status before acute lung injury than population norms and better status than proxy reports; however, the magnitude of these differences in health status may not be clinically important. Proxies had only slight to fair agreement with patients in all five EQ-5D domains, attenuating patients' more extreme ratings toward moderate scores. Caution is required when interpreting proxy retrospective reports of baseline health status for survivors of acute lung injury.

Colloids versus crystalloids for fluid resuscitation in critically ill patients

BACKGROUND

Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.

OBJECTIVES

To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.

SEARCH METHODS

We searched the Cochrane Injuries Group Specialised Register (17 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library) (Issue 10, 2012), MEDLINE (Ovid) 1946 to October 2012, EMBASE (Ovid) 1980 to October 2012, ISI Web of Science: Science Citation Index Expanded (1970 to October 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to October 2012), PubMed (October 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials involving pregnant women and neonates.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.

MAIN RESULTS

We identified 78 eligible trials; 70 of these presented mortality data.COLLOIDS COMPARED TO CRYSTALLOIDS: Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19). Modified gelatin - 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). COLLOIDS IN HYPERTONIC CRYSTALLOID COMPARED TO ISOTONIC CRYSTALLOID: Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06).

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.

Quality of life and pruritus in patients with severe sepsis resuscitated with hydroxyethyl starch long-term follow-up of a randomised trial

INTRODUCTION

The effects of hydroxyethyl starch (HES) on patient-centered outcome measures have not been fully described in patients with severe sepsis. We assessed health-related quality of life (HRQoL) and the occurrence of pruritus in patients with severe sepsis randomized to resuscitation with HES 130/0.42 or Ringer's acetate.

METHODS

We did post hoc analyses of the Danish survivors (n=295) of the 6S trial using mailed questionnaires on self-perceived HRQoL (Short Form (SF) - 36) and pruritus.

RESULTS

Median 14 months (interquartile range 10 to 18) after randomization, 182 (61%) and 185 (62%) completed questionnaires were obtained for the assessment of HRQoL and pruritus, respectively. Responders were older than nonresponders, but characteristics at randomization of the responders in the HES vs. Ringer's groups were comparable. At follow-up, the patients in the HES group had lower mental component summary scores than those in the Ringer's group (median 45 (interquartile range 36 to 55) vs. 53 (39 to 60), P=0.01). The group differences were mainly in the scales of vitality and mental health. There was no difference in the physical component summary scores between groups, but patients in the HES group scored worse in bodily pain. Forty-nine percent of patients allocated to HES had experienced pruritus at any time after ICU discharge compared to 43% of those allocated to Ringer's (relative risk 1.13, 95% confidence interval 0.83 to 1.55, P=0.43).

CONCLUSIONS

At long-term follow-up patients with severe sepsis assigned to resuscitation with HES 130/0.42 had worse self-perceived HRQoL than those assigned to Ringer's acetate whereas there were no statistically significant differences in the occurrence of pruritus.

Randomised trials of 6% tetrastarch (hydroxyethyl starch 130/0.4 or 0.42) for severe sepsis reporting mortality: systematic review and meta-analysis

PURPOSE

To assess the impact of 6% tetrastarch [hydroxyethyl starch (HES) 130/0.4 and 130/0.42] in severe sepsis patients. The primary outcome measure was 90-day mortality.

METHODS

A structured literature search was undertaken to identify prospective randomised controlled trials (RCTs) in adult patients with severe sepsis receiving 6% tetrastarch (of potato or waxy maize origin) as part of fluid resuscitation in comparison with other non-HES fluids after randomisation in the critical care setting. A systematic review and meta-analysis were performed.

