Documento de Consenso (SEMES-SEMICYUC). Recomendaciones del manejo diagnóstico-terapéutico inicial y multidisciplinario de la sepsis grave en los Servicios de Urgencias hospitalarios

Clinical Utility and Evolution of Donor Serum Lactate During Normothermic Regional Perfusion in Uncontrolled Donation After Circulatory Death

BACKGROUND

Kidney transplantation from uncontrolled donor after circulatory death (uDCD) showed a higher incidence of delayed graft function and primary failure. The aim of this study was to study basal and kinetic evolution of lactate values in uDCD preserved on normothermic regional perfusion (NRP) as a predictive factor of kidney suitability exposed to prolong ischemic conditions.

METHODS

Descriptive and prospective study of a cohort of out-of-hospital cardiac arrest patients admitted to the emergency room as potential uDCD. Donors meeting the inclusion criteria were preserved on NRP for at least 2 hours before procurement. Serum lactate levels were determined at arrival as basal level and at 30 minutes intervals and compared with adequate renal perfusion in the operating room (OR).

RESULTS

Forty-five donors met inclusion criteria. Of these, 38 went to the OR (84.5%). No differences were found in basal lactate between accepted and rejected kidneys (203.08 ± 59.21 vs 175.43 ± 75.32 mg/dL, respectively); neither lactate, hematologic, hepatic transaminases, creatinine, or blood gas analysis sequential values evolved while on NRP. Lactate receiver operating characteristic curve failed to predict viability at different time points and did not correlate with the macroscopic kidney poor perfusion in the OR.

CONCLUSIONS

The baseline and kinetic evolution of plasma lactate values while on NRP, were not useful tools to predict the final OR kidney viability owing to previous severe ischemic insult.

[Assessment of outcomes of implementing the Sepsis Code in the emergency department of a tertiary hospital]

INTRODUCTION

A Sepsis Code (CS) is a comprehensive multidisciplinary system which has the aim of optimising the identification and intervention times of patients with sepsis, as well as improving their monitoring and treatment adjustments in order to reduce their mortality.

OBJECTIVES

To present the outcomes of the first year of introducing the CS in the emergency department of a tertiary hospital.

MATERIAL AND METHODS

A single-centre retrospective descriptive observational study was conducted on all patients in whom the CS was activated in the emergency department of a tertiary hospital during the first year of implementation. The variables included: demographics, CS activation, comorbidities, focus of infection, microbiology, antibiotic treatment, and mortality.

RESULTS

CS was activated in 555 patients, of which 302 (54.4%) had a definitive diagnosis of sepsis or septic shock on discharge from the emergency department. The degree of completion of the protocol variables was variable (41.8-95%).The large majority (86.1%) of the patients received antibiotics in the first hour, and in 76.2% blood cultures were collected prior to the antibiotic. Of the blood cultures performed, 13.3% of the isolated germs were multi-resistant and the level of contamination of blood cultures was 9.1%. All patients received empirical treatment and recommendations were followed in patients with septic shock in 28.3%. During follow-up, 64.4% the antibiotic treatment was targeted, and 39.5% received sequential therapy. In-hospital mortality was 32.2%.

CONCLUSIONS

Areas of improvement in the completion of the variables, contamination of blood cultures, and empirical treatment received were detected, with the strong points being the early administration of the antibiotic and the collection of blood cultures.

Quality assessment of meta-analyses evaluating randomized clinical trials to improve the prognosis of septic shock: an overview of systematic reviews

Objective: Clinical guidelines for the treatment of septic shock are based on the studies with the best scientific evidence, which are meta-analyses of clinical trials. However, these meta-analyses may have methodological limitations that prevent their conclusions from being extrapolated to routine clinical practice. Therefore, the objective of this study is to determine the quality of these meta-analyses through a systematic review.Methods: In this systematic review, we searched MEDLINE, Scopus and EMBASE from inception to May 2019. We selected meta-analyses from clinical trials that determined the effectiveness of an intervention in reducing the incidence of mortality in patients with septic shock. All items were extracted from the Overview Quality Assessment Questionnaire (OQAQ), which collects information from both systematic reviews and meta-analyses.Results: A total of 34 studies were included. Most elements of the OQAQ were conducted satisfactorily, although 35.3% of meta-analyses did not use a quality assessment of the studies included in other analyses. In 52.9% of meta-analyses, the quality of the studies was high or very high.Conclusions: The methods used to obtain the results should be taken into account when recommending an intervention to treat septic shock if the evidence comes from a meta-analysis of the analyzed characteristics.

