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Rossiter A, Hilton JA, Fizza Haider S, Nasser SMT, Boyer N, Cooper C, Davis C, Marshall D, Skelding E, Pike J, Jarratt L, Wood L, Knight L, Holmes S, Cowman T, Shepley E, Dubravac N, Gray W, Munday C, Creagh-Brown B, Forni L. A service evaluation of measuring fluid responsiveness in acutely unwell hypotensive patients outside of critical care. Intensive Crit Care Nurs 2024; 84:103694. [PMID: 38653631 DOI: 10.1016/j.iccn.2024.103694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Early recognition and prompt, appropriate management may reduce mortality in patients with sepsis. The Surviving Sepsis Campaign's guidelines suggest the use of dynamic measurements to guide fluid resuscitation in sepsis; although these methods are rarely employed to monitor cardiac output in response to fluid administration outside intensive care units. This service evaluation investigated the introduction of a nurse led protocolised goal-directed fluid management using a non-invasive cardiac output monitor to the standard assessment of hypotensive ward patients. METHODS We introduced the use of a goal-directed fluid management protocol into our critical care outreach teams' standard clinical assessment. Forty-nine sequential patients before and thirty-nine after its introduction were included in the assessment. RESULTS Patients in the post-intervention cohort received less fluid in the 6 h following outreach assessment (750mls vs 1200mls). There were no differences in clinical background or rates of renal replacement therapy, but rates of invasive and non-invasive ventilation were reduced (0% vs 31%). Although the groups were similar, the post-intervention patients had lower recorded blood pressures. CONCLUSION IV fluid therapy in the patient with hypotension complicating sepsis can be challenging. Excessive IV fluid administration is commonplace and associated with harm, and the use of advanced non-invasive haemodynamic monitoring by trained nurses can provide objective evaluation of individualised response to treatment. Avoiding excessive IV fluid and earlier institution of appropriate vasopressor therapy may improve patient outcomes. IMPLICATIONS FOR CLINICAL PRACTICE Adoption of dynamic measures of cardiac output outside of critical care by trained critical care nurses is feasible and may translate into improved patient outcomes. In hospitals with a nurse-led critical care outreach service, consideration should be given to such an approach.
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Affiliation(s)
- Adam Rossiter
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.
| | - James Anthony Hilton
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Syed M T Nasser
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Naomi Boyer
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Cath Cooper
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Charlene Davis
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | | | - Emma Skelding
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Jennifer Pike
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Laura Jarratt
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Laura Wood
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Lucy Knight
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Sophie Holmes
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Tamsin Cowman
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Elaine Shepley
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | | | - Wendy Gray
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Caz Munday
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Ben Creagh-Brown
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Lui Forni
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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La Via L, Sangiorgio G, Stefani S, Marino A, Nunnari G, Cocuzza S, La Mantia I, Cacopardo B, Stracquadanio S, Spampinato S, Lavalle S, Maniaci A. The Global Burden of Sepsis and Septic Shock. EPIDEMIOLOGIA 2024; 5:456-478. [PMID: 39189251 PMCID: PMC11348270 DOI: 10.3390/epidemiologia5030032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/07/2024] [Accepted: 07/18/2024] [Indexed: 08/28/2024] Open
Abstract
A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.
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Affiliation(s)
- Luigi La Via
- Department of Anaesthesia and Intensive Care, University Hospital Policlinico “G. Rodolico-San Marco”, 24046 Catania, Italy
| | - Giuseppe Sangiorgio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy; (G.S.); (S.S.); (S.S.)
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy; (G.S.); (S.S.); (S.S.)
| | - Andrea Marino
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Giuseppe Nunnari
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Salvatore Cocuzza
- Department of Medical, Surgical Sciences and Advanced Technologies “GF Ingrassia” ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (I.L.M.)
| | - Ignazio La Mantia
- Department of Medical, Surgical Sciences and Advanced Technologies “GF Ingrassia” ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (I.L.M.)
| | - Bruno Cacopardo
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Stefano Stracquadanio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy; (G.S.); (S.S.); (S.S.)
| | - Serena Spampinato
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95123 Catania, Italy; (A.M.); (G.N.); (B.C.); (S.S.)
| | - Salvatore Lavalle
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (S.L.); (A.M.)
| | - Antonino Maniaci
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (S.L.); (A.M.)
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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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Costa-Pinto R, Neto AS, Matthewman MC, Osrin D, Liskaser G, Li J, Young M, Jones D, Udy A, Warrillow S, Bellomo R. Dose equivalence for metaraminol and noradrenaline - A retrospective analysis. J Crit Care 2024; 80:154430. [PMID: 38245376 DOI: 10.1016/j.jcrc.2023.154430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Noradrenaline and metaraminol are commonly used vasopressors in critically ill patients. However, little is known of their dose equivalence. METHODS We conducted a single centre retrospective cohort study of all ICU patients who transitioned from metaraminol to noradrenaline infusions between August 26, 2016 and December 31, 2020. Patients receiving additional vasoactive drug infusion were excluded. Dose equivalence was calculated based on the last hour metaraminol dose (in μg/min) and the first hour noradrenaline dose (in μg/min) with the closest matched mean arterial pressure (MAP). Sensitivity analyses were performed on patients with acute kidney injury (AKI), sepsis and mechanical ventilation. RESULTS We studied 195 patients. The median conversion ratio of metaraminol to noradrenaline was 12.5:1 (IQR 7.5-20.0) for the overall cohort. However, the coefficient of variation was 77% and standard deviation was 11.8. Conversion ratios were unaffected by sepsis or mechanical ventilation but increased (14:1) with AKI. One in five patients had a MAP decrease of >10 mmHg during the transition period from metaraminol to noradrenaline. Post-transition noradrenaline dose (p < 0.001) and AKI (p = 0.045) were independently associated with metaraminol dose. The proportion of variation in noradrenaline dose predicted from metaraminol dose was low (R2 = 0.545). CONCLUSIONS The median dose equivalence for metaraminol and noradrenaline in this study was 12.5:1. However, there was significant variance in dose equivalence, only half the proportion of variation in noradrenaline infusion dose was predicted by metaraminol dose, and conversion-associated hypotension was common.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Dean Osrin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasun Li
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Marcus Young
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Charaya S, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Pattern of Fluid Overload and its Impact on Mortality Among Mechanically Ventilated Children: Secondary Analysis of the ReLiSCh Trial. Indian J Pediatr 2024:10.1007/s12098-024-05059-4. [PMID: 38403808 DOI: 10.1007/s12098-024-05059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To assess the pattern of fluid overload (FO) and its impact on mortality among mechanically ventilated children. METHODS In this secondary analysis of an open-label randomized controlled trial (ReLiSCh trial, October 2020-September 2021), hemodynamically stable mechanically ventilated children (n = 100) admitted to a tertiary level pediatric intensive care unit (PICU) in North India were enrolled. The primary outcome was pattern of FO (FO% >10% and cumulative FO% from day 1-7); and secondary outcomes were pattern of FO among survivors and non-survivors, and prescription practices of maintenance fluid. RESULTS The median (IQR) age was 3.5 (0.85-7.5) y and 57% were males. Common diagnoses were pneumonia (27%), scrub typhus (14%), Landry-Guillain-Barré syndrome (9%), dengue (8%), central nervous system infections (7%) and staphylococcal sepsis (6%). Common organ dysfunction included acute respiratory distress syndrome (ARDS) (41%), shock (38%), and acute kidney injury (AKI) (9%). The duration PICU stay was 11 (7-17) d and mortality was 12%. The FO% >10% was noted in 19% children; and there was significant increase in cumulative FO% from day 1-7 [1.2 (0.2-2.6)% to 8.5 (1.7-14.3)%, (p = 0.000)]. Among non-survivors, higher proportion had FO% >10% (66.7% vs. 12.5%, p 0.0001); and trend towards higher cumulative FO% on first seven days. From day 1-7, the percentage of maintenance fluid received increased from 60 (50-71)% to 70 (60-77)% (p = 0.691). CONCLUSIONS One-fifth of mechanically ventilated children had FO% >10% and there was significant increase in cumulative FO% from day 1-7. Non-survivors had significantly higher degree of FO.