RESULTS

Six RCTs were included (n = 3,033): three from 2012 (n = 2,913) had low risk of bias. Median tetrastarch exposure was 37.4 ml/kg (range 30-43 ml/kg). Ninety-day mortality was associated with tetrastarch exposure [relative risk (RR) 1.13; 95% confidence interval (CI) 1.02-1.25; p = 0.02] compared with crystalloid. The number needed to harm (NNH) was 28.8 (95 % CI 14.6-942.5). Publication bias and statistical heterogeneity (I(2) = 0%) were not present. Tetrastarch exposure was also associated with renal replacement therapy (p = 0.01; NNH 15.7) and allogeneic transfusion support (p = 0.001; NNH 9.9). No difference between groups was observed for 28-day mortality, for comparison with colloid as control, or for waxy maize-derived tetrastarch, but power was lacking. Overall mortality was associated with tetrastarch exposure (RR 1.13; 95% CI 1.02-1.25; p = 0.02).

CONCLUSIONS

In our analysis, 6% tetrastarch as part of initial fluid resuscitation for severe sepsis was associated with harm and, as alternatives exist, in our view should be avoided.

Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis

OBJECTIVE

To assess the effects of fluid therapy with hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin on mortality, kidney injury, bleeding, and serious adverse events in patients with sepsis.

DESIGN

Systematic review with meta-analyses and trial sequential analyses of randomised clinical trials.

DATA SOURCES

Cochrane Library, Medline, Embase, Biosis Previews, Science Citation Index Expanded, CINAHL, Current Controlled Trials, Clinicaltrials.gov, and Centerwatch to September 2012; hand search of reference lists and other systematic reviews; contact with authors and relevant pharmaceutical companies.

STUDY SELECTION

Eligible trials were randomised clinical trials comparing hydroxyethyl starch 130/0.38-0.45 with either crystalloid or human albumin in patients with sepsis. Published and unpublished trials were included irrespective of language and predefined outcomes.

DATA EXTRACTION

Two reviewers independently assessed studies for inclusion and extracted data on methods, interventions, outcomes, and risk of bias. Risk ratios and mean differences with 95% confidence intervals were estimated with fixed and random effects models.

RESULTS

Nine trials that randomised 3456 patients with sepsis were included. Overall, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin did not affect the relative risk of death (1.04, 95% confidence interval 0.89 to 1.22, 3414 patients, eight trials), but in the predefined analysis of trials with low risk of bias the relative risk of death was 1.11 (1.00 to 1.23, trial sequential analysis (TSA) adjusted 95% confidence interval 0.95 to 1.29, 3016 patients, four trials). In the hydroxyethyl starch group, renal replacement therapy was used more (1.36, 1.08 to 1.72, TSA adjusted 1.03 to 1.80, 1311 patients, five trials), and the relative risk of acute kidney injury was 1.18 (0.99 to 1.40, TSA adjusted 0.90 to 1.54, 994 patients, four trials). More patients in the hydroxyethyl starch group were transfused with red blood cells (1.29, 1.13 to 1.48, TSA adjusted 1.10 to 1.51, 973 patients, three trials), and more patients had serious adverse events (1.30, 1.02 to 1.67, TSA adjusted 0.93 to 1.83, 1069 patients, four trials). The transfused volume of red blood cells did not differ between the groups (mean difference 65 mL, 95% confidence interval -20 to 149 mL, three trials).

CONCLUSION

In conventional meta-analyses including recent trial data, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin increased the use of renal replacement therapy and transfusion with red blood cells, and resulted in more serious adverse events in patients with sepsis. It seems unlikely that hydroxyethyl starch 130/0.38-0.45 provides overall clinical benefit for patients with sepsis.

Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy

PURPOSE

To determine whether fluid resuscitation of acutely ill adults with 6 % hydroxyethyl starch (6 % HES 130) with a molecular weight of 130 kD and a molar substitution ratio of approximately 0.4 (6 % HES 130) compared with other resuscitation fluids results in a difference in the relative risk of death or treatment with renal replacement therapy (RRT).

METHODS

Systematic review and meta-analysis of randomized controlled trials comparing intravascular fluids for resuscitation of hospitalised adults that reported mortality or treatment with RRT. The risk of bias was assessed independently by two reviewers and meta-analysis was performed using random effects.

