1
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Melville J, Carr T, Goodridge D, Muhajarine N, Groot G. Sepsis screening protocol implementation: a clinician-validated rapid realist review. BMJ Open Qual 2024; 13:e002593. [PMID: 38684345 PMCID: PMC11086359 DOI: 10.1136/bmjoq-2023-002593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/12/2024] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION The failed or partial implementation of clinical practices negatively impacts patient safety and increases systemic inefficiencies. Implementation of sepsis screening guidelines has been undertaken in many settings with mixed results. Without a theoretical understanding of what leads to successful implementation, improving implementation will continue to be ad hoc or intuitive. This study proposes a programme theory for how and why the successful implementation of sepsis screening guidelines can occur. METHODS A rapid realist review was conducted to develop a focused programme theory for the implementation of sepsis screening guidelines. An independent two-reviewer approach was used to iteratively extract and synthesise context and mechanism data. Theoretical context-mechanism-outcome propositions were refined and validated by clinicians using a focus group and individual realist interviews. Implementation resources and clinical reasoning were differentiated in articulating mechanisms. RESULTS Eighteen articles were included in the rapid review. The theoretical domains framework was identified as the salient substantive theory informing the programme theory. The theory consisted of five main middle-range propositions. Three promoting mechanisms included positive belief about the benefits of the protocol, belief in the legitimacy of using the protocol and trust within the clinical team. Two inhibiting mechanisms included pessimism about the protocol being beneficial and pessimism about the team. Successful implementation was defined as achieving fidelity and sustained use of the intervention. Two intermediate outcomes, acceptability and feasibility of the intervention, and adoption, were necessary to achieve before successful implementation. CONCLUSION This rapid realist review synthesised key information from the literature and clinician feedback to develop a theory-based approach to clinical implementation of sepsis screening. The programme theory presents knowledge users with an outline of how and why clinical interventions lead to successful implementation and could be applied in other clinical areas to improve quality and safety.
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Affiliation(s)
- Jonathan Melville
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Tracey Carr
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Donna Goodridge
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nazeem Muhajarine
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Groot
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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2
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Khera D, Suresh C. Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: Few Concerns. Indian J Crit Care Med 2023; 27:605. [PMID: 37636845 PMCID: PMC10452775 DOI: 10.5005/jp-journals-10071-24503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
How to cite this article: Khera D, Suresh C. Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: Few Concerns. Indian J Crit Care Med 2023;27(8):605.
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Affiliation(s)
- Daisy Khera
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Chethan Suresh
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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3
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Prediction of Inhospital Mortality in Critically Ill Patients With Sepsis: Confirmation of the Added Value of 24-Hour Lactate to Acute Physiology and Chronic Health Evaluation IV. Crit Care Explor 2022; 4:e0750. [PMID: 36082375 PMCID: PMC9444407 DOI: 10.1097/cce.0000000000000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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4
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Benakatti G, Ismail J. Protocolized care in sepsis: Does it improve outcomes? JOURNAL OF PEDIATRIC CRITICAL CARE 2022. [DOI: 10.4103/jpcc.jpcc_83_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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5
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 880] [Impact Index Per Article: 293.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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6
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1425] [Impact Index Per Article: 475.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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7
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Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. Evidence for the Application of Sepsis Bundles in 2021. Semin Respir Crit Care Med 2021; 42:706-716. [PMID: 34544188 DOI: 10.1055/s-0041-1733899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
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8
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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9
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 302] [Impact Index Per Article: 100.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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10
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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Escobar MF, Echavarría MP, Zambrano MA, Ramos I, Kusanovic JP. Maternal sepsis. Am J Obstet Gynecol MFM 2020; 2:100149. [PMID: 33345880 DOI: 10.1016/j.ajogmf.2020.100149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/16/2020] [Accepted: 05/23/2020] [Indexed: 12/11/2022]
Abstract
Maternal sepsis is "a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion," with the potential to save millions of lives if a proper approximation is made. Undetected or poorly managed maternal infections can lead to sepsis, death, or disability for the mother, and an increased likelihood of early neonatal infection and other adverse outcomes. Physiological, immunologic, and mechanical changes that occur in pregnancy make pregnant women more susceptible to infections than nonpregnant women and may obscure signs and symptoms of infection and sepsis, resulting in a delay in the recognition and treatment of sepsis. Prioritization of the creation and validation of tools that allow the development of clear and standardized diagnostic criteria of maternal sepsis and septic shock, according to the changes inherent to pregnancy, correspond to highly effective strategies to reduce the impact of these conditions on maternal health worldwide. After an adequate diagnostic approach, the next goal is achieving stabilization, trying to stop the progression from sepsis to septic shock, and improving tissue perfusion to limit cell dysfunction. Management protocol implementation during the first hour of treatment will be the most important determinant for the reduction of maternal mortality associated with sepsis and septic shock.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.