The utility of C-reactive protein and procalcitonin for sepsis diagnosis in critically burned patients: A preliminary study

Objective

To assess the utility of C-reactive protein (CRP) and procalcitonin (PCT) as biomarkers of infection in patients with severe burn injury.

Methods

The present study included severe burn injury patients consecutively admitted to the Virgen del Rocío University Hospital (Andalucia, Spain) intensive care unit during a 12-month period. The variables of interest were: age, sex, mechanism of injury, percentage of burned body surface area, the Abbreviated Burn Severity Index (ABSI) and the absence/presence of sepsis. The authors analyzed serum levels of CRP and PCT at admission and every 48 h thereafter until intensive care unit discharge or death. Each determination was considered to be a sample or unit of analysis.

Results

A total of 157 determinations were analyzed from 17 severe burn injury patients. Fifty-four samples were considered to be septic, 25 of which corresponded to the first day of a new onset of sepsis. The mean duration of these symptoms was four days (interquartile range two to five days). Significant differences were found in the distributions of CRP and PCT values between sepsis and no-sepsis samples. Analysis of the changes in these biomarkers over time showed that PCT increase (ΔPCT) differentiated these diagnoses, whereas CRP increase (ΔCRP) did not. ROC curve analysis revealed that ΔPCT could predict positive sepsis samples (area under the curve 0.75 [95% CI 0.58 to 0.90]; P=0.003).

Conclusion

These preliminary results showed that PCT had a better discriminatory capacity than CRP for identifying infectious processes in patients with severe burn injury. A larger sample size would be needed to confirm these results.

[Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care]

AIMS

1) To assess the prognostic value of levels on admission and serial measurements of lipopolysaccharide binding protein (LBP) and procalcitonin (PCT) in relation to in-hospital mortality; and 2) to determine whether the addition of these parameters to severity scores (APACHE II and SOFA) is able to improve prognostic accuracy.

DESIGN

A single-center, prospective observational study was carried out.

SETTING

Intensive Care unit of a university hospital.

PATIENTS

One hundred severe sepsis and septic shock patients were included.

DATA COLLECTED

Demographic data, APACHE II and SOFA scores, PCT and LBP levels on admission and after 48 hours, and in-hospital mortality.

RESULTS

The best area under the curve for predicting in-hospital mortality corresponded to APACHE II on admission and SOFA after 48 h (AUC ROC: 0.75 for both). PCT and LBP levels on admission and LBP clearance were not statistically different between in-hospital survivors and non-survivors. Only PCT clearance was higher among in-hospital survivors than in non-survivors (AUC ROC: 0.66). The combination of severity scores and PCT clearance did not result in superior areas under the curve.

CONCLUSIONS

LBP and PCT levels on admission and LBP clearance showed no prognostic value in severe sepsis and septic shock patients. Only PCT clearance was predictive of in-hospital mortality. The prognostic accuracy was significantly better for APACHE on admission and SOFA after 48 h than for any of the analyzed biomarkers, and the addition of PCT clearance did not improve their prognostic value.

[Diagnostic and prognostic power of biomarkers to improve the management of community acquired pneumonia in the emergency department]

OBJECTIVES

To analyse the usefulness and performance of several biomarkers [C-reactive protein (CRP), mid-regional pro-adrenomedullin (MR-proADM), procalcitonin (PCT)] and lactate in predicting short- and medium-term mortality compared with the prognostic severity scales (PSS) usually employed for community-acquired pneumonia (CAP) and in assessing the aetiological suspicion of infection by Streptococcus pneumoniae and bacteraemia.

METHODS

Observational, prospective and analytical study was conducted on patients who were diagnosed with CAP in our emergency department (ED). The data collected included socio-demographic and comorbidity variables, Charlson index, priority level according to the Spanish Triage System (STS), stage in the Pneumonia Severity Index (PSI) and in the CURB-65 (confusion, urea, respiratory rate, blood pressure and age ≥65years), criteria of severe CAP, microbiological studies, and biomarkers determinations. The patients were followed-up for 180days to calculate the prognostic power and the diagnostic performance for bacteraemia and aetiology.