RESULTS

Thirty-five trials enrolling 10,391 participants were included. The three largest trials had the lowest risk of bias, were published (or completed) in 2012, and together enrolled 77 % of all participants. Death occurred in 928 of 4,691 patients (19.8 %) in the 6 % HES 130 group versus 871 of 4,720 (18.5 %) in the control fluid groups relative risk (RR) in the 6 % HES 130 group 1.08, 95 % confidence interval (CI) 1.00 to 1.17, I (2) = 0 %). Treatment with RRT occurred in 378 of 4,236 patients (8.9 %) in the 6 % HES 130 group versus 306 of 4,260 (7.2 %) in the control fluid group (RR in the 6 % HES 130 group 1.25, 95 % CI 1.08 to 1.44, I (2) = 0 %).

CONCLUSIONS

The quality and quantity of data evaluating 6 % hydroxyethyl starch (130/0.4 and 130/0.42) as a resuscitation fluid has increased in the last 12 months. Patients randomly assigned to resuscitation with 6 %HES 130 are at significantly increased risk of being treated with RRT.

Fluid management in cardiac surgery: colloid or crystalloid?

The crystalloid-colloid debate has raged for decades, with the publication of many meta-analyses, yet no consensus. There are important differences between colloids and crystalloids, and these differences have direct relevance for cardiac surgical patients. Rather than asking crystalloid or colloid, we believe better questions to ask are (1) High or low chloride content? and (2) Synthetic or natural colloid? In this paper we review the published literature regarding fluid therapy in cardiac surgery and explain the background to these two important and unanswered questions.

Republished: Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

OBJECTIVE

The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.

METHODS

We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians.

RESULTS

Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees.

CONCLUSIONS

The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

Acute kidney injury in 2012: type of resuscitation fluid-it does matter!

2012 saw the publication of four important trials investigating the choice of fluid therapy in patients suffering from critical illness or undergoing major surgery. These studies pave the way for more evidence-based administration of fluid in such patients.

Review article: towards a considered and ethical approach to organ support in critically-ill patients with cirrhosis

BACKGROUND

Increasing numbers of patients are being admitted to hospital with decompensated chronic liver disease in the UK. A significant proportion will develop complicating extra-hepatic organ dysfunction, but the selection of those who should be admitted to intensive care is complex and challenging. Alcohol-related liver disease also presents complex ethical dilemmas.

AIM

To review recent survival analyses and explore differences in secondary and tertiary care; to highlight strengths and weaknesses of prognostic models, therapeutic advances and shifts in prognostic expectation. We also aim to explore the ethical challenges presented by addiction and self-injury in an area of limited resource.

METHODS

We searched PubMed for articles discussing 'cirrhosis', 'prognosis', 'critical illness', 'organ failure', 'renal failure', 'alcohol', 'ethics' and 'addiction'. We also explored particular ethical dilemmas encountered by the authors and colleagues.

RESULTS

Prognosis has improved in many cirrhotic complications and historically poor outcomes in tertiary care may reflect a more complex patient cohort. Previously 'untreatable' complications are now being managed successfully. Estimates of survival are more accurate after a 48-h period of supportive care. Physicians are not best placed to make judgments with regard to deservingness, moral responsibility, rationing and access to organ support in cases of acute deterioration related to alcoholism, and the case for denying support must be made on purely medical grounds.

CONCLUSIONS

An early, aggressive approach to organ support is justified. Further discussions between hepatologists and critical care physicians are required to determine acceptable burden-to-benefit ratios for prolonged intensive care support in young alcoholic patients.

Factors influencing nurses' decisions to activate medical emergency teams

AIMS AND OBJECTIVES

To evaluate the relationship between nurse demographics and correct identification of clinical situations warranting specific nursing actions, including activation of the medical emergency team.

BACKGROUND

If abnormal physiology is left untreated, the patient may develop cardiac arrest. Nurses in general wards are those who perceive any clinical deterioration in patients.

DESIGN

A descriptive, quantitative design was selected.

METHODS

An anonymous survey with 13 multiple choice questions was distributed to 150 randomly selected nurses working in general medical and surgical wards of a large tertiary hospital in Athens, Greece. After explanation of the purposes of the study, 94 nurses (response ratio: 62%) agreed to respond to the questionnaire.