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Affiliation(s)
- Shubham Charaya
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Suresh Kumar Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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Abbott IJ, Peel TN, Cairns KA, Stewardson AJ. Antibiotic management of urinary tract infections in the post-antibiotic era: a narrative review highlighting diagnostic and antimicrobial stewardship. Clin Microbiol Infect 2023; 29:1254-1266. [PMID: 35640839 DOI: 10.1016/j.cmi.2022.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND As one of the most common indications for antimicrobial prescription in the community, the management of urinary tract infections (UTIs) is both complicated by, and a driver of, antimicrobial resistance. OBJECTIVES To highlight the key clinical decisions involved in the diagnosis and treatment of UTIs in adult women, focusing on clinical effectiveness and both diagnostic and antimicrobial stewardship as we approach the post-antimicrobial era. SOURCES Literature reviewed via directed PubMed searches and manual searching of the reference list for included studies to identify key references to respond to the objectives. A strict time limit was not applied. We prioritised recent publications, randomised trials, and systematic reviews (with or without meta-analyses) where available. Searches were limited to English language articles. A formal quality assessment was not performed; however, the strengths and limitations of each paper were reviewed by the authors throughout the preparation of this manuscript. CONTENT We discuss the management of UTIs in ambulatory adult women, with particular focus on uncomplicated infections. We address the diagnosis of UTIs, including the following: definition and categorisation; bedside assessments and point-of-care tests; and the indications for, and use of, laboratory tests. We then discuss the treatment of UTIs, including the following: indications for treatment, antimicrobial sparing approaches, key considerations when selecting a specific antimicrobial agent, specific treatment scenarios, and duration of treatment. We finally outline emerging areas of interest in this field. IMPLICATIONS The steady increase in antimicrobial resistance among common uropathogens has had a substantial affect on the management of UTIs. Regarding both diagnosis and treatment, the clinician must consider both the patient (clinical effectiveness and adverse effects, including collateral damage) and the community more broadly (population-level antimicrobial selection pressure).
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia; Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Abu Sardaneh A, Penm J, Oliver M, Gattas D, Mclachlan A, Patanwala A. Comparison of metaraminol versus no metaraminol on time to resolution of shock in critically ill patients. Eur J Hosp Pharm 2023; 30:214-220. [PMID: 34620686 PMCID: PMC10359804 DOI: 10.1136/ejhpharm-2021-003035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/28/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE There is limited evidence to support metaraminol use in critically ill patients. Metaraminol is not included as a vasopressor choice in international guidelines for the management of shock. Nevertheless, metaraminol is used in rates up to 42% in this patient population. The objective of this study was to investigate the effectiveness of metaraminol for the treatment of critically ill patients with shock. METHODS A single-centre retrospective matched observational study was conducted in a 54-bed intensive care unit of a tertiary hospital. Patients aged 16 years or older who were admitted from 2017 to 2019 with shock were included. Patients treated with metaraminol and norepinephrine (MET-NOR) were compared with those treated with norepinephrine without metaraminol (NOR). The primary outcome was the time to resolution of shock defined as the time to cessation of vasopressors. The secondary outcome was vasopressor-free days until 28 days. RESULTS There were 286 patients included in this study, including 143 patients in each group. The median time to resolution of shock was 44 hours (IQR 28-66 hours) in the MET-NOR group compared with 27 hours (IQR 14-63 hours) in the NOR group (95% CI of median difference 7 to 19 hours; p<0.01). The Cox regression analysis for the time to resolution of shock showed no significant difference between groups (HR 1.24, 95% CI 0.96 to 1.60; p=0.10). However, the proportional hazards assumption was not met (p<0.01). The median number of vasopressor-free days until 28 days was 26 days (IQR 24-27 days) in the MET-NOR group compared with 27 days (IQR 25-27 days) in the NOR group (95% CI of median difference -0.8 to -0.1 day; p<0.01). CONCLUSION In critically ill patients, metaraminol may be associated with a longer time to resolution of shock compared with those who do not receive metaraminol.
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Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Matthew Oliver
- Department of Emergency Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Gattas
- School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Intensive Care Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Andrew Mclachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Asad Patanwala
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Kristine Jessen M, Drescher Petersen A, Kirkegaard H. Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e21. [PMID: 36919142 PMCID: PMC10008217 DOI: 10.22037/aaem.v11i1.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions. Methods The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20th - March 2nd, 2020. Patient groups were "routine-hours" (RH): weekdays 07:00-18:59 or "out-of-hours" (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used. Results 734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis. Conclusion Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.
