The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: a meta-analysis

Dynamic monitoring tools for patients admitted to the emergency department with circulatory failure: narrative review with panel-based recommendations

Intravenous fluid therapy is commonly administered in the emergency department (ED). Despite the deleterious potential of over- and under-resuscitation, professional society guidelines continue to recommend administering a fixed volume of fluid in initial resuscitation. Predicting whether a specific patient will respond to fluid therapy remains one of the most important, but challenging questions that ED clinicians face in clinical practice. Surrogate parameters (i.e. blood pressure and heart rate), are widely used in usual care to estimate changes in stroke volume (SV). Due to their inadequacy in estimating SV, noninvasive techniques (e.g. bioreactance, echocardiography, noninvasive finger cuff technology), have been proposed as a more accurate and readily deployable method for assessing flow and preload responsiveness. Dynamic monitoring systems based on cardiac preload challenge and assessment of SV, by using noninvasive and continuous methods, provide more accurate, feasible, efficient, and reasonably accurate strategy for prediction of fluid responsiveness than static measurements. In this article, we aimed to analyze the different methods currently available for dynamic monitoring of preload responsiveness.

Timing and clinical risk factors for early acquisition of gut pathogen colonization with multidrug resistant organisms in the intensive care unit

BACKGROUND

Microbiome restitution therapies are being developed to prevent gut pathogen colonization among patients in the intensive care unit (ICU) and in other select populations. If preventive therapies are to be effective, they must be administered prior to pathogen acquisition. The timing and risk factors for early acquisition of gut pathogen colonization (within 72 h) are currently unknown and could be helpful to guide ICU trial design.

METHODS

This was a prospective cohort study. Patients in the ICU had deep rectal swabs performed within 4 h of ICU admission and exactly 72 h later. Early gut pathogen colonization was classified as the new presence (based on culture of rectal swabs) of one or more of the following organisms of interest: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant (VRE), and Gram-negative bacteria that showed multidrug resistance (MDR) or third generation Cephalosporin resistance (Ceph-R). Clinical risk factors for early acquisition of gut pathogen colonization were captured using the Acute Physiology and Chronic Health Evaluation IV (APACHE IV) scoring system.

FINDINGS

Among 131 patients who were swabbed at ICU admission and 72 h later, the rates of gut pathogen colonization at ICU admission were 11.4%, 10.6%, 38.6%, and 8.3% for MRSA, VRE, MDR and Ceph-R Gram-negatives respectively. Among the patients who were negative for a given pathogen at ICU admission, the rates of early acquisition of gut pathogen colonization were 7.8% for MRSA (95% CI 3.6 to 14.2%), 7.7% for VRE (95% CI 3.6 to 14.1%), 11.3% for MDR Gram-negatives (95% CI 4.4 to 18.8%), and 4.2% for Ceph-R Gram-negatives (95% CI 1.4 to 9.5%). There were no clinical risk factors which independently predicted early acquisition of gut pathogen colonization.

INTERPRETATION

Early gut pathogen colonization was common in the ICU, but our single-center study could not identify any clinical risk factors which were significantly associated with acquisition of gut pathogens.

Revelation of mindlines in the setting of crisis

During the devastating early months of the unfolding COVID-19 pandemic in New York, healthcare systems and clinicians dynamically adapted to drastically changing everyday practice despite having little guidance from formal research evidence in the face of a novel virus. Through new, silo-breaking networks of communication, clinical teams transformed and synthesized provisional recommendations, rudimentary published research findings and numerous other sources of knowledge to address the immediate patient care needs they faced during the pandemic surge. These experiences illustrated underlying social processes that are always at play as clinicians integrate information from various sources, including research and published guidelines, with their own tacit knowledge to develop shared yet personal approaches to practice. In this article, we provide a narrative account of personal experience during the COVID-19 surge. We draw on the concept of mindlines as developed by Gabbay and Le May as a conceptual framework for interpreting that experience from the standpoint of how early information from research and guidelines was drawn on and transformed in the course of day-to-day struggle with the crisis in New York City emergency rooms. Finally, briefly referencing the challenges to conventional models of healthcare knowledge creation and translation through research and guideline production posed by COVID-19 crisis, we offer a provisional perspective on current and future developments.

Association between different concentrations of human serum albumin and 28-day mortality in intensive care patients with sepsis: A propensity score matching analysis

Background: Human serum albumin (HSA) is a commonly used medication for the treatment of sepsis. However, there is no conclusive evidence as to whether different concentrations of HSA are associated with patient prognosis. This study aimed to evaluate the association between different concentrations of HSA and 28-day mortality in patients with sepsis. Methods: The data for this retrospective study were collected from the Medical Information Mart for Intensive Care IV database. Patients with sepsis were divided into two groups according to the concentration of HSA received: 25% and 5% HSA. The primary outcome of this study was the 28-day mortality in patients with sepsis. To ensure the robustness of our findings, we used multivariate Cox regression, propensity score matching, double-robust estimation, and inverse probability weighting models. Results: A total of 76,943 patients were screened, of whom 5,009 were enrolled. 1,258 and 3,751 patients received 25% and 5% HSA, respectively. The 28-day mortality rate was 38.2% (481/1,258) for patients in the 25% HSA group and 8.7% (325/3,751) for patients in the 5% HSA group. After propensity score matching, 1,648 patients were identified. The inverse probability weighting model suggested that 5% HSA received was associated with lower 28-day mortality (hazard ratio [HR]: 0.63, 95% confidence interval [CI]: 0.54-0.73, p < 0.001). Subgroup and sensitivity analysis confirmed the robustness of the results. Conclusion: In patients with sepsis, 5% HSA received may be associated with a lower risk of 28-day mortality than 25% HSA. Further randomized controlled trials are required to confirm this association.

Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations

Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.

Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis

OBJECTIVE

Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls.

METHODS

The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group.

RESULTS

A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015).

