Nursing considerations to complement the Surviving Sepsis Campaign guidelines:

Nurses' and Physicians' Experiences After Implementation of a Quality Improvement Project to Improve Sepsis Awareness in Hospitals

Purpose

Previous research has explored nurses´ experience with the implementation of early detection alert systems, and nurses and physicians' perceptions of sepsis management and use of sepsis triage. As one of the first, this study aims to investigate the perceived usefulness of an interdisciplinary quality improvement project including standardized sepsis patient pathway to improve the early identification and treatment of sepsis patients.

Participants and Methods

This study was a qualitative study that employed semi-structured interviews with thirteen ward nurses and five ward physicians recruited by convenience and respondent-driven sampling, respectively. The interviews explored the perceived usefulness of mutual training in sepsis care in medical hospital wards. We applied Systematic Text Condensation to analyze the experiences and knowledge of professional identification and cooperation in early identification of sepsis patients.

Results

The results revealed three main themes: Awareness of sepsis, collaboration between nurses and physicians, and clinical assessment and judgement. The findings highlighted the positive impact of the project in terms of raising awareness, improving communication, and enhancing the ability to detect and treat sepsis. The study also identified the importance of repetition and reminders to maintain awareness, the need for ongoing training for new healthcare professionals, and the challenges of collaboration and decision-making processes.

Conclusion

The sepsis intervention seemed successful in improving awareness of sepsis and enhancing interprofessional collaboration between nurses and physicians. Health professionals continued to rely on their clinical judgment but increased the use of objective measurements and communication of vital signs. Continuous repetition and education for new colleagues were identified as important factors for the sustainability of the intervention. Overall, the study highlights the importance of standardized protocols and training for early detection and management of sepsis in healthcare settings.

Comparison of Efficacy and Psychology of Breast-Conserving Surgery and Modified Radical Mastectomy on Patients with Early Breast Cancer under Graded Nursing

Objective

To compare the efficacy and psychology of breast-conserving surgery and modified radical mastectomy in patients with early breast cancer (BC) under graded nursing.

Methods

Forty-one early breast-conserving surgery BC patients admitted to our hospital from April 2020 to March 2022 were regarded as group A, and 52 with modified radical surgery were seen as group B. The operating time, intraoperative bleeding, postoperative drainage, and hospital stay were compared, and the postoperative adverse effects were counted. In addition, patients' psychology and quality of life were assessed using the HAMD, HAMA, and QLSBC rating scales. At the time of discharge, a treatment satisfaction survey was conducted.

Results

The operative time, intraoperative bleeding, postoperative drainage, and hospital stay of patients in group A were lower than those in group B (P < 0.05). After treatment, the HAMD and HAMA scores were lower in group A than in group B, while the QLSBC scores and treatment satisfaction were higher (P < 0.05).

Conclusion

Breast-conserving surgery under graded nursing is less damaging to early BC patients. It can effectively shorten the postoperative recovery process and improve the psychology and quality of life, so it has higher clinical applicability.

Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study

BACKGROUND

The objective of this study is to describe the epidemiology and age-related mortality in older critically ill adults with intra-abdominal infections.

METHODS

This is a secondary analysis of a prospective, multinational, observational study (AbSeS, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 ICUs in 42 countries (January-December, 2016). Mortality was considered as ICU mortality with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis.

RESULTS

The cohort included 2337 patients. Four age groups were defined: middle-aged patients as reference category (40-59 years; n=659 [28.2%]), young-old (60-69 years; n=622 [26.6%]), middle-old (70-79 years; n=667 [28.5%]) and very-old patients (≥80 years; n=389 [16.6%]). Secondary peritonitis was the predominant infection (68.7%) and equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old, 31.2% in middle-old, and 44.7% in very-old patients (p<0.001). Compared to middle-aged patients, young-old age (OR 1.62, 95% CI 1.21-2.17), middle-old age (OR 1.80, 95% CI 1.35-2.41), and very-old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes, and malnutrition.

CONCLUSIONS

For ICU patients with intra-abdominal infections, age above 60 years was associated with mortality while patients above 80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all these factors are non-modifiable it remains unclear how to improve outcomes.