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Affiliation(s)
- Marie Kristine Jessen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.,Department of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Anna Drescher Petersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.,Department of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
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Abbott IJ, van Gorp E, Cottingham H, Macesic N, Wallis SC, Roberts JA, Meletiadis J, Peleg AY. Oral ciprofloxacin activity against ceftriaxone-resistant Escherichia coli in an in vitro bladder infection model. J Antimicrob Chemother 2022; 78:397-410. [PMID: 36473954 PMCID: PMC9890216 DOI: 10.1093/jac/dkac402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/03/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Pharmacodynamic profiling of oral ciprofloxacin dosing for urinary tract infections caused by ceftriaxone-resistant Escherichia coli isolates with ciprofloxacin MIC ≥ 0.25 mg/L. BACKGROUND Urine-specific breakpoints for ciprofloxacin do not exist. However, high urinary concentrations may promote efficacy in isolates with low-level resistance. METHODS Ceftriaxone-resistant E. coli urinary isolates were screened for ciprofloxacin susceptibility. Fifteen representative strains were selected and tested using a dynamic bladder infection model. Oral ciprofloxacin dosing was simulated over 3 days (250 mg daily, 500 mg daily, 250 mg 12 hourly, 500 mg 12 hourly and 750 mg 12 hourly). The model was run for 96 h. Primary endpoint was change in bacterial density at 72 h. Secondary endpoints were follow-up change in bacterial density at 96 h and area-under-bacterial-kill-curve. Bacterial response was related to exposure (AUC0-24/MIC; Cmax/MIC). PTA was determined using Monte-Carlo simulation. RESULTS Ninety-three clinical isolates demonstrated a trimodal ciprofloxacin MIC distribution (modal MICs at 0.016, 0.25 and 32 mg/L). Fifteen selected clinical isolates (ciprofloxacin MIC 0.25-512 mg/L) had a broad range of quinolone-resistance genes. Following ciprofloxacin exposure, E. coli ATCC 25922 (MIC 0.008 mg/L) was killed in all dosing experiments. Six isolates (MIC ≥ 16 mg/L) regrew in all experiments. Remaining isolates (MIC 0.25-8 mg/L) regrew variably after an initial period of killing, depending on simulated ciprofloxacin dose. A >95% PTA, using AUC0-24/MIC targets, supported 250 mg 12 hourly for susceptible isolates (MIC ≤ 0.25 mg/L). For isolates with MIC ≤ 1 mg/L, 750 mg 12 hourly promoted 3 log10 kill at the end of treatment (72 h), 1 log10 kill at follow-up (96 h) and 90% maximal activity (AUBKC0-96). CONCLUSIONS Bladder infection modelling supports oral ciprofloxacin activity against E. coli with low-level resistance (ciprofloxacin MIC ≤ 1 mg/L) when using high dose therapy (750 mg 12 hourly).
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Affiliation(s)
| | - Elke van Gorp
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Hugh Cottingham
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Nenad Macesic
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia,Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, Australia,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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10
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Macdonald S. Fluid Resuscitation in Patients Presenting with Sepsis: Current Insights. Open Access Emerg Med 2022; 14:633-638. [PMID: 36471825 PMCID: PMC9719278 DOI: 10.2147/oaem.s363520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/23/2022] [Indexed: 04/05/2024] Open
Abstract
Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid. The rationale is to restore circulating fluid volume and optimise stroke volume. It is acknowledged that there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design. In the past decade, evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation. Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation, however, translating these findings to other settings is not possible. This uncertainty has led to variation in practice with some advocating a more conservative fluid strategy coupled with the earlier introduction of vasopressors for haemodynamic support. This question is the subject of several ongoing clinical trials. This article summarises the current state of the evidence for IV fluid resuscitation in septic shock and provides guidance for practitioners in the face of our evolving understanding of this important area.
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Affiliation(s)
- Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
- Emergency Department, Royal Perth Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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11
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Jessen MK, Simonsen BY, Thomsen MH, Andersen LW, Kolsen‐Petersen JA, Kirkegaard H. Fluid management of emergency department patients with sepsis-A survey of fluid resuscitation practices. Acta Anaesthesiol Scand 2022; 66:1237-1246. [PMID: 36054552 PMCID: PMC9805143 DOI: 10.1111/aas.14141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fluid administration and resuscitation of patients with sepsis admitted through emergency departments (ED) remains a challenge, and evidence is sparse especially in sepsis patients without shock. We aimed to investigate emergency medicine physicians' and nurses' perceptions, self-reported decision-making and daily behavior, and challenges in fluid administration of ED sepsis patients. METHODS We developed and conducted a multicenter, web-based, cross-sectional survey focusing on fluid administration to ED patients with sepsis sent to all nurses and physicians from the five EDs in the Central Denmark Region. The survey consisted of three sections: (1) baseline information; (2) perceptions of fluid administration and daily practice; and (3) clinical scenarios about fluid administration. The survey was performed from February to June, 2021. RESULTS In total, 138 of 246 physicians (56%) and 382 of 595 nurses (64%) responded to the survey. Of total, 94% of physicians and 97% of nurses regarded fluid as an important part of sepsis treatment. Of total, 80% of physicians and 61% of nurses faced challenges regarding fluid administration in the ED, and decisions were usually based on clinical judgment. The most common challenge was the lack of guidelines for fluid administration. Of total, 96% agreed that they would like to learn more about fluid administration, and 53% requested research in fluid administration of patients with sepsis. For a normotensive patient with sepsis, 46% of physicians and 44% of nurses administered 1000 ml fluid in the first hour. Of total, 95% of physicians and 89% of nurses preferred to administer ≥1000 ml within an hour if the patients' blood pressure was 95/60 at admission. There was marked variability in responses. Blood pressure was the most commonly used trigger for fluid administration. Respondents preferred to administer less fluid if the patient in the scenario had known renal impairment or heart failure. Normal saline was the preferred fluid. CONCLUSION Fluid administration is regarded as an important but challenging aspect of sepsis management. Responses to scenarios revealed variability in fluid volumes. Blood pressure was the most used trigger. ED nurses and physicians request evidence-based guidelines to improve fluid administration.
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Affiliation(s)
- Marie Kristine Jessen
- Research Center for Emergency Medicine, Department of Clinical MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Birgitte Y. Simonsen
- Research Center for Emergency Medicine, Department of Clinical MedicineAarhus University and Aarhus University HospitalAarhusDenmark
| | | | - Lars W. Andersen
- Research Center for Emergency Medicine, Department of Clinical MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
| | | | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Clinical MedicineAarhus University and Aarhus University HospitalAarhusDenmark
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12
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Jessen MK, Andersen LW, Thomsen MH, Kristensen P, Hayeri W, Hassel RE, Messerschmidt TG, Sølling CG, Perner A, Petersen JAK, Kirkegaard H. Restrictive fluids versus standard care in adults with sepsis in the emergency department (REFACED): A multicenter, randomized feasibility trial. Acad Emerg Med 2022; 29:1172-1184. [PMID: 35652491 PMCID: PMC9804491 DOI: 10.1111/acem.14546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fluid treatment in sepsis is a challenge and clinical equipoise exists regarding intravenous (IV) volumes. We aimed to determine whether a 24-h protocol restricting IV fluid was feasible in adult patients with sepsis without shock presenting to the emergency department (ED). METHODS The REFACED Sepsis trial is an investigator-initiated, multicenter, randomized, open-label, feasibility trial, assigning sepsis patients without shock to 24 h of restrictive, crystal IV fluid administration or standard care. In the IV fluid restriction group fluid boluses were only permitted if predefined criteria for hypoperfusion occurred. Standard care was at the discretion of the treating team. The primary outcome was total IV crystalloid fluid volumes at 24 h after randomization. Secondary outcomes included total fluid volumes, feasibility measures, and patient-centered outcomes. RESULTS We included 123 patients (restrictive 61 patients and standard care 62 patients) in the primary analysis. A total of 32% (95% confidence interval [CI] 28%-37%) of eligible patients meeting all inclusion criteria and no exclusion criteria were included. At 24 h, the mean (±SD) IV crystalloid fluid volumes were 562 (±1076) ml versus 1370 (±1438) ml in the restrictive versus standard care group (mean difference -801 ml, 95% CI -1257 to -345 ml, p = 0.001). Protocol violations occurred in 21 (34%) patients in the fluid-restrictive group. There were no differences between groups in adverse events, use of mechanical ventilation or vasopressors, acute kidney failure, length of stay, or mortality. CONCLUSIONS A protocol restricting IV crystalloid fluids in ED patients with sepsis reduced 24-h fluid volumes compared to standard care. A future trial powered toward patient-centered outcomes appears feasible.