| | - María Paula Echavarría
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - María Andrea Zambrano
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia; Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Juan Pedro Kusanovic
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Department of Obstetrics and Gynecology, Hospital Sótero del Río, Santiago, Chile; Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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12
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Webb AL, Kramer N, Rosario J, Dub L, Lebowitz D, Amico K, Leon L, Stead TG, Vera A, Ganti L. Delta Lactate (Three-hour Lactate Minus Initial Lactate) Prediction of In-hospital Death in Sepsis Patients. Cureus 2020; 12:e7863. [PMID: 32483513 PMCID: PMC7255083 DOI: 10.7759/cureus.7863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
This study examines the relationship between serial serum lactate levels and in-hospital mortality in an adult cohort of emergency department patients with severe sepsis or septic shock. Of the 164 patients in the cohort, 130 also got three-hour lactate in addition to the initial one. The median initial lactate was 3.01 (interquartile range [IQR]: 1.71-4.62). The median repeat lactate was 2.58 (IQR: 1.4-3.9). The in-hospital death rate was 23% for men and 29% for women. The delta lactate was significantly higher in women (P=0.0070), driven by a lower initial lactate (P=0.0277). In a multivariate regression model controlled for age and gender, a statistically significant correlation was noted between an increase in the delta lactate and in-hospital death (P=0.0323; R2=11.3%). The results of this single-center study suggest that an increase in serum lactic acid is significantly associated with higher in-hospital death.
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Affiliation(s)
- Amanda L Webb
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Nicholas Kramer
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Javier Rosario
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Larissa Dub
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Lebowitz
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Kendra Amico
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Leoh Leon
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Tej G Stead
- Emergency Medicine, Brown University, Providence, USA
| | - Ariel Vera
- Emergency Medicine, University of Central Florida College of Medicine/Hospital Corporation of America Graduate Medical Education Consortium of Greater Orlando, Kissimmee, USA.,Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
| | - Latha Ganti
- Emergency Medicine, Envision Physician Services, Nashville, USA.,Emergency Medicine, University of Central Florida College of Medicine/Hospital Corporation of America Graduate Medical Education Consortium of Greater Orlando, Orlando, USA.,Emergency Medical Services, Polk County Fire Rescue, Bartow, USA
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13
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The Added Value of Lactate and Lactate Clearance in Prediction of In-Hospital Mortality in Critically Ill Patients With Sepsis. Crit Care Explor 2020; 2:e0087. [PMID: 32259110 PMCID: PMC7098542 DOI: 10.1097/cce.0000000000000087] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. We investigated the added predictive value of lactate and lactate clearance to the Acute Physiology and Chronic Health Evaluation IV model for predicting in-hospital mortality in critically ill patients with sepsis.
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14
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Martin ND, Codner P, Greene W, Brasel K, Michetti C. Contemporary hemodynamic monitoring, fluid responsiveness, volume optimization, and endpoints of resuscitation: an AAST critical care committee clinical consensus. Trauma Surg Acute Care Open 2020; 5:e000411. [PMID: 32201737 PMCID: PMC7066619 DOI: 10.1136/tsaco-2019-000411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/31/2019] [Accepted: 01/29/2020] [Indexed: 01/20/2023] Open
Abstract
This article, on hemodynamic monitoring, fluid responsiveness, volume assessment, and endpoints of resuscitation, is part of a compendium of guidelines provided by the AAST (American Association for the Surgery of Trauma) critical care committee. The intention of these guidelines is to inform practitioners with practical clinical guidance. To do this effectively and contemporarily, expert consensus via the critical care committee was obtained. Strict guideline methodology such a GRADE (Grading of Recommendations Assessment, Development and Evaluation) was purposefully NOT used so as not to limit the possible clinical guidance. The critical care committee foresees this methodology as practically valuable to the bedside clinician.