RESULTS

Categories with the greatest nursing concern were patients with heart rate<40/minute, an atypical thoracic pain, foreign body airway obstruction and bronchial secretions, respiratory rate<5/minute and heart rate=100/minute. However, almost 50% of nurses were able to accurately identify the critical nursing action for patients with respiratory rate<4/minute, 72% for patients with airway obstruction and 73% for patients with chest pain. Nurses who had graduated from a four-year educational programme identified clinical situations that necessitated medical emergency team activation in a significantly higher rate and also scored significantly higher in questions concerning clinical evaluation than nurses who had graduated from a two-year educational programme.

CONCLUSION

Activation of the medical emergency team is influenced by factors such as level of education and cardiopulmonary resuscitation courses attendance.

RELEVANCE TO CLINICAL PRACTICE

Graduating from a four-year educational programme helps nurses identify emergencies. However, irrespective of the educational programme they have followed, undertaking a basic life support or advanced life support provider course is critical as it helps them identify cardiac or respiratory emergencies.

Intensive care unit-acquired weakness: implications for physical therapist management

Patients admitted to the intensive care unit (ICU) can develop a condition referred to as "ICU-acquired weakness." This condition is characterized by profound weakness that is greater than might be expected to result from prolonged bed rest. Intensive care unit-acquired weakness often is accompanied by dysfunction of multiple organ systems. Individuals with ICU-acquired weakness typically have significant activity limitations, often requiring physical assistance for even the most basic activities associated with bed mobility. Many of these individuals have activity limitations months to years after hospitalization. The purpose of this article is to review evidence that guides physical rehabilitation of people with ICU-acquired weakness. Included are diagnostic criteria, medical management, and prognostic indicators, as well as criteria for beginning physical rehabilitation, with an emphasis on patient safety. Data are presented indicating that rehabilitation can be implemented with very few adverse effects. Evidence is provided for appropriate measurement approaches and for physical intervention strategies. Finally, some of the key issues are summarized that should be investigated to determine the best intervention guidelines for individuals with ICU-acquired weakness.

Safety and feasibility of an exercise prescription approach to rehabilitation across the continuum of care for survivors of critical illness

BACKGROUND

Survivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge.

OBJECTIVE

The aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program.

DESIGN

This was a cohort study.

METHODS

As part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response.

RESULTS

During acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred.

LIMITATIONS

Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment.

CONCLUSIONS

Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.

Wire-guided (Seldinger technique) intubation through a face mask in urgent, difficult and grossly distorted airways

We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

Active mobilization for mechanically ventilated patients: a systematic review

OBJECTIVE

To investigate the effectiveness and safety of active mobilization on improving physical function and hospital outcomes in patients undergoing mechanical ventilation for more than 24 hours.

DATA SOURCES

PubMed, Embase, CINAHL, CENTRAL, Physiotherapy Evidence Database, SinoMed, and ISI Web of Knowledge were searched for randomized controlled trials (RCTs), quasi-RCTs, other comparative studies, and case series with 10 or more consecutive cases. Additional studies were identified through references, citation tracking, and by contacting the authors of eligible studies.

STUDY SELECTION

Two reviewers independently selected potential studies according to the inclusion criteria.

DATA EXTRACTION

Two reviewers independently extracted data and assessed the methodologic quality.

DATA SYNTHESIS

A narrative form was used to summarize study characteristics and outcomes, because the substantial heterogeneity between the individual studies precluded formal meta-analyses. Among the 17 eligible studies, 7 RCTs, 1 quasi-RCT, 1 prospective cohort study, and 1 history controlled study were used to examine the effectiveness; and 2 RCTs, 1 prospective cohort study, and 7 case series were used to examine the safety of active mobilization in patients receiving mechanical ventilation for more than 24 hours. We found that active mobilization may improve muscle strength, functional independence, and the ability to wean from ventilation and may decrease the length of stay in the intensive care unit (ICU) and hospital. However, only 1 study reported that active mobilization reduced the 1-year mortality rate. No serious adverse events were reported among included studies.