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Affiliation(s)
- Marie K. Jessen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Lars W. Andersen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
| | - Marie‐Louise H. Thomsen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Peter Kristensen
- Department of Emergency MedicineRegional Hospital ViborgViborgDenmark
| | - Wazhma Hayeri
- Department of Emergency MedicineRegional Hospital RandersRandersDenmark
| | - Ranva E. Hassel
- Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | | | | | - Anders Perner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Jens Aage K. Petersen
- Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
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13
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Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department: a retrospective cohort study. BMC Emerg Med 2022; 22:98. [PMID: 35659554 PMCID: PMC9166492 DOI: 10.1186/s12873-022-00650-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/18/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Appropriate and timely administration of intravenous fluids to patients with sepsis-induced hypotension is one of the mainstays of sepsis management in the emergency department (ED), however, fluid resuscitation remains an ongoing challenge in ED. Our study has been undertaken with two specific aims: firstly, for patients with sepsis, to identify factors associated with receiving intravenous fluids while in the ED; and, secondly to identify determinants associated with the actual time to fluid administration.
Methods
We conducted a retrospective multicentre cohort study of adult ED presentations between October 2018 and May 2019 in four metropolitan hospitals in Western Sydney, Australia. Patients meeting pre-specified criteria for sepsis and septic shock and treated with antibiotics within the first 24 h of presentation were included. Multivariable models were used to identify factors associated with fluid administration in sepsis.
Results
Four thousand one hundred forty-six patients met the inclusion criteria, among these 2,300 (55.5%) patients with sepsis received intravenous fluids in ED. The median time to fluid administration from the time of diagnosis of sepsis was 1.6 h (Interquartile Range (IQR) 0.5 to 3.8), and the median volume of fluids administered was 1,100 mL (IQR 750 to 2058). Factors associated with patients receiving fluids were younger age (Odds Ratio (OR) 1.05, 95% Confidence Interval (CI (1.03 to 1.07), p < 0.001); lower systolic blood pressure (OR 1.11, 95% CI (1.08 to 1.13), p < 0.001); presenting to smaller hospital (OR 1.48, 95% CI (1.25 to 1.75, p < 0.001) and a Clinical Rapid Response alert activated (OR 1.64, 95% CI (1.28 to 2.11), p < 0.001). Patients with Triage Category 1 received fluids 101.22 min earlier (95% CI (59.3 to131.2), p < 0.001) and those with Category 2 received fluids 43.58 min earlier (95% CI (9.6 to 63.1), p < 0.001) compared to patients with Triage Category 3–5. Other factors associated with receiving fluids earlier included septic shock (-49.37 min (95% CI (-86.4 to -12.4), p < 0.001)); each mmol/L increase in serum lactate levels (-9.0 min, 95% CI (-15.7 to -2.3), p < 0.001) and presenting to smaller hospitals (-74.61 min, 95% CI (-94.0 to -55.3), p < 0.001).
Conclusions
Younger age, greater severity of sepsis, and presenting to a smaller hospital increased the probability of receiving fluids and receiving it earlier. Recognition of these factors may assist in effective implementation of sepsis management guidelines which should translate into better patient outcomes. Future studies are needed to identify other associated factors that we have not explored.
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14
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Heubner L, Hattenhauer S, Güldner A, Petrick PL, Rößler M, Schmitt J, Schneider R, Held HC, Mehrholz J, Bodechtel U, Ragaller M, Koch T, Spieth PM. Characteristics and outcomes of sepsis patients with and without COVID-19. J Infect Public Health 2022; 15:670-676. [PMID: 35617831 PMCID: PMC9110019 DOI: 10.1016/j.jiph.2022.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The aim of this study was to describe and compare clinical characteristics and outcomes in critically ill septic patients with and without COVID-19. METHODS From February 2020 to March 2021, patients from surgical and medical ICUs at the University Hospital Dresden were screened for sepsis. Patient characteristics and outcomes were assessed descriptively. Patient survival was analyzed using the Kaplan-Meier estimator. Associations between in-hospital mortality and risk factors were modeled using robust Poisson regression, which facilitates derivation of adjusted relative risks. RESULTS In 177 ICU patients treated for sepsis, COVID-19 was diagnosed and compared to 191 septic ICU patients without COVID-19. Age and sex did not differ significantly between sepsis patients with and without COVID-19, but SOFA score at ICU admission was significantly higher in septic COVID-19 patients. In-hospital mortality was significantly higher in COVID-19 patients with 59% compared to 29% in Non-COVID patients. Statistical analysis resulted in an adjusted relative risk for in-hospital mortality of 1.74 (95%-CI=1.35-2-24) in the presence of COVID-19 compared to other septic patients. Age, procalcitonin maximum value over 2 ng/ml, need for renal replacement therapy, need for invasive ventilation and septic shock were identified as additional risk factors for in-hospital mortality. CONCLUSION COVID-19 was identified as independent risk factor for higher in-hospital mortality in sepsis patients. The need for invasive ventilation and renal replacement therapy as well as the presence of septic shock and higher PCT should be considered to identify high-risk patients.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Sara Hattenhauer
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Paul Leon Petrick
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Martin Rößler
- Center for Evidence-Based Healthcare (ZEGV), University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare (ZEGV), University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Ralph Schneider
- Department of General, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Hanns Christoph Held
- Department of Medicine I, University Hospital Carl Gustav Carus, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Jan Mehrholz
- Wissenschaftliches Institut, Klinik Bavaria Kreischa, Germany
| | - Ulf Bodechtel
- Department of Interdisciplinary Intensive Care Medicine and Intensive Rehabilitation, Klinik Bavaria Kreischa, Germany
| | - Maximilian Ragaller
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, TU Dresden, Dresden, Germany.