Exploring nursing and medical perceptions of sepsis management in a New Zealand emergency department: A qualitative study

OBJECTIVE

Early sepsis recognition and treatment are essential in order to reduce the burden of disease. Initial assessment of patients with infection is often undertaken by ED nurses and resident doctors. This descriptive qualitative study aimed to explore their perceptions and perspectives regarding the factors that impede the identification and management of patients with sepsis.

METHODS

This was a qualitative study conducted between 30 January 2020 and 27 February 2020. Semi-structured focus group interviews were performed to collect data. All participants provided written informed consent and completed a basic demographic and work experience form. Two study investigators facilitated the interviews. Interviews were audio-recorded and later transcribed. Thematic analysis was performed with the aid of NVivo 12 software.

RESULTS

Six focus group interviews were conducted involving 40 ED nurses and doctors. Interview length ranged from 27 to 38 min (mean 33.5 min). Three major themes were identified: (i) clinical management; (ii) challenges and delays; and (iii) communication. Each of these themes was broken down into subthemes, which are presented in more detail.

CONCLUSION

ED nurses and doctors have identified important factors that limit and enhance their capacity to recognise and respond to patients with sepsis. Complex interactions exist between clinical and organisational structures that can affect the care of patients and the ability of clinicians to provide optimal care. The three major themes and specific subthemes provide a useful framework and stimulus for service improvements and research that could help foster future sepsis management improvement strategies.

Nursing Care for the Initial Resuscitation of Severe Sepsis Patients

Sepsis is recognized as a major health care problem worldwide. In the United States, mortality from severe sepsis and septic shock remains a serious health problem; yet, the early recognition of sepsis by nurses reduces can reduce mortality, morbidity, and long-term consequences of sepsis for patients. Improving the knowledge of nurses to first recognize the early signs of sepsis and then how to apply the most up-to-date evidence-based treatments can improve outcomes. Enhanced monitoring includes the use of computerized early warning systems to alert nurses of worrisome clinical patterns and promote the early recognition of sepsis.

Antimicrobial properties of olive oil phenolic compounds and their regenerative capacity towards fibroblast cells

Some micronutrients of vegetable origin are considered potentially useful as wound-healing agents because they can increase fibroblast proliferation and differentiation.

THE AIM OF THIS STUDY

was to evaluate the regenerative effects of selected olive oil phenolic compounds on cultured human fibroblasts and explore their antimicrobial properties.

MATERIAL AND METHODS

The CCD-1064Sk fibroblast line was treated for 24 h with 10^-6M luteolin, apigenin, ferulic, coumaric acid or caffeic acid, evaluating the effects on cell proliferation by using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) spectrophotometric assay; the migratory capacity by the scratch assay and determining the expression of Fibroblast Growth Factor (FGF), Vascular Endothelial Growth Factor (VEGF), Transforming Growth Factor- β1 (TGFβ1), Platelet Derived Growth Factor (PDGF), and Collagen Type I (COL-I) genes by real-time polymerase chain reaction. The antimicrobial capacity of the polyphenols was evaluated by the disc diffusion method.

RESULTS

All compounds except for ferulic acid significantly stimulated the proliferative capacity of fibroblasts, increasing their migration and their expression of the aforementioned genes. With respect to their antimicrobial properties, treatment with the studied compounds inhibited the growth of Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Proteus spp., and Candida Albicans.

CONCLUSIONS

The phenolic compounds in olive oil have a biostimulatory effect on the regeneration capacity, differentiation, and migration of fibroblasts and exert major antibacterial activity. According to the present findings, these compounds may have a strong therapeutic effect on wound recovery.