CONCLUSION

Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Hemodynamic support in septic shock

PURPOSE OF REVIEW

The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients.

RECENT FINDINGS

The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center.

SUMMARY

Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.

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.

Early lactate area scores and serial blood lactate levels as prognostic markers for patients with septic shock: a systematic review

Septic shock is the main cause of morbidity and mortality in patients and second leading cause of mortality among subjects in noncoronary intensive care units. Based on the literature, elevated serum lactate levels are associated with poor outcomes in patients with septic shock, which may occur due to various reasons, such as tissue hypoxia and anaerobic metabolism. This systematic review was conducted to collect data on the lactate area and area under the curve (AUC) of serial lactate levels for the determination of the predictive values of these factors to diagnose septic shock. For this purpose, the articles published up to 2019 were searched in four databases, including Google Scholar, PubMed, Scopus, and Medline. This study was carried out based on the seven stages recommended in the Cochrane Handbook. All articles were searched using several keywords, including 'Lactate Area Score' and 'Serial Lactate Levels' in combination with 'Septic Shock'. There were a total of 14 studies mainly focused on the assessment of the lactate area and serial lactate levels in patients with septic shock. The inclusion criteria were a clear explanation of the predictive role of repeated lactate measurements in patients with septic shock, sample size larger than 50, examination on human samples, and publication in English. All case-control, prospective, and retrospective studies on human subjects assessing the predictive value of repeated lactate measurements in the diagnosis of patients with septic shock at high risk of mortality were entered in the present review. The lactate area is a new concept introduced as the sum of the AUC of serial lactate levels. This factor can determine the severity and duration of hyperlactatemia. Based on the obtained results, there was an association between the lactate area score and 28-day mortality of patients with septic shock; therefore, early lactate area score can be considered a prognostic marker for the prediction of mortality rate in these patients. There are few studies on the evaluation of the lactate area score and no more information about the prognostic ability of the lactate area score. This was the main limitation of the present study. Moreover, the lactate area is introduced as the sum of the AUC of serial lactate levels and cannot reflect the trend of serial lactate. The trend may be supported by lactate clearance but not lactate area.

A Multivariate Metabolomics Method for Estimating Platelet Mitochondrial Oxygen Consumption Rates in Patients with Sepsis

Background: Sepsis-induced alterations in mitochondrial function contribute to organ dysfunction and mortality. Measuring mitochondrial function in vital organs is neither feasible nor practical, highlighting the need for non-invasive approaches. Mitochondrial function may be reflected in the concentrations of metabolites found in platelets and whole blood (WB) samples. We proposed to use these as alternates to indirectly estimate platelet mitochondrial oxygen consumption rate (mOCR) in sepsis patients. Methods: We determined the relationships between platelet mOCR and metabolites in both platelets and WB, as measured by quantitative ¹H-NMR metabolomics. The associations were identified by building multiple linear regression models with stepwise forward-backward variable selection. We considered the models to be significant with an ANOVA test (p-value ≤ 0.05) and a positive predicted-R². Results: The differences in adjusted-R² and ANOVA p-values (platelet adj-R²: 0.836 (0.0003), 0.711 (0.0004) vs. WB adj-R²: 0.428 (0.0079)) from the significant models indicate the platelet models were more associated with platelet mOCR. Conclusions: Our data suggest there are groups of metabolites in WB (leucine, acetylcarnitine) and platelets (creatine, ADP, glucose, taurine) that are associated with platelet mOCR. Thus, WB and platelet metabolites could be used to estimate platelet mOCR.

Quick Sepsis-related Organ Failure Assessment predicts 72-h mortality in patients with suspected infection

OBJECTIVE

The aim of this study was to compare quick Sepsis-related Organ Failure Assessment (qSOFA) and Systemic Inflammatory Response Syndrome (SIRS) scores for predicting mortality.

PATIENTS AND METHODS

A single-center, retrospective study of adult patients with suspected infection was conducted. Area under the curve (AUC) and multivariate analyses were used to explore associations between the qSOFA and SIRS scores and mortality.

RESULTS

Of the 69 115 patients enrolled, 1798 died within 72 h and 5640 within 28 days. The qSOFA scores were better than SIRS scores at predicting 72-h mortality (AUC: 0.77 vs. 0.64). However, the discriminatory power of both scores was low in terms of 28-day mortality (AUC: 0.69 vs. 0.60). Patients with qSOFA score of at least 2 had a higher hazard ratio for 72-h mortality than for 28-day mortality (2.64 vs. 1.91).

CONCLUSION

The qSOFA scores are more accurate than SIRS scores for predicting 72-h mortality and are better at predicting 72-h mortality than 28-day mortality.

Sepsis patients with complication of hypoglycemia and hypoalbuminemia are an early and easy identification of high mortality risk

Either hypoglycemia or hypoalbuminemia alone is an independent condition associated with increased risk of mortality in critical illness. This study evaluates whether the mortality risk increases in septic patients if these conditions are combined. Patients admitted to our hospital from 2008 to 2015 who satisfied the definition of sepsis were targeted (n = 336). We classified cases into three groups based on blood glucose (BG) level measured at admission: hypoglycemia (Hypo-G; BG < 80 mg/dl), intermediate glycemia (Inter-G; 80-199 mg/dl), and hyperglycemia (Hyper-G; ≥ 200 mg/dl) group, and then estimated mortality. We also compared the clinical data of these glycemic groups in combination with hypoalbuminemia (Hypo-A) or Inter-G with non-hypoalbuminemia (Inter-G + Nonhypo-A), as a secondary analysis. Diagnostic cut-off level of Hypo-A (< 2.8 mg/dl) was determined using the ROC curve between blood albumin and mortality. In Hypo-G group (n = 40), APACHE II/SOFA scores are significantly higher than in the Inter-G (n = 196) and Hyper-G groups (n = 100). Mortality is 52.5% in the Hypo-G and 60.0% in the Hypo-G with Hypo-A (Hypo-G + Hypo-A) groups. Significantly higher APACHE II or SOFA scores and mortality are observed in the Hypo-G + Hypo-A group compared to the Inter-G + Nonhypo-A group. A higher mortality risk is observed in cases with Hypo-G + Hypo-A (OR 5.065) than those with Hypo-G (OR 3.503), Inter-G (OR 1.175), Hyper-G (OR 1.756) or Hypo-A (OR 3.243), calculated by a single logistic-regression analysis. Hypo-G + Hypo-A in patients with sepsis is related to higher ICU mortality. Physicians should be keenly aware of these conditions to provide immediate intensive treatment after admission of septic patients.