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Affiliation(s)
- Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Panna Codner
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Wendy Greene
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Christopher Michetti
- Department of Surgery, Inova Fairfax Medical Center, Falls Church, Virginia, USA
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15
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Seok H, Song J, Jeon JH, Choi HK, Choi WS, Moon S, Park DW. Timing of antibiotics in septic patients: a prospective cohort study. Clin Microbiol Infect 2020; 26:1495-1500. [PMID: 32062049 DOI: 10.1016/j.cmi.2020.01.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate the effect of timing and appropriateness of antibiotics administration on mortality in patients diagnosed with sepsis according to the Sepsis-3 definition. METHODS This prospective cohort study was conducted in patients diagnosed with sepsis according to the Sepsis-3 definition at the emergency department of Korea University Ansan Hospital from January 2016 to January 2019. The time to antibiotics was defined as the time in hours from emergency department arrival to the first antibiotic administration. Cox proportional hazards regression analysis was used to estimate the association between time to antibiotics and 7-, 14- and 28-day mortality. RESULTS Of 482 patients enrolled onto this study, 203 (42.1%) of 482 and 312 (64.7%) of 482 were diagnosed with septic shock and high-grade infection respectively. The median time to receipt of antibiotic therapy was 115 minutes. Antibiotics were administered within 3 and 6 hours in 340 (70.4%) of 482 and 450 (93.2%) of 482 patients respectively. Initial appropriate empirical antibiotics were administered in 375 (77.8%) of 482 patients. The time to and appropriateness of the initial antibiotics were not associated with 7-, 14- and 28-day mortality in multivariate analysis. The Sequential Organ Failure Assessment (SOFA) score (adjusted hazard ratio (aHR) 1.229, 95% confidence interval (CI) 1.093-1.381, p 0.001) and initial lactate levels (aHR 1.128, 95% CI 1.034-1.230, p 0.007), Charlson comorbidity index (aHR 1.115, 95% CI 1.027-1.210, p 0.014), 2-hour lactate level (aHR 1.115, 95% CI 1.027-1.210, p 0.009) and SOFA score (aHR 1.077, 95% CI 1.013-1.144, p 0.018) affected 7-, 14- and 28-day mortality respectively. Subgroup analysis with septic shock, bacteraemia and high-grade infection did not affect mortality rates. CONCLUSIONS Time to receipt of antibiotics may not affect the prognosis of patients with sepsis if a rapid and well-trained resuscitation is combined with appropriate antibiotic administration within a reasonable time.
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Affiliation(s)
- H Seok
- Division of Infectious Diseases, Department of Medicine, Republic of Korea
| | - J Song
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - J H Jeon
- Division of Infectious Diseases, Department of Medicine, Republic of Korea
| | - H K Choi
- Division of Infectious Diseases, Department of Medicine, Republic of Korea
| | - W S Choi
- Division of Infectious Diseases, Department of Medicine, Republic of Korea
| | - S Moon
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - D W Park
- Division of Infectious Diseases, Department of Medicine, Republic of Korea.