Knowledge, perceptions and experiences of nurses in antimicrobial optimization or stewardship in the intensive care unit

There is an urgent and recognized need for an interprofessional collaborative approach to support global action in addressing antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) refers to systematic approaches for antimicrobial optimization within healthcare organizations. In areas with high antimicrobial utilization such as intensive care units (ICUs), specific roles for nurses in AMS are not clearly defined. This review aimed to identify and to critically evaluate primary studies that examined knowledge, perspectives and experiences of nurses associated with antimicrobial use and optimization in ICUs. A systematic search of Medline, CINAHL, PsychINFO, EMBASE, PubMed, SCOPUS, Cochrane Library and Web of Science databases for primary studies published from 1^st January 2000 to 20^th March 2020 was performed. A convergent synthesis design was used to synthesize quantitative and qualitative data. Of the 898 studies initially screened, 26 were included. Most (18/26) studies were quantitative. All qualitative studies (6/26) were of high methodological quality. Studies where interventions were used (10/26) identified significant potential for ICU nurses to reduce antimicrobial use, time-to-antibiotic administration, and error rates. Barriers to nursing engagement included knowledge deficits in antimicrobial use, interprofessional dissonance and the culture of deference to physicians. Enhancing education, technology utilization, strong nursing leadership and robust organizational structures that support nurses were perceived as enablers to strengthen their roles in optimizing antimicrobial use. This review showed that nursing initiatives have significant potential to strengthen antimicrobial optimization in ICUs. Barriers and enablers to active engagement were identified.

Implementing a quick Sequential (Sepsis-Related) Organ Failure Assessment sepsis screening tool: an interrupted times series study

OBJECTIVE

The aim of this study was to evaluate the outcomes of implementing a sepsis screening (SS) tool based on the quick Sequential [Sepsis-Related] Organ Failure Assessment (qSOFA) and the presence of confirmed/suspected infection. The implementation of the 6-h bundle was also evaluated.

DESIGN

Interrupted times series with prospective data collection.

SETTING

Five hospital wards in a developing nation, Argentina.

PARTICIPANTS

A total of 1151 patients (≥18 years) recruited within 24-48 h of hospital admission.

INTERVENTION

The qSOFA-based SS tool and the 6-h bundle.

MAIN OUTCOME MEASURES

The primary outcome was the timing of implementation of the first 6-h bundle element. Secondary outcomes were related to the adherence to the screening procedures.

RESULTS

Of 1151 patients, 145 (12.6%) met the qSOFA-based SS tool criteria, among them intervention (39/64) patients received the first 6-h bundle element earlier (median 8 h; 95% confidence interval (CI): 0.1-16) than baseline (48/81) patients (median 22 h; 95% CI: 3-41); these times, however, did not differ significantly (P = 0.525). Overall, 47 (4.1%) patients had sepsis; intervention patients (18/25) received the first 6-h bundle element sooner (median 5 h; 95% CI: 4-6) than baseline patients (15/22) did (median 12 h; 95% CI: 0-33); however, times were not significantly different (P = 0.470). While intervention patients were screened regularly, only one-third of patients who required sepsis alerts had them activated.

CONCLUSION

The implementation of the qSOFA-based SS tool resulted in early, but not significantly improved, provision of 6-h bundle care. Screening procedures were regularly conducted, but sepsis alerts rarely activated. Further research is needed to better understand the implementation of sepsis care in developing settings.

Early Recognition of Pediatric Sepsis Simulation Checklist - An Exploratory Study

PURPOSE

To report on the modification and exploration of a 21-item Early Detection of Pediatric Sepsis Assessment Checklist aimed at improving nursing students' recognition of key factors that contribute to early detection of sepsis in pediatric patients through clinical simulation.

DESIGN AND METHODS

One hundred and thirty-one undergraduate, pre-licensure nursing students were evaluated using the adapted 21-item Early Detection of Pediatric Sepsis Assessment Checklist in simulation using high-fidelity manikins. Categorical Principle Component Analysis was used to evaluate for factor structure, with items accounting for <0.20 of the variance were dropped from the loadings.

RESULTS

Two factors emerged from the analysis: assessment and deterioration, accounting for 68% of the variance. Factor one, assessment, contained nine items (α = 0.77; λ = 3.36). Factor two, deterioration, contained seven items (α = 0.72; λ = 2.85). Five items did not load and were dropped from the factor structure, resulting in a 16-item checklist.