Antibiotics has more impact on mortality than other early goal-directed therapy components in patients with sepsis: An instrumental variable analysis

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.

Importance of Markers of Sepsis in Surgical Patients

Sepsis, severe sepsis, and septic shock represent a serious medicinal and general social problem and still maintain an important position among the present issues in the basic and clinical research. In the prospective analysis of patients satisfying the criteria of septic condition, we determined serum levels of bioparameters in three consecutive days from the first signs of sepsis depending on the stage or advancement of the septic condition. We determined the most significant parameter/parameters which are able to determine the stage of sepsis or to predict patient's death. In the group of 68 patients, all monitored biomarkers showed significant difference in serum concentrations versus the control group (P = 0.001). The strongest positive connection between the seriousness of sepsis and serum level is in case of procalcitonin. Predictor of mortality (r = -0.468; P = 0.001), transferrin (r = -0.506; P = 0.003), and tumor necrosis factor-α (r = 0.939; P = 0.001). Our results show that the monitored parameters (procalcitonin, C-reactive protein, tumor necrosis factor-a, and interleukin 6) have strong correlations between the serum levels and the stage of disease. Examination of at least one cytokine in normal clinical practice might lead to better interpretation of the patient's condition, determining the risk of death.

Heart Rate Variability Measurement in Sepsis Patients

Objectives

Inflammation makes an influence on autonomic nervous system and a change in autonomic nervous activity affects heart rate. Heart rate variability (HRV) test can quantify the autonomous nervous activity. In this study, we evaluated the meaning of heart rate variability in sepsis patients.

Methods

Heart rate variability test was performed for sepsis patients and healthy volunteers. Normalised low frequency power, reflecting sympathetic activity, was compared to acute physiology and chronic health evaluation II (APACHE II) score and mortality in emergency department sepsis (MEDS) score in sepsis patients. Then the patients were divided into four groups: 1) severe sepsis patients, 2) sepsis patients admitted to general ward, 3) sepsis patients discharged within 24 hours and 4) healthy volunteers. We obtained averages for the HRV results in all four groups. The receiver operating characteristics curve was examined to determine whether or not HRV variables could be used to triage sepsis patients.

Results

Correlations between normalised low frequency power (LFnu) with APACHE II score and MEDS score were −0.595 and −0.514, respectively. Low frequency power (LF) and LFnu values decreased in sepsis patients with the higher scores observed in the discharged sepsis patients and healthy volunteers. The areas under the curve for the values of LF and LFnu in the admission and discharge groups were 0.746 and 0.635, respectively (p<0.05).

Conclusion

Variables related to heart rate variability are significantly correlated with the severity of sepsis patients. Although the HRV test alone cannot accurately predict the disposition of sepsis patients, in the emergency room setting it helps to assign beds to sepsis patients within the triage system, and avoid over-population. (Hong Kong j.emerg.med. 2014;21:73-79)

Stakeholder-Driven Quality Improvement: A Compelling Force for Clinical Practice Guidelines

Clinical practice guideline development should be driven by rigorous methodology, but what is less clear is where quality improvement enters the process: should it be a priority-guiding force, or should it enter only after recommendations are formulated? We argue for a stakeholder-driven approach to guideline development, with an overriding goal of quality improvement based on stakeholder perceptions of needs, uncertainties, and knowledge gaps. In contrast, the widely used topic-driven approach, which often makes recommendations based only on randomized controlled trials, is driven by epidemiologic purity and evidence rigor, with quality improvement a downstream consideration. The advantages of a stakeholder-driven versus a topic-driven approach are highlighted by comparisons of guidelines for otitis media with effusion, thyroid nodules, sepsis, and acute bacterial rhinosinusitis. These comparisons show that stakeholder-driven guidelines are more likely to address the quality improvement needs and pressing concerns of clinicians and patients, including understudied populations and patients with multiple chronic conditions. Conversely, a topic-driven approach often addresses “typical” patients, based on research that may not reflect the needs of high-risk groups excluded from studies because of ethical issues or a desire for purity of research design.

Sepsis and Septic Shock Strategies

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.

Sonographic assessment of volaemia: development and validation of a new method in dogs

OBJECTIVES

The aims of this study were to describe a method for the sonographic assessment of volaemia, to determinate inter- and intra-operator variability and to assess the ability to detect blood loss after blood donation in healthy dogs.

MATERIALS AND METHODS

The left kidney was identified in a spleno-renal view, and transverse views of the caudal vena cava and aorta were obtained in 12 dogs. Vessel diameters were measured in B-mode, in duplicate by two operators, and the caudal vena cava:aorta ratio was calculated. Intra- and inter-operator variabilities were assessed using a Bland-Altman method by plotting the differences between the repeated measurements obtained from the same subject by the same operator and by the two operators against their means. Before and after blood donation measurements were compared using paired t-tests or one-sample t-tests, if appropriate.

RESULTS

Intra- and inter-operator variability was within the limit of agreement for the vast majority of measurements. After a blood donation of 9·8 ±2·2 mL/kg, the mean aorta measurements were not significantly different from those obtained before blood donation (1·11 versus 1·10, P=0·28), whereas the mean caudal vena cava measurements and caudal vena cava:aorta ratios were significantly lower (1·28 versus 1·01, P<0·0001; 1·17 versus 1·01, P=0·0001, respectively).