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16
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Higgins AM, Brooker JE, Mackie M, Cooper DJ, Harris AH. Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review. J Intensive Care 2020; 8:5. [PMID: 31934338 PMCID: PMC6950865 DOI: 10.1186/s40560-019-0412-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis is a global health priority. Interventions to reduce the burden of sepsis need to be both effective and cost-effective. We performed a systematic review of the literature on health economic evaluations of sepsis treatments in critically ill adult patients and summarised the evidence for cost-effectiveness. Methods We systematically searched MEDLINE, Embase, and the Cochrane Library using thesaurus (e.g. MeSH) and free-text terms related to sepsis and economic evaluations. We included all articles that reported, in any language, an economic evaluation of an intervention for the management of sepsis in critically ill adult patients. Data extracted included study details, intervention details, economic evaluation methodology, and outcomes. Included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results We identified 50 records representing 46 economic evaluations for a variety of interventions including antibiotics (n = 5), fluid therapy (n = 2), early goal-directed therapy and other resuscitation protocols (n = 8), immunoglobulins (n = 2), and interventions no longer in clinical use such as monoclonal antibodies (n = 7) and drotrecogin alfa (n = 13). Twelve (26%) evaluations were of excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (lower costs and higher effectiveness) for early goal-directed therapy, albumin, and a multifaceted sepsis education program to dominated (higher costs and lower effectiveness) for polymerase chain reaction assays (LightCycler SeptiFast testing MGRADE®, SepsiTest™, and IRIDICA BAC BSI assay). ICERs varied widely across evaluations, particularly in subgroup analyses. Conclusions There is wide variation in the cost-effectiveness of sepsis interventions. There remain important gaps in the literature, with no economic evaluations identified for several interventions routinely used in sepsis. Given the high economic and social burden of sepsis, high-quality economic evaluations are needed to increase our understanding of the cost-effectiveness of these interventions in routine clinical practice and to inform decision makers. Trial registration PROSPERO CRD42018095980
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Affiliation(s)
- Alisa M Higgins
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Joanne E Brooker
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Michael Mackie
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - D Jamie Cooper
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia.,2Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria Australia
| | - Anthony H Harris
- 3Centre for Health Economics, Monash University, Melbourne, Victoria Australia
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17
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Lactate Level Versus Lactate Clearance for Predicting Mortality in Patients With Septic Shock Defined by Sepsis-3. Crit Care Med 2019; 46:e489-e495. [PMID: 29432347 DOI: 10.1097/ccm.0000000000003030] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock. DESIGN This retrospective study was performed from a prospective septic shock registry. SETTINGS This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016. PATIENTS We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use. INTERVENTIONS Serum lactate levels were measured at initial and 6 hours from septic shock recognition. MEASUREMENTS AND MAIN RESULTS Lactate clearance was calculated as ([initial lactate - 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21-1.34] and 0.992 [95% CI, 0.989-0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%). CONCLUSIONS Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.
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18
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Abstract
Immune cell populations determine the balance between ongoing damage and repair following tissue injury. Cells responding to a tissue-damaged environment have significant bioenergetic and biosynthetic needs. In addition to supporting these needs, metabolic pathways govern the function of pro-repair immune cells, including regulatory T cells and tissue macrophages. In this Review, we explore how specific features of the tissue-damaged environment such as hypoxia, oxidative stress, and nutrient depletion serve as metabolic cues to promote or impair the reparative functions of immune cell populations. Hypoxia, mitochondrial DNA stress, and altered redox balance each contribute to mechanisms regulating the response to tissue damage. For example, hypoxia induces changes in regulatory T cell and macrophage metabolic profiles, including generation of 2-hydroxyglutarate, which inhibits demethylase reactions to modulate cell fate and function. Reactive oxygen species abundant in oxidative environments cause damage to mitochondrial DNA, initiating signaling pathways that likewise control pro-repair cell function. Nutrient depletion following tissue damage also affects pro-repair cell function through metabolic signaling pathways, specifically those sensitive to the redox state of the cell. The study of immunometabolism as an immediate sensor and regulator of the tissue-damaged environment provides opportunities to consider mechanisms that facilitate healthy repair of tissue injury.
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19
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Park MS. Recent lactate findings: is repeated serum lactate testing necessary in septic shock patients? Acute Crit Care 2019; 34:155-157. [PMID: 31723921 PMCID: PMC6786669 DOI: 10.4266/acc.2019.00528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 05/13/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
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20
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Kramer A, Urban N, Döll S, Hartwig T, Yahiaoui-Doktor M, Burkhardt R, Petros S, Gries A, Bernhard M. Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study). J Emerg Med 2018; 56:135-144. [PMID: 30538084 DOI: 10.1016/j.jemermed.2018.10.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/20/2018] [Accepted: 10/25/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes. OBJECTIVE As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients. METHODS In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (LacTW) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission. RESULTS The admission lactate, LacTW, and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and LacTW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and LacTW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ. CONCLUSIONS In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and LacTW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design.