CONCLUSIONS

Two factors emerged from the analysis which is key to improving the early detection of pediatric sepsis. Assessment, factor one, accounted for the nursing students' central skills of recognizing baseline vital signs and timely medication administration. Deterioration, factor two, contained items reflecting the recognition of changes from baseline that require action. Conceptually, these factors reflect the most central points in the early detection of signs in pediatric patients at risk for sepsis.

PRACTICE IMPLICATIONS

This checklist forms a valuable tool to assess the knowledge of pre-licensure students and may possibly be extended as a tool to assess the clinical readiness and performance of new graduates through the safety and supervision allotted by simulation.

Emergency nurses' knowledge and understanding of their role in recognising and responding to patients with sepsis: A qualitative study

AIM

Sepsis is a significant and time-sensitive clinical concern for patients who present to Emergency Departments (EDs). Existing guidelines do not define nurses' roles in managing sepsis. This study explored ED nurses' experiences and perceptions around recognising and responding to patients with sepsis, and their awareness of sepsis screening and prognostic tools. The knowledge and insights gained from this study may be used to inform local and international ED policies, and enrich nursing educational packages that may be used to improve quality of patient care and patient outcomes.

METHODS

Qualitative design incorporating semi-structured interviews with 14 ED nurses was undertaken. Thematic and consensus-based content analyses were used to explore transcripts.

FINDINGS

Six key themes were identified; (1) contribution of the organisation, (2) appreciation of knowledge, (3) appreciation of clinical urgency, (4) appreciation of importance of staff supervision, (5) awareness of the importance of staff experience, and (6) awareness of the need to seek advice.

CONCLUSION

ED nurses' identified deficits in their capacity to recognise and respond to patients with sepsis, despite their vital role within the multidisciplinary team that cares for patients with sepsis. The knowledge and insights gained from this study can be used to inform ED policies, to enrich context-specific educational packages that aim to improve quality of patient care and outcomes and identify areas for further research. Development and implementation of a nurse-inclusive sepsis pathway may address many deficits identified in this study.

Hospital Costs Associated with Sepsis Compared with Other Medical Conditions

Sepsis is a condition that has become a main focus for health care organizations owing to the alarming cost of caring for patients, as well as the disturbing mortality rates, that accompany this condition. Sepsis is one of the costliest conditions billed to all payer groups: Medicare, Medicaid, private insurance, and uninsured patients. Health care organizations have implemented multiple strategies and best practices to improve the outcomes of patients with a diagnosis of sepsis.

Telehealth Intensive Care Unit Nurse Surveillance of Sepsis

The purpose of this article is to describe the usability and human factors engineering standards used in development of a sepsis alert known as the sepsis prompt. Sensory processing, cognitive processing, signal detection, criterion response, and user satisfaction were evaluated with controlled user testing and critical incident response techniques. Nurses reported that the sepsis prompt was visible and distinct, making it easily detectable. The prompt provided a clear response mechanism and adequately balanced the number of false alerts with the likelihood of misses. Designers were able to use a mental model approach as they designed the prompt because the nurses were already using a manual sepsis detection process. This may have predisposed the nurses to response bias, and as such, they were willing to accommodate more false alarms than nurses who are not familiar with sepsis screening (surveillance). Nurses not currently screening for sepsis may not place the same value on this alert and find it an annoyance. The sepsis prompt met usability standards, and the nurses reported that it improved efficiency over the manual screening method.

Screening for sepsis in general hospitalized patients: a systematic review

BACKGROUND

Sepsis is a condition widely observed outside critical care areas.

AIM

To examine the application of sepsis screening tools for early recognition of sepsis in general hospitalized patients to: (i) identify the accuracy of these tools; (ii) determine the outcomes associated with their implementation; and (iii) describe the implementation process.

METHODS

A systematic review method was used. PubMed, CINAHL, Cochrane, Scopus, Web of Science, and Embase databases were systematically searched for primary articles, published from January 1990 to June 2016, that investigated screening tools or alert mechanisms for early identification of sepsis in adult general hospitalized patients. The review protocol was registered with PROSPERO (CRD42016042261).