CLINICAL SIGNIFICANCE

The low intra- and inter-operator variabilities in the caudal vena cava, aorta and caudal vena cava:aorta ratio measurements support their reliability and operator independency. The sonographic assessment of volaemia appears to be a promising non-invasive, repeatable point-of-care ultrasound protocol for assessment and monitoring of blood loss. Further studies are needed to assess the sonographic assessment of volaemia protocol in spontaneously bleeding dogs.

The effect of early goal-directed therapy for treatment of severe sepsis or septic shock: A systemic review and meta-analysis

PURPOSE

To assess the effects of early goal-directed therapy (EGDT) on reducing mortality compared with conventional management of severe sepsis or septic shock.

MATERIALS AND METHODS

We included a systemic review, using the Medline and EMBASE. Seventeen randomized trials with 5765 patients comparing EGDT with usual care were included.

RESULTS

There were no significant differences in mortality between EGDT and control groups (relative risk [RR], 0.89; 95% confidence interval [CI], 0.79-1.00), with moderate heterogeneity (I2=56%). The EGDT was associated with lower mortality rates when the mortality rate of the usual care group was greater than 30% (12 trials; RR, 0.83; 95% CI, 0.72-0.96), but not when the mortality rate in the usual care group was less than 30% (5 trials; RR, 1.03; 95% CI, 0.92-1.16). The mortality benefit was seen only in subgroup of population analyzed between publication of the 2004 and 2012 Surviving Sepsis Campaign guidelines, but not before and after these publications.

CONCLUSION

This meta-analysis was heavily influenced by the recent addition of the trio of trials published after 2014. The results of the recent trio of trials may be biased due to methodological issues. This includes lack of blinding by incorporating similar diagnostic and therapeutic interventions as the original EGDT trial.

The haemodynamic dilemma in emergency care: Is fluid responsiveness the answer? A systematic review

BACKGROUND

Fluid therapy is a common and crucial treatment in the emergency department (ED). While fluid responsiveness seems to be a promising method to titrate fluid therapy, the evidence for its value in ED is unclear. We aim to synthesise the existing literature investigating fluid responsiveness in ED.

METHODS

MEDLINE, Embase and the Cochrane library were searched for relevant peer-reviewed studies published from 1946 to present.

RESULTS

A total of 249 publications were retrieved of which 22 studies underwent full-text review and eight relevant studies were identified. Only 3 studies addressed clinical outcomes - including 2 randomised controlled trials and one feasibility study. Five articles evaluated the diagnostic accuracy of fluid responsiveness techniques in ED. Due to marked heterogeneity, it was not possible to combine results in a meta-analysis.

CONCLUSION

High quality, adequately powered outcome studies are still lacking, so the place of fluid responsiveness in ED remains undefined. Future studies should have standardisation of patient groups, the target response and the underpinning theoretic concept of fluid responsiveness. The value of a fluid responsiveness based fluid resuscitation protocol needs to be established in a clinical trial.

Surgical Critical Care for the Patient with Sepsis and Multiple Organ Dysfunction

Sepsis and multiple organ dysfunction syndrome (MODS) is common in the surgical intensive care unit. Sepsis involves infection and the patient's immune response. Timely recognition of sepsis and swift application of evidence-based interventions is critical to the success of therapy. This article reviews the nature of the septic process, existing definitions of sepsis, and current evidence-based treatment strategies for sepsis and MODS. An improved understanding of the process of sepsis and its relation to MODS has resulted in clinical definitions and scoring systems that allow for the quantification of disease severity and guidelines for treatment.

Early sepsis bundle compliance for non-hypotensive patients with intermediate versus severe hyperlactemia

OBJECTIVE

To compare the association of 3-h sepsis bundle compliance with hospital mortality in non-hypotensive sepsis patients with intermediate versus severe hyperlactemia.

METHODS

This was a cohort study of all non-hypotensive, hyperlactemic sepsis patients captured in a prospective quality-improvement database, treated October 2014 to September 2015 at five tertiary-care centers. We defined sepsis as 1) infection, 2) ≥2 SIRS criteria, and 3) ≥1 organ dysfunction criterion. "Time-zero" was the first time a patient met all sepsis criteria.

INCLUSION CRITERIA

systolic blood pressure>90 mmHg, mean arterial pressure>65 mmHg, and serum lactate≥2.2 mmol/L. Primary exposures: 1) intermediate(2.2-3.9 mmol/L) versus severe(≥4.0 mmol/L) hyperlactemia and 2) full 3-h bundle compliance. Bundle elements: The primary outcome was 60-day in-hospital mortality.

RESULTS

2417 patients met inclusion criteria. 704(29%) had lactate≥4.0 mmol/L versus 1775 patients with lactate 2.2-3.9 mmol/L. Compliance was 75% for antibiotics and 53% for fluids. Full-compliance was comparable between lactate groups (n=200(29%) and 488(28%), respectively). We observed 424(17.5%) mortalities: intermediate/non-compliant - 182(14.9%), intermediate/compliant - 41(8.4%), severe/non-compliant - 147(29.2%), severe/compliant - 54(27.0%) [difference-of-differences=4.3%, CI=2.6-5.9%]. In multivariable regression, mortality predictors included severe hyperlactemia (OR=1.99, CI=1.51-2.63) and bundle compliance (OR=0.62, CI=0.42-0.90), and their interaction was significant: p_{(interaction)}=0.022.

CONCLUSION

We observed a significant interaction between 3-h bundle compliance and initial hyperlactemia. Bundle compliance may be associated with greater mortality benefit for non-hypotensive sepsis patients with less severe hyperlactemia.

Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients

Early aggressive hemodynamic resuscitation using elevated plasma lactate as a marker is an essential component of managing critically ill patients. Therefore, measurement of blood lactate is recommended to stratify patients based on the need for fluid resuscitation and the risks of multiple organ dysfunction syndrome and death. Hyperlactatemia is common among critically ill patients, and lactate levels and their trend may be reliable markers of illness severity and mortality. Although hyperlactatemia has been widely recognized as a marker of tissue hypoxia/hypoperfusion, it can also result from increased or accelerated aerobic glycolysis during the stress response. Additionally, lactate may represent an important energy source for patients in critical condition. Despite its inherent complexity, the current simplified view of hyperlactatemia is that it reflects the presence of global tissue hypoxia/hypoperfusion with anaerobic glycolysis. This review of hyperlactatemia in critically ill patients focuses on its pathophysiological aspects and recent clinical approaches. Hyperlactatemia in critically ill patients must be considered to be related to tissue hypoxia/hypoperfusion. Therefore, appropriate hemodynamic resuscitation is required to correct the pathological condition immediately. However, hyperlactatemia can also result from aerobic glycolysis, unrelated to tissue dysoxia, which is unlikely to respond to increases in systemic oxygen delivery. Because hyperlactatemia may be simultaneously related to, and unrelated to, tissue hypoxia, physicians should recognize that resuscitation to normalize plasma lactate levels could be over-resuscitation and may worsen the physiological status. Lactate is a reliable indicator of sepsis severity and a marker of resuscitation; however, it is an unreliable marker of tissue hypoxia/hypoperfusion.

Diarrhoea in the critically ill is common, associated with poor outcome, and rarely due to Clostridium difficile

Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15–38%. Many factors may cause diarrhoea, including Clostridium difficile, drugs (e.g. laxatives, antibiotics) and enteral feeds. Diarrhoea impacts on patient dignity, increases nursing workload and healthcare costs, and exacerbates morbidity through dermal injury, impaired enteral uptake and subsequent fluid imbalance. We analysed a cohort of 9331 consecutive patients admitted to a mixed general intensive care unit to establish the prevalence of diarrhoea in intensive care unit patients, and its relationship with infective aetiology and clinical outcomes. We provide evidence that diarrhoea is common (12.9% (1207/9331) prevalence) in critically ill patients, independently associated with increased intensive care unit length of stay (mean (standard error) 14.8 (0.26) vs 3.2 (0.09) days, p < 0.001) and mortality (22.0% (265/1207) vs 8.7% (705/8124), p < 0.001; adjusted hazard ratio 1.99 (95% CI 1.70–2.32), p < 0.001) compared to patients without diarrhoea even after adjusting for potential confounding factors, and infrequently caused by infective aetiology (112/1207 (9.2%)) such as Clostridium difficile (97/1048 (9.3%) tested) or virological causes (9/172 (5.7%) tested). Our findings suggest non-infective causes of diarrhoea in ICU predominate and pathophysiology of diarrhoea in critically ill patients warrants further investigation.

Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay

STUDY OBJECTIVE

We evaluate the association of intravenous fluid resuscitation initiation within 30 minutes of severe sepsis or septic shock identification in the emergency department (ED) with inhospital mortality and hospital length of stay. We also compare intravenous fluid resuscitation initiated at various times from severe sepsis or septic shock identification's association with the same outcomes.

METHODS

This was a review of a prospective, observational cohort of all ED severe sepsis or septic shock patients during 13 months, captured in a performance improvement database at a single, urban, tertiary care facility (90,000 ED visits/year). The primary exposure was initiation of a crystalloid bolus at 30 mL/kg within 30 minutes of severe sepsis or septic shock identification. Secondary analysis compared intravenous fluid initiated within 30, 31 to 60, or 61 to 180 minutes, or when intravenous fluid resuscitation was initiated at greater than 180 minutes or not provided.

RESULTS

Of 1,866 subjects, 53.6% were men, 72.5% were white, mean age was 72 years (SD 16.6 years), and mean initial lactate level was 2.8 mmol/L. Eighty-six percent of subjects were administered intravenous antibiotics within 180 minutes; 1,193 (64%) had intravenous fluid initiated within 30 minutes. Mortality was lower in the within 30 minutes group (159 [13.3%] versus 123 [18.3%]; 95% confidence interval [CI] 1.4% to 8.5%), as was median hospital length of stay (6 days [95% CI 6 to 7] versus 7 days [95% CI 7 to 8]). In multivariate regression that included adjustment for age, lactate, hypotension, acute organ dysfunction, and Emergency Severity Index score, intravenous fluid within 30 minutes was associated with lower mortality (odds ratio 0.63; 95% CI 0.46 to 0.86) and 12% shorter length of stay (hazard ratio=1.14; 95% CI 1.02 to 1.27). In secondary analysis, mortality increased with later intravenous fluid resuscitation initiation: 13.3% (≤30 minutes) versus 16.0% (31 to 60 minutes) versus 16.9% (61 to 180 minutes) versus 19.7% (>180 minutes). Median hospital length of stay also increased with later intravenous fluid initiation: 6 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 8 days) versus 8 days (95% CI 7 to 9 days).

CONCLUSION

The time of intravenous fluid resuscitation initiation was associated with improved mortality and could be used as an easier obtained alternative to intravenous fluid completion time as a performance indicator in severe sepsis and septic shock management.

Goal-Directed Resuscitation in Septic Shock: A Critical Analysis

The Early Goal-Directed Therapy versus Standard Care for Sepsis trial by Rivers and colleagues in 2001 suggested that a significant mortality reduction may be realized through goal-directed interventions early in the care of patients with septic shock. However, the recent publication of the Protocol-Based Care for Early Septic Shock (ProCESS), Australasian Resuscitation in Sepsis Evaluation (ARISE), and Protocolised Management in Sepsis (ProMISE) trials did not demonstrate the superiority of early goal-directed therapy over usual care. If usual care includes timely and meticulous care, a protocol may not be needed to realize the continued lowering mortality rates.