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15
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No association between intravenous fluid volume and endothelial glycocalyx shedding in patients undergoing resuscitation for sepsis in the emergency department. Sci Rep 2022; 12:8733. [PMID: 35610344 PMCID: PMC9130214 DOI: 10.1038/s41598-022-12752-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/28/2022] [Indexed: 11/29/2022] Open
Abstract
Endothelial glycocalyx (EG) shedding is associated with septic shock and described following intravenous (IV) fluid administration. To investigate the possible impact of IV fluids on the pathobiology of septic shock we investigated associations between biomarkers of EG shedding and endothelial cell activation, and relationships with IV fluid volume. Serum samples were obtained on admission (T0) and at 24 h (T24) in patients undergoing haemodynamic resuscitation for suspected septic shock in the emergency department. Biomarkers of EG shedding—Syndecan-1 (Syn-1), Syndecan-4 (Syn-4), Hyaluronan, endothelial activation—Endothelin-1 (ET-1), Angiopoeitin-2 (Ang-2), Vascular Endothelial Growth Factor Receptor-1(VEGF-1) and leucocyte activation/inflammation—Resistin, Neutrophil Gelatinase Associated Lipocalin (NGAL) and a marker of cardiac stretch—Pro-Atrial Natriuretic Peptide (Pro-ANP) were compared to the total IV fluid volume administered using Tobit regression. Data on 86 patients (52 male) with a mean age of 60 (SD 18) years were included. The mean fluid volume administered to T24 was 4038 ml (SD 2507 ml). No significant association between fluid volume and Pro-ANP or any of the biomarkers were observed. Syn-1 and Syn-4 were significantly correlated with each other (Spearman Rho 0.43, p < 0.001) but not with Hyaluronan. Syn-1 and Syn-4 both correlated with VEGFR-1 (Rho 0.56 and 0.57 respectively, p < 0.001) whereas Hyaluronan correlated with ET-1 (Rho 0.43, p < 0.001) and Ang-2 (Rho 0.43, p < 0.001). There was no correlation between Pro-ANP and any of the EG biomarkers. Distinct patterns of association between biomarkers of EG shedding and endothelial cell activation were observed among patients undergoing resuscitation for sepsis. No relationship between IV fluid volume and Pro-ANP or any of the other biomarkers was observed.
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16
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Andaluz-Ojeda D, Cantón-Bulnes M, Pey Richter C, Garnacho-Montero J. Fármacos vasoactivos en el tratamiento del shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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17
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Andaluz-Ojeda D, Cantón-Bulnes ML, Pey Richter C, Garnacho-Montero J. [Vasoactive drugs in the treatment of septic shock]. Med Intensiva 2022; 46 Suppl 1:26-37. [PMID: 38341258 DOI: 10.1016/j.medine.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/03/2022] [Indexed: 02/12/2024]
Abstract
Septic shock is a high mortality complication frequently associated with sepsis. Early initiation of vasopressor treatment, even before completion of initial fluid resuscitation, is a determining factor in prognosis. In this sense, norepinephrine continues to be the drug of first choice, although there is increasing evidence of benefit combining it with other non-adrenergic drugs, such as vasopressin, instead of escalating norepinephrine doses. The pathophysiology of septic shock is multifactorial, and sometimes is associated with a situation of myocardial dysfunction that contributes to hemodynamic instability. It is essential to identify this situation since it worsens the prognosis and may benefit from combined treatment with inotropic drugs. There are novel vasoactive agents under study, more selective than the classic ones that in a next future could help to design more individualized and precise treatments. In the present work, the current knowledge about vasoactive drugs and their use in the management of septic shock is summarized according to the most recent scientific evidence.
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Affiliation(s)
- D Andaluz-Ojeda
- Servicio de Medicina Intensiva, Hospital Universitario HM Sanchinarro. Hospitales Madrid, Madrid, España.
| | - M L Cantón-Bulnes
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Virgen Macarena, Sevilla, España
| | - C Pey Richter
- Servicio de Medicina Intensiva, Hospital Universitario HM Sanchinarro. Hospitales Madrid, Madrid, España
| | - J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Virgen Macarena, Sevilla, España
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18
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Jessen MK, Andersen LW, Thomsen MLH, Kristensen P, Hayeri W, Hassel RE, Perner A, Petersen JAK, Kirkegaard H. Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)-protocol for a multicenter, randomized, clinical, proof-of-concept trial. Pilot Feasibility Stud 2022; 8:75. [PMID: 35351214 PMCID: PMC8962933 DOI: 10.1186/s40814-022-01034-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/17/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)-a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care. METHODS This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care. The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions. Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022. DISCUSSION Sepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis. TRIAL REGISTRATION EudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics - Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).
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Affiliation(s)
- Marie Kristine Jessen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J103, DK-8200, Aarhus N, Denmark.
- Department of Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark.
| | - Lars Wiuff Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J103, DK-8200, Aarhus N, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Aarhus N, Denmark
| | | | - Peter Kristensen
- Department of Emergency Medicine, Regional Hospital Viborg, Viborg, Denmark
| | - Wazhma Hayeri
- Department of Emergency Medicine, Regional Hospital Randers, Randers, Denmark
| | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J103, DK-8200, Aarhus N, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Aarhus N, Denmark
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Sardaneh AA, Narayan S, Penm J, Oliver M, Gattas D, McLachlan AJ, Patanwala AE. Efficacy and safety of metaraminol in critically ill patients with shock: a systematic review. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Arwa Abu Sardaneh
- School of Pharmacy Faculty of Medicine and Health The University of Sydney Sydney Australia
- Department of Pharmacy Royal Prince Alfred Hospital Sydney Australia
| | - Sujita Narayan
- School of Pharmacy Faculty of Medicine and Health The University of Sydney Sydney Australia
| | - Jonathan Penm
- School of Pharmacy Faculty of Medicine and Health The University of Sydney Sydney Australia
- Department of Pharmacy Prince of Wales Hospital Randwick Australia
| | - Matthew Oliver
- Department of Emergency Medicine Royal Prince Alfred Hospital Sydney Australia
- School of Medicine Faculty of Medicine and Health The University of Sydney Sydney Australia
| | - David Gattas
- School of Medicine Faculty of Medicine and Health The University of Sydney Sydney Australia
- Intensive Care Services Royal Prince Alfred Hospital Sydney Australia
| | - Andrew J. McLachlan
- School of Pharmacy Faculty of Medicine and Health The University of Sydney Sydney Australia
| | - Asad E. Patanwala
- School of Pharmacy Faculty of Medicine and Health The University of Sydney Sydney Australia
- Department of Pharmacy Royal Prince Alfred Hospital Sydney Australia
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Eyeington CT, Canet E, Cutuli SL, Ancona P, Brown AJ, Jenkins E, Taylor DM, Eastwood GM, Bellomo R. COMBED: Rapid non-invasive Cardiac Output Monitoring Baseline assessment in adult Emergency Department patients with haemodynamic instability. Emerg Med Australas 2022; 34:528-538. [PMID: 34981648 DOI: 10.1111/1742-6723.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The application of rapid, non-operator-dependent, non-invasive cardiac output monitoring (COM) may provide early physiological information in ED patients with haemodynamic instability (HI). Our primary objective was to assess the feasibility of measuring pre-intervention (baseline) cardiac index (CI) and associated haemodynamic parameters. METHODS We performed a prospective observational study of adults shortly after presentation to the ED of a large university hospital with tachycardia or hypotension or both. We applied non-invasive COM for 5 min and recorded CI, mean arterial pressure (MAP), stroke volume index (SVI) and systemic vascular resistance index (SVRI). We assessed for differences between those presenting with hypotension or hypotension and tachycardia with tachycardia alone and between those with or without suspected infection. RESULTS We obtained haemodynamic parameters in 46 of 49 patients. In patients with hypotension or hypotension and tachycardia (n = 15) rather than tachycardia alone (n = 31), we observed a lower MAP (60.8 vs 87.7, P < 0.0001), CI (2.8 vs 3.9, P = 0.0167) and heart rate (85.5 vs 115.4, P < 0.0001). There was no difference in SVI (33.7 vs 33.4, P = 0.93) or SVRI (1970 vs 2088, P = 0.67). Patients with suspected infection had similar haemodynamic values except for a lower SVRI (1706 vs 2237, P = 0.011). CONCLUSIONS Rapid, non-operator-dependent, non-invasive COM was possible in >90% of ED patients presenting with HI. Compared with tachycardia alone, patients with hypotension had lower CI, MAP and heart rate, while those with suspected infection had a lower SVRI. This technology provides novel insights into the early state of the circulation in ED patients with HI.
