Surviving sepsis: a systems issue

A Comparative Study to Assess the Determinants and Outcomes of Sepsis Treated in Medical Wards and ICU in an Indian Teaching Hospital

INTRODUCTION

Sepsis is the primary cause of death from infection worldwide. In resource-limited countries, increasing number of sepsis is managed in non-ICU settings, in Medical Wards (MW).

AIM

To compare the burden, aetiology and short term outcome of sepsis treated in MW with ICU.

MATERIALS AND METHODS

Prospective, observational, analytical study in sepsis patients in general MW and medical ICU in a tertiary care hospital. Two hundred forty five sepsis patients (MW=150, ICU=95), ≥18 years, selected randomly, were studied to compare aetiology, co-morbidities, clinical & microbiological profile and short-term outcome between MW and ICU sepsis. Sepsis following surgery, trauma, those transferred to/from ICU, those with other life threatening diseases were excluded. Chi-square test/Fisher's-exact test was used for comparing ratios. A 'p-value' <0.05 was considered statistically significant.

RESULTS

Sepsis was more common in elderly males, both in MW and ICU (median age: 56.7, 59.2 years; male: female ratios = 1.34:1, 1.63:1 respectively). Frequency of presenting symptoms, co-morbidities and sources of sepsis were similar in both groups (p>0.05). Frequency of positive microbiological culture, pattern of microbial flora and antimicrobial resistance patterns were similar in both groups (p>0.05). Number of antibiotics used was significantly higher in ICU compared to MW (p<0.01); multi-organ dysfunction and mortality were significantly higher in ICU settings (55.8% vs. 38.7%, p=0.04; 48.4% vs. 32.6%, p=0.041 respectively). While sepsis and severe sepsis were significantly higher in MW (34.6% vs. 22.1 %, p=0.03; 47.3% vs. 26.3%, p<0.01 respectively), septic shock was significantly higher in ICU (51.6% vs. 18.0%, p<0.01). Mortality in both settings was highest in septic shock (55.5% and 61.2%, p>0.05) and multi-organ dysfunction (55.1% and 64.2%, p>0.05). Duration of hospital stay was significantly shorter in MW than ICU (7.3 vs. 11.0 days, p<0.01).

CONCLUSION

Our study aimed to identify determinants and outcome of sepsis in MW and compare with ICU settings. Antibiotic usage in the two settings differed: concurrent use of ≥3 antibiotics, and carbapenems & linezolid usage were significantly higher in ICU compared to MW. Sepsis in MW had significantly lower incidence of multi-organ failure, lower mortality and shorter hospital stay compared to ICU.

Crossing the handover chasm: Clinicians' perceptions of barriers to the early detection and timely management of severe sepsis and septic shock

PURPOSE

The purpose was to identify barriers to the early detection and timely management of severe sepsis throughout the emergency department (ED), general ward (GW), intermediate care unit (IMC), and the intensive care unit (ICU).

MATERIALS AND METHODS

Five multicenter focus group discussions with 29 clinicians were conducted. Discussions were based on a moderation guide were recorded and transcribed. Qualitative analysis was performed according to the principles of the concept mapping method and the framework approach.

RESULTS

The major causes of the delayed detection and treatment could be summarized in a framework of communication errors and handover difficulties throughout patients' course of treatment, which can be divided into 5 core areas: inadequate histories before hospital admission; poorly coordinated handovers between the ambulance service and the ED; delayed patient transfer between the ED and the GW as well as delays in patient transfers between the GW and the ICU by, for example, a lack of bed capacity and a shortage of staff. Generally, participants from all wards mentioned that the urgency with which septic patients needed to be treated was not communicated.

CONCLUSIONS

Our study shows the need to improve intra- and interunit handover processes in hospital care, which would ensure a holistic treatment concept, thereby improving patient care.

Sepsis outside intensive care unit: the other side of the coin

INTRODUCTION

A growing body of evidence points out that a large amount of patients with sepsis are admitted and treated in medical ward (MW). With most of the sepsis studies conducted in intensive care unit (ICU), these patients, older and with more comorbidities have received poor attention. Provided the differences between the two groups of patients, results of diagnostic and therapeutic trials from ICU should not be routinely transferred to MW, where sepsis seems to be at least as common as in ICU.

METHODS

We analyzed clinical trials on novel tools for an early diagnosis of sepsis published in the last two year adopting strict research criteria. Moreover we conducted a target review of the literature on non-invasive monitoring of severe sepsis and septic shock.

RESULTS AND CONCLUSIONS

The combination of innovative and non-invasive tools for sepsis rule in/out, as quick alternatives to blood cultures (gold standard) with bedside integrated ultrasonography could impact triage, diagnosis and prognosis of septic patients managed in MW, preventing ICU admissions, poor outcomes and costly complications, especially in elderly that are usually highly vulnerable to invasive procedures.

Transcriptional instability during evolving sepsis may limit biomarker based risk stratification

Background

Sepsis causes extensive morbidity and mortality in children worldwide. Prompt recognition and timely treatment of sepsis is critical in reducing morbidity and mortality. Genomic approaches are used to discover novel pathways, therapeutic targets and biomarkers. These may facilitate diagnosis and risk stratification to tailor treatment strategies.

Objective

To investigate the temporal gene expression during the evolution of sepsis induced multi-organ failure in response to a single organism, Neisseria meningitidis, in previously healthy children.

Method

RNA was extracted from serial blood samples (6 time points over 48 hours from presentation) from five critically ill children with meningococcal sepsis. Extracted RNA was hybridized to Affymetrix arrays. The RNA underwent strict quality control and standardized quantitation. Gene expression results were analyzed using GeneSpring software and Ingenuity Pathway Analysis.

Result

A marked variability in differential gene expression was observed between time points and between patients revealing dynamic expression changes during the evolution of sepsis. While there was evidence of time-dependent changes in expected gene networks including those involving immune responses and inflammatory pathways, temporal variation was also evident in specific “biomarkers” that have been proposed for diagnostic and risk stratification functions. The extent and nature of this variability was not readily explained by clinical phenotype.

Conclusion

This is the first study of its kind detailing extensive expression changes in children during the evolution of sepsis. This highlights a limitation of static or single time point biomarker estimation. Serial estimations or more comprehensive network approaches may be required to optimize risk stratification in complex, time-critical conditions such as evolving sepsis.