Sepsis-associated pulmonary complications in emergency department patients monitored with serial lactate: An observational cohort study

PURPOSE

Patients with severe sepsis and septic shock are at high risk for development of pulmonary complications, including acute respiratory distress syndrome (ARDS). Serial lactate monitoring is a useful tool to gauge global tissue hypoxia in emergency department (ED) patients with sepsis. We hypothesized that patients undergoing serial lactate monitoring (SL) would demonstrate a decreased incidence of pulmonary complications.

METHODS

This is a retrospective observational cohort study of adult severe sepsis and septic shock patients with elevated lactate presenting to a large academic ED. A total of 243 patients were assigned to SL (n=132) or no serial lactate monitoring (NL; n=111). The primary outcome was a composite of pulmonary complications: (1) ARDS development and (2) respiratory failure.

RESULTS

Twenty-eight patients (21%) in the SL group and 37 patients (33%) in the NL group developed the primary outcome (P=.03). Multivariate analysis demonstrated an association between the NL group and development of pulmonary complications (adjusted odds ratio [aOR], 2.1; confidence interval [CI], 1.15-3.78). Emergency department mechanical ventilation was independently associated with development of ARDS (aOR, 3.5; 1.8-7.0). In the a priori subgroup of patients mechanically ventilated in the ED (n=97), those who developed ARDS received higher tidal volumes compared to patients who did not develop ARDS (8.7 mL/kg predicted body weight [interquartile range, 7.6-9.5] vs 7.6 [interquartile range, 6.8-9.0]; P<.01).

CONCLUSIONS

Serial lactate monitoring is associated with a decrease in major pulmonary complications in severe sepsis and septic shock. Acute respiratory distress syndrome incidence is also influenced by ED-based mechanical ventilation. These results provide 2 potentially modifiable variables to be targeted in future studies to prevent pulmonary complications in this patient subset.

The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis

OBJECTIVES

We sought to systematically review and meta-analyze the available data on the association between timing of antibiotic administration and mortality in severe sepsis and septic shock.

DATA SOURCES

A comprehensive search criteria was performed using a predefined protocol.

STUDY SELECTION

INCLUSION CRITERIA

adult patients with severe sepsis or septic shock, reported time to antibiotic administration in relation to emergency department triage and/or shock recognition, and mortality.

EXCLUSION CRITERIA

immunosuppressed populations, review article, editorial, or nonhuman studies.

DATA EXTRACTION

Two reviewers screened abstracts with a third reviewer arbitrating. The effect of time to antibiotic administration on mortality was based on current guideline recommendations: 1) administration within 3 hours of emergency department triage and 2) administration within 1 hour of severe sepsis/septic shock recognition. Odds ratios were calculated using a random effect model. The primary outcome was mortality.

DATA SYNTHESIS

A total of 1,123 publications were identified and 11 were included in the analysis. Among the 11 included studies, 16,178 patients were evaluable for antibiotic administration from emergency department triage. Patients who received antibiotics more than 3 hours after emergency department triage (< 3 hr reference) had a pooled odds ratio for mortality of 1.16 (0.92-1.46; p = 0.21). A total of 11,017 patients were evaluable for antibiotic administration from severe sepsis/septic shock recognition. Patients who received antibiotics more than 1 hour after severe sepsis/shock recognition (< 1 hr reference) had a pooled odds ratio for mortality of 1.46 (0.89-2.40; p = 0.13). There was no increased mortality in the pooled odds ratios for each hourly delay from less than 1 to more than 5 hours in antibiotic administration from severe sepsis/shock recognition.

CONCLUSION

Using the available pooled data, we found no significant mortality benefit of administering antibiotics within 3 hours of emergency department triage or within 1 hour of shock recognition in severe sepsis and septic shock. These results suggest that currently recommended timing metrics as measures of quality of care are not supported by the available evidence.

Utilizing Geographic Information Systems to Identify Clusters of Severe Sepsis Patients Presenting in the Out-of-Hospital Environment

Understanding the geographic distribution of critical illness within a community may provide public health stakeholders with information that can be used to expedite access to specialized care. We hypothesized that severe sepsis patients transported by emergency medical services (EMS) exhibit geospatial clustering and that prehospital providers would recognize sepsis more frequently in patients transported from sepsis clusters. Retrospective review of a prospective, observational study of patients with severe sepsis transported to the emergency department (ED) by EMS and treated with early goal-directed therapy (EGDT).

INCLUSION CRITERIA

suspected infection, 2 or more criteria for systemic inflammation, and either systolic blood pressure <90 mmHg after a fluid bolus or lactate >4 mmol/liter.

EXCLUSION CRITERIA

age <18 or need for immediate surgery. Patient location at the time of EMS activation was recorded. Analysis of the addresses identified clusters, defined as a location in which EMS transported more than one patient experiencing the above associated signs and symptoms of septic shock. Other data collected included self-reported patient location as private residence or chronic care facility. One hundred sixty severe sepsis patients transported by EMS were eligible for analysis, presenting from 125 locations. Ninety-one patients (57%) presented from a private residence and 69 (37%) from a chronic care facility. Fifty (31%) patients were transported from 15 locations, with 25 of those transported from just 4 locations. Cluster patients tended to be older, come from medical facilities, and were more likely to have sepsis recognized by prehospital providers. Results from this study demonstrate low pre-hospital recognition of sepsis, as well as geospatially clustered presentations, most notably from skilled nursing facilities. Community education, public health initiatives, and EMS interventions could be targeted in such clusters of cases in order to both improve sepsis recognition and potentially expedite time-sensitive interventions.

The end of early-goal directed therapy?

Emergency medicine practitioners around the world have been confronted with the increasing challenge of managing patients in severe sepsis and septic shock. Introduction of early goal-directed therapy (EGDT) revolutionized sepsis care and was adopted worldwide. Since then, multiple randomized controlled trials have been published questioning the superiority of EGDT. The purpose of this article is to review and provide clinical commentary on the ProCESS, ARISE, and ProMISE trials, which address whether invasive, expensive interventions are needed to achieve mortality reduction goals in septic patients. This article discusses that EGDT bundled care is not necessary to achieve mortality reduction goals.