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Affiliation(s)
- Christopher T Eyeington
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Division of Anaesthesia, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Emmanuel Canet
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Salvatore L Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Alistair J Brown
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Emily Jenkins
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,ANZIC Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre (DARE), Austin Hospital and The University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,ANZIC Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre (DARE), Austin Hospital and The University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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21
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Abbott IJ, van Gorp E, Wyres KL, Wallis SC, Roberts JA, Meletiadis J, Peleg AY. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1324-1333. [PMID: 35211736 PMCID: PMC9047678 DOI: 10.1093/jac/dkac045] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/24/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction The use of oral fosfomycin for urinary tract infections (UTIs) caused by non-Escherichia coli uropathogens is uncertain, including Klebsiella pneumoniae, the second most common uropathogen. Methods A multicompartment bladder infection in vitro model was used with standard media and synthetic human urine (SHU) to simulate urinary fosfomycin exposure after a single 3 g oral dose (fAUC0–72 16884 mg·h/L, t½ 5.5 h) against 15 K. pneumoniae isolates including ATCC 13883 (MIC 2 to >1024 mg/L) with a constant media inflow (20 mL/h) and 4-hourly voiding of each bladder. The impact of the media (CAMHB + G6P versus SHU) on fosfomycin MIC measurements, drug-free growth kinetics and regrowth after fosfomycin administration was assessed. A low and high starting inoculum (5.5 versus 7.5 log10 cfu/mL) was assessed in the bladder infection model. Results Compared with CAMHB, isolates in SHU had a slower growth rate doubling time (37.7 versus 24.1 min) and reduced growth capacity (9.0 ± 0.3 versus 9.4 ± 0.3 log10 cfu/mL), which was further restricted with increased inflow rate (40 mL/h) and more frequent voids (2-hourly). Regrowth was commonly observed in both media with emergence of fosfomycin resistance promoted by a high starting inoculum in CAMHB (MIC rise to ≥1024 mg/L in 13/14 isolates). Resistance was rarely detected in SHU, even with a high starting inoculum (MIC rise to ≥1024 mg/L in 2/14 isolates). Conclusions Simulated in an in vitro UTI model, the regrowth of K. pneumoniae urinary isolates was inadequately suppressed following oral fosfomycin therapy. Efficacy was further reduced by a high starting inoculum.
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Affiliation(s)
- Iain J. Abbott
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Corresponding author. E-mail:
| | - Elke van Gorp
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly L. Wyres
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Steven C. Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Haidari, Athens, Greece
| | - Anton Y. Peleg
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, Australia
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22
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Rogan A, Lockett J, Peckler B, Robinson B, Raymond N. Exploring nursing and medical perceptions of sepsis management in a New Zealand emergency department: A qualitative study. Emerg Med Australas 2021; 34:417-427. [PMID: 34889063 DOI: 10.1111/1742-6723.13911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 11/03/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Alice Rogan
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Jessica Lockett
- Wellington Emergency Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Brad Peckler
- Wellington Emergency Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Brian Robinson
- School of Nursing and Midwifery, Victoria University of Wellington, Wellington, New Zealand
| | - Nigel Raymond
- Infection Service and General Medicine Department, Wellington Regional Hospital, Wellington, New Zealand
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23
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Kabil G, Liang S, Delaney A, Macdonald S, Thompson K, Saavedra A, Suster C, Moscova M, McNally S, Frost S, Hatcher D, Shetty A. Association between intravenous fluid resuscitation and outcome among patients with suspected infection and sepsis: A retrospective cohort study. Emerg Med Australas 2021; 34:361-369. [PMID: 34773387 DOI: 10.1111/1742-6723.13893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/29/2021] [Accepted: 10/17/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all-cause in-hospital mortality. METHODS Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May 2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included. RESULTS During the study period, 7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in-hospital mortality (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.76-0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49-0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI 0.56-0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in-hospital mortality (AOR 0.44, 95% CI 0.22-0.91; AOR 0.16, 95% CI 0.05-0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in-hospital mortality among survivors and non-survivors (2.3 vs 2.5 h, P = 0.50). CONCLUSION We observed a reduction in risk of in-hospital mortality for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU suggesting illness severity to be a likely effect modifier.
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Affiliation(s)
- Gladis Kabil
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia.,Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sophie Liang
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Delaney
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia
| | - Kelly Thompson
- Critical Care and Trauma Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Aldo Saavedra
- Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Carl Suster
- Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Michelle Moscova
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen McNally
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Steven Frost
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Deborah Hatcher
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Amith Shetty
- Westmead Hospital, Westmead Institute for Medical Research, Sydney, New South Wales, Australia.,Patient Experience System Performance Support Division, NSW Ministry of Health, Sydney, New South Wales, Australia
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24
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W. Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C. Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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25
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Jessen MK, Andersen LW, Thomsen MH, Jensen ME, Kirk ME, Kildegaard S, Petersen P, Mohey R, Madsen AH, Perner A, Kølsen Petersen JA, Kirkegaard H. Twenty-four-hour fluid administration in emergency department patients with suspected infection: A multicenter, prospective, observational study. Acta Anaesthesiol Scand 2021; 65:1122-1142. [PMID: 33964019 DOI: 10.1111/aas.13848] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/15/2021] [Accepted: 04/17/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND To describe 24-hour fluid administration in emergency department (ED) patients with suspected infection. METHODS A prospective, multicenter, observational study conducted in three Danish hospitals, January 20 to March 2, 2020. We included consecutive adult ED patients with suspected infection (drawing of blood culture and/or intravenous antibiotic administration within 6 hours of admission). Oral and intravenous fluids were registered for 24 hours. PRIMARY OUTCOME 24-hour total fluid volume. We used linear regression to investigate patient and disease characteristics' effect on 24-hour fluids and to estimate the proportion of the variance in fluid administration explained by potential predictors. RESULTS 734 patients had 24-hour fluids available: 387 patients had simple infection, 339 sepsis, eight septic shock. Mean total 24-hour fluid volumes were 3656 mL (standard deviation [SD]:1675), 3762 mL (SD: 1839), and 6080 mL (SD: 3978) for the groups, respectively. Fluid volumes varied markedly. Increasing age (mean difference [MD]: 60-79 years: -470 mL [95% CI: -789, -150], +80 years; -974 mL [95% CI: -1307, -640]), do-not-resuscitate orders (MD: -466 mL [95% CI: -797, -135]), and preexisting atrial fibrillation (MD: -367 mL [95% CI: -661, -72) were associated with less fluid. Systolic blood pressure < 100 mmHg (MD: 1182 mL [95% CI: 820, 1543]), mean arterial pressure < 65 mmHg (MD: 1317 mL [95% CI: 770, 1864]), lactate ≥ 2 mmol/L (MD: 655 mL [95% CI: 306, 1005]), heart rate > 120 min (MD: 566 [95% CI: 169, 962]), low (MD: 1963 mL [95% CI: 813, 3112]) and high temperature (MD: 489 mL [95% CI: 234, 742]), SOFA score > 5 (MD: 1005 mL [95% CI: 501, 510]), and new-onset atrial fibrillation (MD: 498 mL [95% CI: 30, 965]) were associated with more fluid. Clinical variables explained 37% of fluid variation among patients. CONCLUSIONS Patients with simple infection and sepsis received equal fluid volumes. Fluid volumes varied markedly, a variation that was partly explained by clinical characteristics.