FINDINGS

More than 8000 citations were screened for eligibility after duplicates had been removed. Six articles met the inclusion criteria testing two types of sepsis screening tools. Electronic tools can capture, recognize abnormal variables, and activate an alert in real time. However, accuracy of these tools was inconsistent across studies with only one demonstrating high specificity and sensitivity. Paper-based, nurse-led screening tools appear to be more sensitive in the identification of septic patients but were only studied in small samples and particular populations. The process of care measures appears to be enhanced; however, demonstrating improved outcomes is more challenging. Implementation details are rarely reported. Heterogeneity of studies prevented meta-analysis.

CONCLUSION

Clinicians, researchers and health decision-makers should consider these findings and limitations when implementing screening tools, research or policy on sepsis recognition in general hospitalized patients.

A survey of critical care nurses' practices and perceptions surrounding early intravenous antibiotic initiation during septic shock

BACKGROUND

Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized.

AIM

To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock.

METHODS

A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition.

RESULTS

Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%).

CONCLUSIONS

Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts.

Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival

BACKGROUND

Systemic inflammatory response syndrome (SIRS) and sepsis are now frequently identified by observations of vital signs and detection of organ failure during triage in the emergency room. However, there is less focus on the effect on patient outcome with better observation and treatment at the ward level.

METHODS

This was a before-and-after intervention study in one emergency and community hospital within the Mid-Norway Sepsis Study catchment area. All patients with confirmed bloodstream infection have been prospectively registered continuously since 1994. Severity of sepsis, observation frequency of vital signs, treatment data, length of stay (LOS) in high dependency and intensive care units, and mortality were retrospectively registered from the patients' medical journals.

RESULTS

The post-intervention group (n = 409) were observed better and had higher odds of surviving 30 days (OR 2.7, 95 % CI 1.6, 4.6), lower probability of developing severe organ failure (0.7, 95 % CI 0.4, 0.9), and on average, 3.7 days (95 % CI 1.5, 5.9 days) shorter LOS than the pre-intervention group (n = 472).

CONCLUSIONS

In a cohort with stable mortality rates, early sepsis recognition by ward nurses may have reduced progression of disease and improved survival for patients in hospital with sepsis.

Essentials of sepsis management

Despite remarkable advances in the knowledge of infection and human response to it, sepsis continues to be one of the most common challenges surgeons and critical care providers face. Surgeons confront the problem of infection every day, in treating established infections or reacting to a consequence of surgical intervention. Infections after surgery continue to be a problem despite massive efforts to prevent them. Patients rely on the surgeon's ability to recognize infection and treat it. Also, preventing nosocomial infection and antibiotic resistance is a primary responsibility. This article describes diagnostic and therapeutic measures for sepsis in the perioperative surgical patient.

Effectiveness of platelet-rich plasma and hyaluronic acid for the treatment and care of pressure ulcers

Platelet-rich growth factor (PRGF) is a natural source of growth factors (GF), while hyaluronic acid (HA) is a biopolymer present in the extracellular matrix of skin, cartilage, bone, and brain, among other tissues. Both are involved in the pathophysiological mechanisms underlying wound healing. The objective of this study was to evaluate the clinical efficacy (as measured by ulcer area) and safety (as measured by signs of infection) of PRGF and PRGF plus HA in the treatment of pressure ulcers (PUs). Patients (N = 100) with 124 Stage II-III PUs were randomized to a control group (n = 25 PUs) for standard care or to case groups for treatment with one (n = 34 PUs) or two (n = 25 PUs) doses of PRGF from their own peripheral blood, or two doses of PRGF plus HA (n = 40 PUs). All ulcers were followed up every 3 days for a 36-day period. At 36 days, a significant reduction in ulcer area (p ≤ .001) was observed in all treatment groups, with a mean reduction of more than 48.0% versus baseline. The greatest mean reduction (80.4% vs. baseline) was obtained with the PRGF plus HA regimen. Complete wound healing was observed in 32.0% of PUs treated with two doses of PRGF (p ≤ .002) and in 37.5% of those treated with two doses of PRGF plus HA (p ≤ .004). There were no signs of infection in any PUs during the 36-day follow-up period. The degree of wound healing was inversely correlated with the consumption of drugs such as statins and with the peripheral blood platelet levels of patients at baseline.