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Affiliation(s)
- Andre Kramer
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Norman Urban
- Institute for Informatics, Martin-Luther-University of Halle-Wittenberg, Halle, Germany
| | - Stephanie Döll
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Hartwig
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Maryam Yahiaoui-Doktor
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Ralph Burkhardt
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - André Gries
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital of Leipzig, Leipzig, Germany; Emergency Department, University Hospital of Düsseldorf, Düsseldorf, Germany; Working Group Trauma and Resuscitation Room Management, Task Force Emergency Medicine, German Society of Anaesthesiology and Intensive Care Medicine, Nümberg, Germany
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21
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Early goal-directed and lactate-guided therapy in adult patients with severe sepsis and septic shock: a meta-analysis of randomized controlled trials. J Transl Med 2018; 16:331. [PMID: 30486885 PMCID: PMC6264603 DOI: 10.1186/s12967-018-1700-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 11/20/2018] [Indexed: 12/29/2022] Open
Abstract
Background The ProCESS, ARISE, and ProMISe trials have failed to show that early goal-directed therapy (EGDT) reduces mortality in patients with severe sepsis and septic shock. Although lactate-guided therapy (LGT) has been shown to result in significantly lower mortality, its use remains controversial. Therefore, we performed a meta-analysis to evaluate EGDT vs. LGT or usual care (UC) in adult patients with severe sepsis and septic shock. Methods Relevant randomized controlled trials published from January 1, 2001 to March 30, 2017 were identified in PubMed, EMBASE, Web of Science, and the Cochrane Library. The primary outcome was mortality; secondary outcomes included red cell transfusions, dobutamine use, vasopressor infusion, and mechanical ventilation support within the first 6 h and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Results Sixteen studies enrolling 5968 patients with 2956 in EGDT, 2547 in UC, and 465 in LGT were included in this meta-analysis. Compared with UC, EGDT was associated with a lower mortality (10 trials; RR 0.85, 95% CI 0.74–0.97, P = 0.01), and this difference was more pronounced in the subgroup of UC patients with mortality > 30%. In addition, EGDT patients received more red cell transfusions, dobutamine, and vasopressor infusions within the first 6 h. Compared with LGT, EGDT was associated with higher mortality (6 trials; RR 1.42, 95% CI 1.19–1.70, P = 0.0001) with no heterogeneity (P = 0.727, I2 = 0%). Conclusion EGDT seems to reduce mortality in adult patients with severe sepsis and septic shock, and the benefit may primarily be attributed to red cell transfusions, dobutamine administration, and vasopressor infusions within the first 6 h. However, LGT may result in a greater mortality benefit than EGDT. Electronic supplementary material The online version of this article (10.1186/s12967-018-1700-7) contains supplementary material, which is available to authorized users.
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22
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Londoño J, Niño C, Archila A, Valencia M, Cárdenas D, Perdomo M, Moncayo G, Vargas C, Vallejo CE, Hincapié C, Ascuntar J, León A, Jaimes F. Antibiotics has more impact on mortality than other early goal-directed therapy components in patients with sepsis: An instrumental variable analysis. J Crit Care 2018; 48:191-197. [PMID: 30218959 DOI: 10.1016/j.jcrc.2018.08.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/30/2018] [Accepted: 08/24/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To estimate the effect of each of the EGDT components, as well as of the antibiotics, on length-of-stay and mortality. METHODS Prospective cohort in three hospitals. Adult patients admitted by the Emergency Rooms (ER) with infection and any of systolic blood pressure < 90 mmHg or lactate >4 mmol/L. An instrumental analysis with hospital of admission as the instrumental variable was performed to estimate the effect of each intervention on hospital mortality and secondary outcomes. RESULTS Among 2587 patients evaluated 884 met inclusion criteria, with a hospital mortality rate of 17% (n = 150). In the instrumental analysis, the only intervention associated with an absolute reduction in mortality (21%) was the use of antibiotics in the first 3 h. In patients with lactate values ≥4 mmol/L in the ER, a non-decrease of at least 10% at six hours was independently associated with mortality (OR = 3.1; 95%CI = 1.5-6.2). CONCLUSIONS Among patients entering ER with infection and shock or hypoperfusion criteria, the use of appropriate antibiotics in the first 3 h is the measure that has the greatest impact on survival. In addition, among patients with hyperlactatemia >4 mmol/L, the clearance of >10% of lactate during resuscitation is associated with better outcomes.