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Affiliation(s)
- Marie K. Jessen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Lars W. Andersen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
- Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
| | - Marie‐Louise H. Thomsen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Marie E. Jensen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
| | - Mathilde E. Kirk
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
| | - Sofie Kildegaard
- Department of Emergency Medicine Regional Hospital Randers Randers Denmark
- Department of Anesthesiology and Intensive Care Regional Hospital Randers Randers Denmark
| | - Poul Petersen
- Department of Emergency Medicine Regional Hospital Herning Herning Denmark
| | - Rajesh Mohey
- Department of Internal Medicine Regional Hospital Herning Herning Denmark
| | - Anders H. Madsen
- Department of Abdominal Surgery Regional Hospital Herning Herning Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | - Hans Kirkegaard
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
- Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
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26
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Lee H, Choi SH, Kim K, Shin TG, Park YS, Ryoo SM, Suh GJ, Kwon WY, Lim TH, Son D, Kim WY, Ko BS. Effect of rapid fluid administration on the prognosis of septic shock patients with isolated hyperlactatemia: A prospective multicenter observational study. J Crit Care 2021; 66:154-159. [PMID: 34294426 DOI: 10.1016/j.jcrc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND We aimed to investigate the association between initial fluid resuscitation in septic shock patients with isolated hyperlactatemia and outcomes. METHODS This multicenter prospective study was conducted using the data from the Korean Shock Society registry. Patients diagnosed with isolated hyperlactatemia between October 2015 and December 2018 were included and divided into those who received 30 mL/kg of fluid within 3 or 6 h and those who did not receive. The primary outcome was in-hospital mortality; the secondary outcomes were intensive care unit (ICU) admission, length of ICU stay, mechanical ventilation, and renal replacement therapy (RRT). RESULTS A total of 608 patients were included in our analysis. The administration of 30 mL/kg crystalloid within 3 or 6 h was not significantly associated with in-hospital mortality in multivariable logistic regression analysis ([OR, 0.8; 95% CI, 0.52-1.23, p = 0.31], [OR, 0.96; 95% CI, 0.59-1.57, p = 0.88], respectively). The administration of 30 mL/kg crystalloid within 3-h was not significantly associated with mechanical ventilation and RRT ([OR, 1.19; 95% CI, 0.77-1.84, p = 0.44], [OR, 1.2; 95% CI, 0.7-2.04, p = 0.5], respectively). However, the administration of 30 mL/kg crystalloid within 6 h was associated with higher ICU admission and RRT ([OR, 1.57; 95% CI, 1.07-2.28, p = 0.02], [OR, 2.08; 95% CI, 1.19-3.66, p = 0.01], respectively). CONCLUSIONS Initial fluid resuscitation of 30 mL/kg within 3 or 6 h was neither associated with an increased or decreased in-hospital mortality in septic shock patients with isolated hyperlactatemia.
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Affiliation(s)
- Heekyung Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA University School of Medicine, CHA Bundang Medical Center, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Donghee Son
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea.
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27
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Kusakabe A, Sweeny A, Keijzers G. Early compared to later commencement of vasopressors in the management of Emergency Department patients with sepsis and hypotension, a multi-centre observational study. Arch Med Res 2021; 52:836-842. [PMID: 34275667 DOI: 10.1016/j.arcmed.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
AIM To describe and compare early with late vasopressor commencement in emergency department (ED) patients with sepsis and hypotension. METHODS This is a sub-study of the ARISE FLUIDS observational study conducted in 70 EDs in Australia and New Zealand. Adults with suspected sepsis and hypotension who received a vasopressor infusion in the first 24 h after ED presentation were included. 'Early' was defined as vasopressor commenced within 2 h from a) sepsis recognition, or b) triage. RESULTS 177 patients (mean age 68 years) received vasopressors and had a lactate of 3.0 (IQR 2.0-4.9) mmol/L and APACHE II score of 17.8 (SD 6.3). 110 (62%) received a single agent vasopressor with noradrenaline being the most common (n = 74) and 67 (38%) received multiple vasopressors, most commonly metaraminol then noradrenaline (20.3%, n = 36). One-third (34.7%, n = 62) had vasopressors started via a peripheral line. Vasopressors were started within 2 h of sepsis recognition in 74 patients and within 2 h of triage in 24 patients. Both early groups had a higher lactate (3.5 vs. 2.9mmol/L and 5.0 vs. 2.9mmol/L, both p <0.05) and received lower fluid volumes prior to vasopressor commencement (2.0 vs. 2.85 L and 1.55 vs. 2.4 L, both p <0.001), compared to patients receiving vasopressors later. No differences in duration of vasopressor infusion, need for organ support or in-hospital mortality were found. CONCLUSION Early vasopressor commencement was associated with the administration of lower intravenous fluid volumes but not with duration of vasopressor use, organ support or mortality. Large prospective studies addressing this question are required.
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Affiliation(s)
- Ayano Kusakabe
- Gold Coast Health, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Amy Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia; School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia; School of Medicine, Griffith University, Gold Coast, QLD, Australia.
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28
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Young TL. A narrative review of paracetamol-induced hypotension: Keeping the patient safe. Nurs Open 2021; 9:1589-1601. [PMID: 34102027 PMCID: PMC8994964 DOI: 10.1002/nop2.943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/01/2021] [Accepted: 04/28/2021] [Indexed: 12/21/2022] Open
Abstract
Aim To understand the prevalence and epidemiology of paracetamol‐induced hypotension and clinical implications for contemporaneous practice. Design Narrative review. Methods In May and June 2020, an open‐date literature search of English publications indexed in ProQuest, PubMed, and EBSCO was conducted with the search terms ‘acetaminophen’ and ‘hypotension’ and related search combinations (‘paracetamol’, ‘propacetamol’, ‘low blood pressure’, ‘fever’, ‘sepsis’, and ‘shock’) to identify peer‐reviewed publications of blood pressure changes after paracetamol administration in humans. Results A pattern of blood pressure reduction following the administration of paracetamol is demonstrated in the 27 studies included in this review. Haemodynamic intervention often followed persistent blood pressure reduction, and was greatest in febrile critically ill patients who received parenteral paracetamol.