The influence of acute kidney injury on antimicrobial dosing in critically ill patients: are dose reductions always necessary?

Optimal dosing of antimicrobial therapy is pivotal to increase the likelihood of survival in critically ill patients with sepsis. Drug exposure that maximizes bacterial killing, minimizes the development of antimicrobial resistance, and avoids concentration-related toxicities should be considered the target of therapy. However, antimicrobial dosing is problematic as pathophysiological factors inherent to sepsis that alter may result in reduced concentrations. Alternatively, sepsis may evolve to multiple-organ dysfunction including acute kidney injury (AKI). In this case, decreased clearance of renally cleared drugs is possible, which may lead to increased concentrations that may cause drug toxicities. Consequently, when dosing antibiotics in septic patients with AKI, one should consider factors that may lead to underdosing and overdosing. Drug-specific pharmacokinetic and pharmacodynamic data may be helpful to guide dosing in these circumstances. Yet, because of the high interpatient variability in pharmacokinetics of antibiotics during sepsis, this issue remains a significant challenge.

Insights and advances in multidisciplinary critical care: a review of recent research

The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatric sepsis: preparing for the future against a global scourge

Sepsis is a leading cause of morbidity and mortality among children worldwide. As consensus statements emerge regarding early recognition and goal-directed management of sepsis, scrutiny should be given to the unique characteristics of sepsis in children. Pediatric patients are not small adults! Sepsis epidemiology, pathophysiology, and management strategy can vary significantly from those for adults. Herein, we describe the epidemiology of pediatric sepsis, in both resource-rich and resource-poor worlds, and discuss how the pathophysiology of pediatric sepsis differs from that for adults. We discuss the timeline of management of pediatric sepsis, studying how discoveries over the past 50 years have changed the way sepsis is treated. Finally, we discuss the future of pediatric sepsis. We focus on approaches that carry the most substantive impact on the global burden of disease.

Early detection and treatment of severe sepsis in the emergency department: identifying barriers to implementation of a protocol-based approach

INTRODUCTION

Despite evidence to support efficacy of early goal-directed therapy for resuscitation of patients with severe sepsis and septic shock in the emergency department, implementation remains incomplete. To identify and address specific barriers at our institution and maximize benefits of a planned sepsis treatment initiative, a baseline assessment of knowledge, attitudes, and behaviors regarding detection and treatment of severe sepsis was performed.

METHODS

An online survey was offered to nurses and physicians in the emergency department of a major urban academic medical center. The questionnaire was designed to assess (1) baseline knowledge and self-reported confidence in identification of systemic inflammatory response syndrome and sepsis; (2) current practices in treatment; (3) difficulties encountered in managing sepsis cases; (4) perceived barriers to implementation of a clinical pathway based on early quantitative resuscitation goals; and (5) to elicit suggestions for improvement of sepsis treatment within the department.

RESULTS

Respondents (n = 101) identified barriers to a quantitative resuscitation protocol for sepsis. These barriers included the inability to perform central venous pressure/central venous oxygen saturation monitoring, limited physical space in the emergency department, and lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians; among physicians, a delay in availability of ICU beds and nursing delays were the greatest barriers. Despite these issues, respondents indicated that a written protocol would be helpful to them.

DISCUSSION

Knowledge gaps and procedural hurdles identified by the survey will inform both educational and process components of an initiative to improve sepsis care in the emergency department.

Implementing Sepsis Quality Initiatives in a Multiprofessional Care Model

Studies of acute myocardial infarction, trauma, and stroke have resulted in improved outcomes through earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most critical therapies for these diseases are frequently instituted prior to admission to an ICU. This systems-based approach to the sepsis patient has been lacking. To change this paradigm, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using specific criteria for the early identification of high-risk sepsis patients and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. One decade later, EGDT has been shown to modulate inflammation, decrease the progression of organ failure, improve microcirculatory function, and decrease health resource consumption and mortality. A standard operating procedure beginning with EGDT for severe sepsis and septic shock is a hospital-wide initiative.