RESULTS

A total of 127patients were finally enrolled in the study. The 30-day mortality was 10.3% (13), and 22.6% (28) at 180 days. Blood cultures were positive in 29 patients (23%) and S.pneumoniae was identified as the responsible pathogen in 28 cases (22.2%). The area under the ROC curve (AUC-ROC) for lactate and MR-proADM to predict 30-day mortality was 0.898 (95%CI: 0.824-0.973; P<.0001) and 0.892 (95%CI: 0.811-0.974; P<.0001), respectively, and for MR-proADM at 180 days it was 0.921 (95%CI: 0.874-0.968; P<.0001). The AUC-ROC for PCT to predict bacteraemia was 0.952 (95%CI: 0.898-1.000; P<.0001) and, considering a cut-off value ≥0.95ng/ml, the negative predictive value (NPV) and the likelihood ratio (LR+) were 97.8% and 9.03, respectively. Using a PCT cut-off value >0.85ng/ml, the NPV and the LR+ were 96.6% and 5.89%, respectively, to predict a S.pneumoniae infection.

CONCLUSIONS

MR-proADM and lactate showed a similar or even better performance for 30-day intra-hospital mortality than PSI, CURB-65, STS and CAP severity criteria in patients diagnosed with CAP (P>.05). Furthermore, the MR-proADM capacity to predict 180-day mortality was higher than PSS and the rest of biomarkers (P>.05), and its AUC-ROC increased if it was used in combination with PSI, CURB65 and STS. The determination of PCT has a remarkable diagnostic performance to rule out bacteraemia and to orientate the aetiology towards a S.pneumoniae infection.

New clinical practice guidelines of the surviving sepsis campaign: a critical appraisal

In 2004 was published the first edition of the "Surviving sepsis campaign" guidelines for the management of severe sepsis and septic shock, opening a new era in the treatment of this syndrome. The paradox is that guidelines application have produced positive results despite including in some cases treatments proven ineffective. Eight years later has been published the third edition of the guides, which updates the prior in the light of new knowledge, but the quality of evidence remains weak. In this paper the authors express their critical view on the current edition of the guides, pointing out their weaknesses and suggesting how the development of future editions should be.

[Usefulness of procalcitonin upon admission to intensive care in the diagnosis and prognosis of sepsis]

OBJECTIVE

To assess the usefulness of procalcitonin (PCT) upon admission to the Intensive Care Unit (ICU) in the diagnosis and prognosis of sepsis

DESIGN

A 12-month prospective observational cohort study was carried out

SETTING

An 11-bed polyvalent ICU Belonging to a University hospital

PATIENTS

Fifty patients with systemic inflammatory response syndrome (SIRS) were included. The mean age of the patients was 51.66 years, and 68% of them were males

VARIABLES OF INTEREST

Upon admission, the concentration of PCT and C-reactive protein (CRP) was assessed. At discharge, the final diagnosis and outcome were reviewed

RESULTS

Thirty-six patients had sepsis. Mean PCT ± SD was higher in sepsis than in non-infectious SIRS (19.3 ± 4.9 vs. 0.65 ± 0.2) ng/ml) (P=.001). PCT had greater discriminating power than CRP (AUC 0.932 vs. 0.827). The cut-off value of PCT for the diagnosis of sepsis was 0.92 ng/dl, with a sensitivity of 80.56%, specificity 85.71%, positive predictive value 93.55% and negative predictive value 63.16%, LR+ 5.64 and LR- 0.23. Mortality was higher in patients with sepsis (52.78% vs. 21.43%) (P=.039). Mean PCT ± SD upon admission among survivors and deceased patients with sepsis was 18.7 ± 6.7 and 19.5 ± 7.5 ng/ml, respectively (P=.934).

CONCLUSIONS

PCT upon admission to the ICU is useful for the diagnosis of sepsis, and is more effective than PCR in this respect. However, it is of no help in estimating the short-term prognosis.

Prognostic value of the biomarkers procalcitonin, interleukin-6 and C-reactive protein in severe sepsis

AIM

To determine the prognostic value of the biomarkers procalcitonin, interlukin-6 and C-reactive protein in septic patients.

DESIGN

A cohort of 81 septic patients.

SETTING

Critical Care Unit. Dr. Peset Hospital. Valencia (Spain).

PATIENTS

Divided according to sepsis classification (sepsis, severe sepsis and septic shock), source and two different groups (medical and postsurgical). VARIABLES ANALYZED: Quantitative (procalcitonin, interleukin-6, C-reactive protein, lactate, age, Apache II and SOFA scores upon admission and after 3 and 7 days). Qualitative (ICU mortality, multiorgan failure development and sex).