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Affiliation(s)
- Jessica Londoño
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia; Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - César Niño
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia
| | - Andrea Archila
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Marta Valencia
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia; Medical division, IPS Universitaria León XIII, Medellín, Colombia
| | - Diana Cárdenas
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Mayla Perdomo
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Giovanny Moncayo
- Medical division, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - César Vargas
- Medical division, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Carlos E Vallejo
- Medical division, IPS Universitaria León XIII, Medellín, Colombia; GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Carolina Hincapié
- GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Johana Ascuntar
- GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Alba León
- GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia
| | - Fabián Jaimes
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia; GRAEPIC - Clinical Epidemiology Academic Research Group (Grupo Académico de Epidemiología Clínica), University of Antioquia; Medellín, Colombia; Research Direction, Hospital Universitario San Vicente Fundación, Medellín, Colombia.
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Xu C, Wang Z, Lu K, Jin H. Hotspot Analysis of Sepsis Literature. Med Sci Monit 2018; 24:5427-5436. [PMID: 30078031 PMCID: PMC6091165 DOI: 10.12659/msm.908950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/14/2018] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a common life-threatening pathological process. However, the transformation efficiency of studies on the treatment of sepsis is relatively low. Therefore, a hotspot and trend development study was attempted on the treatment area of sepsis in accordance with the literature. We selected 2511 studies most related to the treatment of sepsis within the past 5 years as research samples. Text and co-word matrix were established by analyzing and selecting high-frequency words using BICOMB software. Classifications in hotspot areas were obtained through biclustering and visual analysis of high-frequency words using Ggluto software. Strategy coordinates for hotspot research were conducted using a co-word matrix. A total of 41 high-frequency words, text, and co-word matrix were conducted within the 2511 studies. A peak map was drawn based on biclustering analysis. The density and concentricity of each hotspot were calculated using the result of the co-word matrix and biclustering analysis. The research concluded 4 categories and 9 aspects for the treatment of sepsis. Additionally, calculation results showed that the relationship between the prognosis of sepsis and the hematological prognosis was in the fourth quadrant of the strategic diagram, that means it was the potential hotspot area for the treatment of sepsis. This conclusion provides potential value for future exploratory stages of study.
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Affiliation(s)
- Changhai Xu
- Department of Emergency Medicine, General Hospital of Shenyang Military Command, Shenyang, Liaoning, P.R. China
| | - Zhe Wang
- Medical Oncology Department of Gastrointestinal Cancer, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning, P.R. China
| | - Kaining Lu
- Department of Urology, China Medical University, Hospital 1, Shenyang, Liaoning, P.R. China
| | - Hongxu Jin
- Department of Emergency Medicine, General Hospital of Shenyang Military Command, Shenyang, Liaoning, P.R. China
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24
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Wang T, Cai Q, Yang WJ, Fan HH, Yi JF, Xu F. MicroRNA-219 alleviates glutamate-induced neurotoxicity in cultured hippocampal neurons by targeting calmodulin-dependent protein kinase II gamma. Neural Regen Res 2018; 13:1216-1224. [PMID: 30028330 PMCID: PMC6065221 DOI: 10.4103/1673-5374.235059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2017] [Indexed: 12/18/2022] Open
Abstract
Septic encephalopathy is a frequent complication of sepsis, but there are few studies examining the role of microRNAs (miRs) in its pathogenesis. In this study, a miR-219 mimic was transfected into rat hippocampal neurons to model miR-219 overexpression. A protective effect of miR-219 was observed for glutamate-induced neurotoxicity of rat hippocampal neurons, and an underlying mechanism involving calmodulin-dependent protein kinase II γ (CaMKIIγ) was demonstrated. miR-219 and CaMKIIγ mRNA expression induced by glutamate in hippocampal neurons was determined by quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR). After neurons were transfected with miR-219 mimic, effects on cell viability and apoptosis were measured by 3-(4,5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry. In addition, a luciferase reporter gene system was used to confirm CaMKIIγ as a target gene of miR-219. Western blot assay and rescue experiments were also utilized to detect CaMKIIγ expression and further verify that miR-219 in hippocampal neurons exerted its effect through regulation of CaMKIIγ. MTT assay and qRT-PCR results revealed obvious decreases in cell viability and miR-219 expression after glutamate stimulation, while CaMKIIγ mRNA expression was increased. MTT, flow cytometry, and caspase-3 activity assays showed that miR-219 overexpression could elevate glutamate-induced cell viability, and reduce cell apoptosis and caspase-3 activity. Moreover, luciferase CaMKIIγ-reporter activity was remarkably decreased by co-transfection with miR-219 mimic, and the results of a rescue experiment showed that CaMKIIγ overexpression could reverse the biological effects of miR-219. Collectively, these findings verify that miR-219 expression was decreased in glutamate-induced neurons, CaMKIIγ was a target gene of miR-219, and miR-219 alleviated glutamate-induced neuronal excitotoxicity by negatively controlling CaMKIIγ expression.