An Electronic Tool for the Evaluation and Treatment of Sepsis in the ICU: A Randomized Controlled Trial

OBJECTIVES

To determine whether addition of an electronic sepsis evaluation and management tool to electronic sepsis alerting improves compliance with treatment guidelines and clinical outcomes in septic ICU patients.

DESIGN

A pragmatic randomized trial.

SETTING

Medical and surgical ICUs of an academic, tertiary care medical center.

PATIENTS

Four hundred and seven patients admitted during a 4-month period to the medical or surgical ICU with a diagnosis of sepsis established at the time of admission or in response to an electronic sepsis alert.

INTERVENTIONS

Patients were randomized to usual care or the availability of an electronic tool capable of importing, synthesizing, and displaying sepsis-related data from the medical record, using logic rules to offer individualized evaluations of sepsis severity and response to therapy, informing users about evidence-based guidelines, and facilitating rapid order entry.

MEASUREMENTS AND MAIN RESULTS

There was no difference between the electronic tool (218 patients) and usual care (189 patients) with regard to the primary outcome of time to completion of all indicated Surviving Sepsis Campaign 6-hour Sepsis Resuscitation Bundle elements (hazard ratio, 1.98; 95% CI, 0.75-5.20; p = 0.159) or time to completion of each element individually. ICU mortality, ICU-free days, and ventilator-free days did not differ between intervention and control. Providers used the tool to enter orders in only 28% of available cases.

CONCLUSIONS

A comprehensive electronic sepsis evaluation and management tool is feasible and safe but did not influence guideline compliance or clinical outcomes, perhaps due to low utilization.

Lactate as a hemodynamic marker in the critically ill

PURPOSE OF REVIEW

An early quantitative resuscitation strategy improves outcome in critically ill patients. The hemodynamic endpoints of such a strategy have been a topic of debate in the literature. This review focuses on the use of lactate as a marker for risk stratification, lactate clearance as a hemodynamic endpoint, and its use compared to mixed venous oxygenation as a resuscitation goal.

RECENT FINDINGS

Lactate clearance is associated with improved outcome across several cohorts of critically ill patients. Lactate levels and central venous oxygen saturations are frequently discordant. Targeting lactate clearance as part of a quantitative resuscitation strategy may be as effective as targeting central venous oxygen saturation.

SUMMARY

Resuscitation of the critically ill patient should be aimed at the reversal of tissue hypoxia. The use of lactate as a hemodynamic marker and resuscitation endpoint makes physiologic sense, and is supported by the recent data. The use of lactate clearance versus other traditional endpoints of resuscitation, such as mixed venous oxygen saturation, should be based on the clinical characteristics and response of the individual patient.

[Septic shock in intensive care units. Current focus on treatment]

Essential therapeutic principles in children with septic shock persist over time, although some new concepts have been recently incorporated, and fully awareness of pediatricians and intensivists is essential. Fluid resuscitation is a fundamental intervention, but the kind of ideal fluid has not been established yet, as each of these interventions has specific limitations and there is no evidence supportive of the superiority of one type of fluid. Should septic shock persists despite adequate fluid resuscitation, the use of inotropic medication and/or vasopressors is indicated. New vasoactive drugs can be used in refractory septic shock caused by vasopressors, and the use of hydrocortisone should be considered in children with suspected adrenal insufficiency, as it reduces the need for vasopressors. The indications for red blood cells transfusion or the optimal level of glycemia are still controversial, with no consensus on the threshold value for the use of these blood products or the initiation of insulin administration, respectively. Likewise, the use of high-volume hemofiltration is a controversial issue and further study is needed on the routine recommendation in the course of septic shock. Nutritional support is crucial, as malnutrition is a serious complication that should be properly prevented and treated. The aim of this paper is to provide update on the most recent advances as concerns the treatment of septic shock in the pediatric population.

The impact of serial lactate monitoring on emergency department resuscitation interventions and clinical outcomes in severe sepsis and septic shock: an observational cohort study

Monitoring in the setting of critical illness must be linked to beneficial therapy to affect clinical outcome. Elevated serum lactate is associated with an increase in mortality in emergency department (ED) patients with severe sepsis and septic shock. The reduction of lactate levels toward normal during acute resuscitation is associated with improved clinical outcomes. The majority of data demonstrating the interventions used to achieve a reduction in lactate levels and the associated clinical outcomes have been obtained during protocolized randomized trials. We therefore conducted a retrospective observational cohort study of 243 adult patients with severe sepsis and septic shock to assess the interventions associated with nonprotocolized serial lactate monitoring and to assess clinical outcomes. A multivariable model was used to assess outcome differences between the serial lactate (SL) and no serial lactate (NL) cohorts. The SL group received more crystalloid resuscitation (3.6 L vs. 2.5 L; P < 0.01), central venous oxygen saturation monitoring (30% vs. 12%; P < 0.01), and central venous pressure monitoring (23.5% vs. 11.8%; P = 0.02). By day 28, a total of 31 patients in the SL group (23.5%) and 44 in the NL group (39.6%) had died. Multivariable logistic regression analysis demonstrated that the lack of serial lactate monitoring was independently associated with mortality (adjusted odds ratio, 2.09; 95% confidence interval [CI], 1.12 - 3.89; P = 0.02). The SL group also showed greater improvement in 24-h Sequential Organ Failure Assessment scores (1.16 vs. 0.19; P = 0.03), decreased intensive care unit length of stay in days (4.6 vs. 6.0; P = 0.04), and more ventilator-free (19.9 vs. 16; P = 0.05) and vasopressor-free (21.6 vs. 17.9; P = 0.02) days. In the setting of routine clinical care, serial lactate monitoring is associated with an increase in crystalloid administration, resuscitation interventions, and improved clinical outcomes in ED patients with severe sepsis and septic shock. This suggests that serial lactate monitoring, targeting a reduction in lactate levels to normal, is a generalizable resuscitation target in the ED.