STATISTICAL ANALYSIS

Mann-Whitney U-test for the comparison of quantitative variables, χ² test for qualitative variables. Multivariate analysis with mortality and multiorgan failure as dependent variables and the described quantitative parameters as independent variables. ROC curves of the variables found to be significant in the multivariate analysis.

RESULTS

Septic shock patients showed greater mortality and more frequent multiorgan failure. Comparison of survivors versus deceased patients showed significant differences in Apache II score, interleukin-6 and lactate (p<0.001) upon admission and after 3 and 7 days. Similar findings applied to the comparison of patients with and without multiorgan failure, and on the same days. Procalcitonin only showed differences on days 3 and 7 (p=0.001). In the multivariate analysis with mortality as dependent variable, interleukin-6 proved significant on day 3 (OR 2.6). With multiorgan failure as dependent variable, only the SOFA score showed significance (OR 2.3). The Apache II and interleukin-6 ROC curves corresponding to day 3 showed areas of 0.80 and 0.86, respectively.

CONCLUSIONS

1) Interleukin-6 is an inflammatory biomarker with mortality prognostic value. 2) None of the biomarkers proved predictive of multiorgan failure.

[Antibiotics and timing in infectious disease in the emergency department]

Infectious diseases, besides being a major cause of mortality in developing countries, are one of the main reasons for consultation in emergency medicine. In the last few years, there have been numerous published studies on the importance of starting antibiotic treatment at an early stage in the Emergency Department. However, this issue is of great controversy, owing to some contradictory studies as well as the implications this may have on the pressure of the patient care. This review is presents a summary of the scientific evidence published in this regard, and makes some recommendations based on this published evidence to improve the initial management of patients with an infection; a question of great importance as it can reduce mortality in some specific situations.

[Introduction of a management system in intensive care medicine based on the safety of the seriously ill patient during the entire hospitalization process: extended intensive care medicine]

The clinical care of hospitalized seriously ill patients must be suitably proportionate independently of the functional unit to which they have been admitted. Most of these patients are admitted to the Intensive Care Unit (ICU), where uninterrupted management is provided, with important technological and care resources. However, hospitalization of the seriously ill patient must be understood as a continuum starting and ending beyond hospital stay. Anticipating critical worsening requiring admission to the ICU would be of benefit to the patient, avoiding greater clinical worsening, and also would be of benefit to the hospital, by allowing improved resource management. Intensivists are the professionals best suited for this purpose, since they are trained to recognize the seriousness of an always dynamic clinical situation. Addressing this task implies a change in the traditional way of working of the ICU, since a critical patient is not only a patient already admitted to the Unit but also any other patient admitted to hospital whose clinical situation is becoming destabilized. In this context, our ICU has established two strategic lines. One consists of the identification of patients at risk outside the Unit and is based on the recognition, diagnostic orientation and early treatment of the seriously ill patient, in collaboration with other clinical specialties and independently of the hospital area to which the patient has been admitted. The second line in turn comprises clinical care within the actual Unit, and is based on the promotion of safety and the vigilance of nosocomial infections.

[New therapeutic alternatives for severe sepsis in the critical patient. A review]

BACKGROUND

Despite efforts to establish uniform protocols for the management of severe sepsis, this condition continues to have high morbidity and mortality. This is due, among other factors, to the many barriers for the development of the protocols and the application time. That is why new therapeutic measures are continuing to be investigated and developed.

OBJECTIVE

To review the literature on the new and future therapeutic alternatives available in the management of sepsis in critically ill patients. DATA SOURCE AND SEARCH METHOD: A search was made for articles consistent with evidence- based medicine guidelines published between 2004 and 2009 in different databases (Cochrane Plus Library, National Guideline Clearinghouse, Clinical Evidence, REMI and PubMed) and the NIH Clinical Trails database (ClinicalTrials.gov) using the TRIP meta-search engine.

STUDY SELECTION

A total of 357 documents were retrieved, selecting 48 of which included systematic reviews, meta-analyses, clinical practice guidelines, structured abstracts of original articles, and clinical trials. The selection criteria followed the peer review process.

DATA EXTRACTION

Data were extracted by two independent reviewers.

CONCLUSIONS

Based on the 2004-2009 study period, sufficient evidence was not obtained to make further recommendations on the treatment of sepsis. Although the abundant evidence needed to suggest the utility of these therapeutic measures, inhaled nitric oxide, statins, and immunoglobulins are probably good options for the adjuvant treatment of sepsis. However, we must wait for the results of different ongoing clinical trials on new treatment modalities. Stem cells and gene therapy will probably emerge as novel therapies in the future.