CONCLUSIONS

Active mobilization appears to have a positive effect on physical function and hospital outcomes in mechanical ventilation patients. Early active mobilization protocols may be initiated safely in the ICU setting and continued in post-ICU settings. However, the current available studies have great heterogeneity and limited methodologic quality. Further research is needed to provide more robust evidence to support the effectiveness and safety of active mobilization.

Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data

Introduction

Medical emergency teams (MET) are implemented to ensure prompt clinical review of patients with deteriorating physiology with the intention of averting further deterioration, cardiac arrest and death. We sought to determine if MET implementation has led to reductions in hospital mortality across a large metropolitan health network utilising routine administrative data submitted by hospitals to the Department of Health Victoria.

Methods

The Victorian admissions episodes data set (VAED) contains data on all individual hospital separations in the State of Victoria, Australia. After gaining institutional ethics approval, we extracted data on all acute admissions to metropolitan hospitals for which we had information on the presence and timing of a MET system. Using logistic regression we determined whether there was an effect of MET implementation on mortality controlling for age, gender, Charlson comorbidity diagnostic groupings, emergency admission, same day admission, ICU admission, mechanical ventilation, year, indigenous ethnicity, liaison nurse service and hospital designation.

Results

5911533 individual admissions and 73,599 associated deaths from July 1999 to June 2010 were included in the analysis. 52.2% were male and median age was 57(42-72 IQR). Mortality rates for MET and non-MET periods were 3.92 (3.88-3.95 95%CI) and 4.56 (4.51-4.61 95%CI) deaths per 1000 patient days with a rate ratio after adjustment for year of 0.88 (0.86-0.89 95%CI) P < 0.001. In a multivariable logistic regression, mortality was associated with a MET team being active in the hospital for more than 2 years. The odds ratio for mortality in hospitals where a MET system had been in place for greater than 4 years duration was 0.90 (0.88-0.92). Mortality during the first 2 years of a MET system being in place was not statistically different from pre-MET periods.

Conclusions

Utilising routinely collected administrative data we demonstrated that the presence of a hospital MET system for greater than 2 years was associated with an independent reduction in hospital mortality across a major metropolitan health network. Mortality benefits after the introduction of a MET system take time to become apparent.

Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia

INTRODUCTION

The purpose of the study was to assess the long term outcome and quality of life of patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia.

METHODS

A retrospective observational study with prospective health related quality of life (HRQoL) assessment was conducted in ARDS patients who had ECMO as a rescue therapy for reversible refractory hypoxemia from January 2009 until April 2011 in a tertiary Australian centre. Survival and long-term quality of life assessment, using the Short-Form 36 (SF-36) and the EuroQol health related quality of life questionnaire (EQ5D) were assessed and compared to international data from other research groups.

RESULTS

Twenty-one patients (mean age 36.3 years) with ARDS receiving ECMO for refractory hypoxemia were studied. Eighteen (86%) patients were retrieved from external intensive care units (ICUs) by a dedicated ECMO retrieval team. Eleven (55%) had H1N1 influenza A-associated pneumonitis. Eighteen (86%) patients survived to hospital discharge. Of the 18 survivors, ten (56%) were discharged to other hospitals and 8 (44%) were discharged directly home. Sequelae and health related quality of life were evaluated for 15 of the 18 (71%) long-term survivors (assessment at median 8 months). Mean SF-36 scores were significantly lower across all domains compared to age and sex matched Australian norms. Mean SF-36 scores were lower (minimum important difference at least 5 points) than previously described ARDS survivors in the domains of general health, mental health, vitality and social function. One patient had long-term disability as a result of ICU acquired weakness. Only 26% of survivors had returned to previous work levels at the time of follow-up.

CONCLUSIONS

This ARDS cohort had a high survival rate (86%) after use of ECMO support for reversible refractory hypoxemia. Long term survivors had similar physical health but decreased mental health, general health, vitality and social function compared to other ARDS survivors and an unexpectedly poor return to work.