Defining goals of resuscitation in the critically ill patient

There is still no "universal" consensus on an optimal endpoint for goal directed therapy (GDT) in the critically ill patient. As in other areas of medicine, this should help providers to focus on a more "individualized approach" rather than a protocolized approach to ensure proper patient care. Hemodynamic optimization needs more than simply blood pressure, heart rate, central venous pressure and urine output monitoring. It is essential to also monitor flow variables (cardiac output/stroke volume) and dynamic parameters of fluid responsiveness whenever available. This article will provide a review of current and trending approaches of the goals of resuscitation in the critically ill patient.

Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database

OBJECTIVE

The Surviving Sepsis Campaign guidelines recommend obtaining a serum lactate measurement within 6 hours of presentation for all patients with suspected severe sepsis or septic shock. A lactate greater than 4 mmol/L qualifies for administration of early quantitative resuscitation therapy. We evaluated lactate elevation (with special attention to values > 4 mmol/L) and presence or absence of hypotension as a marker of clinical outcome.

DESIGN AND SETTING

The Surviving Sepsis Campaign developed a database to assess the overall effect of the sepsis bundles as a performance improvement tool for clinical practice and patient outcome. This analysis focuses on one element of the Surviving Sepsis Campaign's resuscitation bundle, measuring serum lactate in adult severe sepsis or septic shock patients and its interaction with hypotension. This analysis was conducted on data submitted from January 2005 through March 2010.

SUBJECTS

Data from 28,150 subjects at 218 sites were analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Unadjusted analysis of the 28,150 observations from the Surviving Sepsis Campaign database demonstrated a significant mortality increase with the presence of hypotension in conjunction with serum lactate elevation greater than 2 mmol/L. On multivariable analysis, only lactate values greater than 4 mmol/L, in conjunction with hypotension, significantly increased mortality when compared with the referent group of lactate values less than 2 mmol/L and not hypotensive. Mortality was 44.5% in patients with combined lactate greater than 4 mmol/L and hypotension when compared with 29% mortality in patients not meeting either criteria.

CONCLUSIONS

Serum lactate was commonly measured within 6 hours of presentation in the management of severe sepsis or septic shock in this subset analysis of the Surviving Sepsis Campaign database in accordance with the Surviving Sepsis Campaign guidelines. Our results demonstrate that elevated lactate levels are highly associated with in-hospital mortality. However, only patients who presented with lactate values greater than 4 mmol/L, with and without hypotension, are significantly associated with in-hospital mortality and is associated with a significantly higher risk than intermediate levels (2-3 and 3-4 mmol/L). This supports the use of the cutoff of greater than 4 mmol/L as a qualifier for future clinical trials in severe sepsis or septic shock in patient populations who use quantitative resuscitation and the Surviving Sepsis Campaign bundles as standard of care.

Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate

BACKGROUND

Strategies for identifying normotensive patients with acute symptomatic PE at high risk of PE-related complications remain to be defined.

METHODS

This prospective cohort study aimed to determine the role of plasma lactate levels in the risk assessment of normotensive patients with acute PE. Outcomes assessed over the 7 days after the diagnosis of PE included PE-related mortality and haemodynamic collapse, defined as need for cardiopulmonary resuscitation, systolic blood pressure <90 mm Hg for at least 15 min, need for catecholamine administration, or need for mechanical ventilation.

RESULTS

Between December 2012 and January 2014, the study enrolled 496 normotensive outpatients with acute symptomatic PE. PE-related complications occurred in 20 (4.0%; 95% CI 2.5% to 6.2%) of the 496 patients. These patients had higher baseline lactate levels (median 2.66 mmol/L; IQR 1.56-5.96 mmol/L) than patients without complications (1.20 mmol/L; IQR 1.20-2.00 mmol/L) (p<0.001). Overall, 135 patients (27.2%) had plasma lactate ≥2 mmol/L. Fourteen (10.4%) of them had PE-related complications versus 6 of 361 patients with low lactate (negative predictive value 98.3%; p<0.001). Patients with elevated plasma lactate had an increased rate of PE-related complications (adjusted OR 5.3; 95% CI 1.9 to 14.4; p=0.001) compared with those with low lactate. The combination of elevated plasma lactate with markers of right ventricular dysfunction (by echocardiogram) and myocardial injury (by cardiac troponin) was a particularly useful prognostic indicator (positive predictive value 17.9%; 95% CI 6.1% to 36.9%).

CONCLUSIONS

Plasma lactate represents a powerful predictor of short-term PE-related complications and may provide guidance for decision-making in PE care.

The effect of early quantitative resuscitation on organ function in survivors of septic shock

OBJECTIVE

The objective of this study is to determine if early quantitative resuscitation (QR) attenuates organ dysfunction in survivors of septic shock.

METHODS

This is a secondary analysis of a completed implementation study. Inclusion criteria are suspected infection, greater than or equal to 2 systemic inflammatory response syndrome criteria and either systolic blood pressure less than 90 mm Hg after a fluid bolus or lactate more than 4 mmol/L and survival to hospital discharge. Data were prospectively collected on eligible patients for 1 year before and 3 years after implementation of early QR. Patients in the before phase received nonprotocolized care (NPC) at physician discretion. Survivors who received QR were compared with survivors who received NPC. The primary outcome was the worst sequential organ failure assessment (SOFA) score during hospitalization.

RESULTS

Two hundred sixty patients in the QR group and 41 patients in the NPC group were included. There were no significant differences in demographics between the 2 groups. The initial SOFA score in the QR group was 6 and in the NPC group was 6 (P = .17). There was no significant difference in the worst SOFA score during hospitalization between the QR and NPC groups (6 vs 6, respectively; P = .16).

CONCLUSIONS

In survivors of septic shock, we found no difference in maximal organ dysfunction during hospitalization between patients who received QR vs NPC.