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Affiliation(s)
- Ting Wang
- Department of Emergency, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
- Department of Emergency, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Qun Cai
- Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Wen-Jie Yang
- Medical College of Nantong University, Nantong, Jiangsu Province, China
| | - Hai-Hua Fan
- Medical College of Nantong University, Nantong, Jiangsu Province, China
| | - Jian-Feng Yi
- Medical College of Nantong University, Nantong, Jiangsu Province, China
| | - Feng Xu
- Department of Emergency, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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25
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Jain S. Sepsis: An Update on Current Practices in Diagnosis and Management. Am J Med Sci 2018; 356:277-286. [PMID: 30286823 DOI: 10.1016/j.amjms.2018.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
Despite several advancements in care over the last few decades, sepsis continues to carry a high morbidity and mortality burden in the United States. With its varied presentations, cases of sepsis are likely to be encountered by general practitioners in both inpatient and outpatient settings. In the recent years, there has been much debate about the appropriate criteria to diagnose patients with sepsis with a concurrent change in management guidelines. This article reviews definitions, diagnosis and treatment guidelines in current practice in the management of patients with sepsis.
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Affiliation(s)
- Snigdha Jain
- Division of Hospital Medicine, UT Southwestern Medical Center, Dallas, Texas.
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26
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Diehl JW, Hullsiek KH, Okirwoth M, Stephens N, Abassi M, Rhein J, Meya DB, Boulware DR, Musubire AK. Cerebral Oximetry for Detecting High-mortality Risk Patients with Cryptococcal Meningitis. Open Forum Infect Dis 2018; 5:ofy105. [PMID: 29942819 PMCID: PMC6007269 DOI: 10.1093/ofid/ofy105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/07/2018] [Indexed: 11/13/2022] Open
Abstract
Background Cryptococcus is the commonest cause of adult meningitis in Africa, with 50%–70% experiencing increased intracranial pressure. Cerebral oximetry is a noninvasive near-infrared spectroscopy technology to monitor percent regional cerebral tissue oxygenation (rSO2). We assessed if cerebral oximetry predicts meningitis mortality. Methods We performed cerebral oximetry within 14 days of cryptococcal meningitis diagnosis on 121 Ugandans from April 2016 to September 2017. We evaluated baseline rSO2 association with mortality by multivariable logistic regression and correlation with other clinical factors. We compared groups formed by initial rSO2 <30% vs ≥30% for longitudinal change with mixed effects models. We measured change in %rSO2 before and after lumbar puncture (LP). Results The median initial rSO2 (interquartile range) was 36% (29%–42%), and it was <30% in 29% (35/121). For 30-day mortality, the unadjusted odds ratio (per 5% increase in rSO2) was 0.73 (95% confidence interval [CI], 0.58 to 0.91; P = .005). Those with initial rSO2 <30% had 3.4 (95% CI, 1.5 to 8.0) higher odds of 30-day mortality than those with initial rSO2 ≥30%. Hemoglobin correlated with initial rSO2 (rho = .54; P < .001), but rSO2 did not correlate with pulse oximetry, intracranial pressure, cerebral perfusion pressure, or quantitative cerebrospinal fluid culture, and rSO2 was unchanged pre/post–lumbar punctures. The longitudinal rSO2 measurements change was 15% (95% CI, 12% to 18%) lower in the group with initial rSO2 <30%. Conclusions Individuals with cryptococcal meningitis and low cerebral oximetry (rSO2 < 30%) have high mortality. Cerebral oximetry may be useful as a prognostic marker of mortality. Targeted interventions to improve rSO2 should be tested in trials to try to decrease mortality in meningitis.