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Affiliation(s)
- Tricia L Young
- Australia and Bairnsdale Regional Health Service, University of New England, Armadale, VIC, Australia
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29
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Harley A, Schlapbach LJ, Johnston ANB, Massey D. Challenges in the recognition and management of paediatric sepsis - The journey. Australas Emerg Care 2021; 25:23-29. [PMID: 33865753 DOI: 10.1016/j.auec.2021.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/25/2021] [Accepted: 03/16/2021] [Indexed: 01/06/2023]
Abstract
Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.
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Affiliation(s)
- Amanda Harley
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Switzerland.
| | - Amy N B Johnston
- School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia; Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, QLD, Australia.
| | - Debbie Massey
- School of Nursing and Midwifery, Southern Cross University, Coolangatta, QLD, Australia.
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Kreß JS, Rüppel M, Haake H, Vom Dahl J, Bergrath S. Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department. Anaesthesist 2021; 71:30-37. [PMID: 33830277 DOI: 10.1007/s00101-021-00953-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/11/2021] [Accepted: 01/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency medical care for critically ill nontrauma patients (CINT) varies between different emergency departments (ED) and healthcare systems, while resuscitation of trauma patients is always performed within the ED. In many ED CINT are treated and stabilized while in many German smaller hospitals CINT are transferred directly to the intensive care unit (ICU) without performing critical care measures in the ED. Little is known about the resuscitation room management of CINT regarding patient characteristics and outcome although bigger hospitals perform ED resuscitation of CINT in routine care. Against this background we conducted this retrospective analysis of CINT treated by an ED resuscitation room concept in a German 756 bed teaching hospital. METHODS The collective of CINT treated within the ED resuscitation room (1 October 2018 to 31 March 2019) was analyzed after ethical approval. After each resuscitation room operation, the team leader filled out a standardized paper-based questionnaire and qualified the patient as a resuscitation room patient this way. Only patients who underwent invasive procedures and were admitted to ICU or died in the ED were included. Patient characteristics, performed critical care measures, short-term outcomes and the comparison of admission characteristics between survivors and non-survivors were evaluated. Additionally, the accordance of ED admission diagnoses and discharge diagnoses were analyzed. RESULTS Overall, 243 of 19,854 ED patients (1.22%) were treated in the resuscitation room. After exclusion of trauma patients, 193 (0.97%) CINT were included. Overall mortality was 29% (n = 56), 24‑h mortality was 13% (n = 25). Patient characteristics (vital signs, blood gas analysis) differed significantly between survivors and nonsurvivors except for respiratory rate and pain scale. An excerpt of conducted resuscitation room measures was as follows: arterial line n = 78 (40%); noninvasive ventilation n = 60 (31%); endotracheal intubation n = 56 (29%); cardiopulmonary resuscitation n = 19 (10%), central venous line n = 8 (4%). The number of conducted measures differed between survivors and nonsurvivors (median and interquartile range, IQR): 4 (IQR 2) vs. 4 (IQR 3) p = 0.0453. The length of ED stay was 148.2 ± 202.7 min until the patient was admitted to an ICU or died within the ED. ED admission diagnoses matched with hospital discharge diagnoses in 78%. CONCLUSION The observed mortality was high and was comparable to patient collectives with septic shock. Nonsurvivors showed significantly more impaired vital parameters and blood gas analysis parameters. Vital parameters together with blood gas analysis might enable ED risk stratification of CINT. Resuscitation room management enables immediate stabilization and diagnostic work-up of CINT even when no ICU bed is available. Furthermore, optimal allocation to specialized ICUs can probably be enabled more accurately after a first diagnostic work-up; however, although a first diagnostic work-up including laboratory tests and computed tomography in many cases was performed, ED admission and hospital discharge diagnoses matched only in 78%.
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Affiliation(s)
- Jessika Stefanie Kreß
- Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany.,Lehrstuhl für Anästhesiologie, Medizinische Fakultät RWTH Aachen, Uniklinik RWTH Aachen, Aachen, Germany
| | - Marc Rüppel
- Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany
| | - Hendrik Haake
- Klinik für Kardiologie, Elektrophysiologie und internistische Intensivmedizin, Kliniken Maria Hilf, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany
| | - Jürgen Vom Dahl
- Klinik für Kardiologie, Elektrophysiologie und internistische Intensivmedizin, Kliniken Maria Hilf, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany
| | - Sebastian Bergrath
- Kliniken Maria Hilf, Zentrum für klinische Akut- und Notfallmedizin, Akademisches Lehrkrankenhaus der RWTH Aachen, Mönchengladbach, Germany. .,Lehrstuhl für Anästhesiologie, Medizinische Fakultät RWTH Aachen, Uniklinik RWTH Aachen, Aachen, Germany.
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Mochizuki K, Fujii T, Paul E, Anstey M, Pilcher DV, Bellomo R. Early metabolic acidosis in critically ill patients: a binational multicentre study. CRIT CARE RESUSC 2021; 23:67-75. [PMID: 38046393 PMCID: PMC10692578 DOI: 10.51893/2021.1.oa6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: We aimed to measure the incidence, prevalence, characteristics and outcomes of intensive care unit (ICU) patients with early (first 24 hours) metabolic acidosis (MA) according to two different levels of severity with a focus on recent data. Design: We retrospectively applied two diagnostic criteria to our analysis based on literature for early MA: i) severe MA criteria (pH ≤ 7.20 and Paco2 ≤ 45 mmHg and HCO3- ≤ 20 mmol/L with total Sequential Organ Failure Assessment [SOFA] score ≥ 4 or lactate ≥ 2 mmol/L), and ii) moderate MA criteria (pH < 7.30 and base excess < -4 mmol/L and Paco2 ≤ 45 mmHg). Setting: ICUs in the Australian and New Zealand Intensive Care Society Adult Patient Database program. Participants: Adult patients registered to the database from 2008 to 2018. Main outcome measures: Incidence, prevalence, and hospital mortality of patients with MA by the two criteria. Results: We screened 1 076 087 patients. Given the Australian and New Zealand population during the study period, we estimated the incidence of severe MA at 39.5 per million per year versus 349.2-411.5 per million per year for moderate MA. In the most recent 2 years, we observed early severe MA in 1.5% (1350/87 110) of patients compared with 8.4% (20 679/244 740) for moderate MA. Overall, hospital mortality for patients with early severe MA was 48.3% (652/1350) compared with 21.5% (4444/20 679) for moderate MA. Conclusions: Early severe MA is uncommon in Australian and New Zealand ICUs and carries a very high mortality. Moderate MA is over seven-fold more common and still carries a high mortality.
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Affiliation(s)
- Katsunori Mochizuki
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Matthew Anstey
- Intensive Care, Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - David V. Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine, the University of Melbourne, Melbourne, VIC, Australia
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Affiliation(s)
- Tomoko Fujii
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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