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Affiliation(s)
- John W Diehl
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota.,Emory University School of Medicine, Atlanta, Georgia
| | | | - Michael Okirwoth
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | - Joshua Rhein
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | - David B Meya
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
| | | | - Abdu K Musubire
- Infectious Disease Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis, Minnesota
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Kim K, Choi HS, Chung SP, Kwon WY. Septic Shock. ESSENTIALS OF SHOCK MANAGEMENT 2018. [PMCID: PMC7121676 DOI: 10.1007/978-981-10-5406-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
For more than 20 years, sepsis has been defined as symptoms associated with the response to microorganism infection, which was more specifically called systemic inflammatory response syndrome (SIRS). With the evidence of organ failure, it was called severe sepsis, and this could lead to hypotension (septic shock). However, with the deep understanding of the pathophysiology of sepsis, sepsis has been known as both inflammatory and anti-inflammatory. Additionally, the classic use of SIRS could lead to overestimation of sepsis. For example, usual common cold could be identified as sepsis in classic definition. With this background, new sepsis definition, Sepsis 3, was introduced and sepsis was defined as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.” The management of sepsis has been changed dramatically, with the development of Surviving Sepsis Campaign, which substantially increased the survival of sepsis. However, this is not with the help of a new drug, but the implementation of a treatment system. Unfortunately, no specific drug for sepsis has survived in clinical use even though many candidate drugs have been successfully investigated in preclinical setting, and this leads to the new approach to the sepsis.
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Sutton AJ. Not enough I say! Expand the remit of living systematic reviews to inform future research. J Clin Epidemiol 2017; 91:54-55. [DOI: 10.1016/j.jclinepi.2017.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.
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Affiliation(s)
- Bracken A Armstrong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA.
| | - Richard D Betzold
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with 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 these critically ill patients with high mortality.
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Zhang Z, Hong Y, Smischney NJ, Kuo HP, Tsirigotis P, Rello J, Kuan WS, Jung C, Robba C, Taccone FS, Leone M, Spapen H, Grimaldi D, Van Poucke S, Simpson SQ, Honore PM, Hofer S, Caironi P. Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002. J Thorac Dis 2017; 9:392-405. [PMID: 28275488 PMCID: PMC5334094 DOI: 10.21037/jtd.2017.02.10] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Severe sepsis and septic shock are major causes of morbidity and mortality in patients entering the emergency department (ED) or intensive care unit (ICU). Despite substantial efforts to improve patient outcome, treatment of sepsis remains challenging to clinicians. In this context, early goal directed therapy (EGDT) represents an important concept emphasizing both early recognition of sepsis and prompt initiation of a structured treatment algorithm. As part of the AME evidence series on sepsis, we conducted a systematic review of all randomized controlled EGDT trials. Focus was laid on the setting (emergency department versus ICU) where EGDT was carried out. Early recognition of sepsis, through clinical or automated systems for early alert, together with well-timed initiation of the recommended therapy bundles may improve patients' outcome. However, the original "EGDT" protocol by Rivers and coworkers has been largely modified in subsequent trials. Currently, many investigators opt for an "expanded" EGDT (as suggested by the Surviving Sepsis Campaign). Evidence is also presented on the effectiveness of automated systems for early sepsis alert. Early recognition of sepsis and well-timed initiation of the SSC bundle may improve patient outcome.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | | | - Han-Pin Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - 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 Institute of Research, Universitat Autonoma de Barcelona, Spain
| | - 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
| | - Christian Jung
- University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Division of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany
| | - Chiara Robba
- Neurosciences Critical Care Unit, Box 1, Addenbrooke’s Hospital, Cambridge, UK
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marc Leone
- Service d’anesthésie et de réanimation, Hôpital Nord, Assistance Publique – Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Herbert Spapen
- Intensive Care Department, University Hospital, Vrije Universiteit, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sven Van Poucke
- Department of Anesthesiology, Emergency Medicine, Critical Care and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Steven Q. Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas, USA
| | - Patrick M. Honore
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel Brussels, Brussels, Belgium
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Pietro Caironi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3705] [Impact Index Per Article: 529.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with 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 these critically ill patients with high mortality.
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