Sepsis-related organ failure assessment and withholding or withdrawing life support from critically ill patients

Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study

BACKGROUND

Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis.

OBJECTIVE

To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis.

DESIGN

Retrospective cohort study using multivariable analysis of clinical data.

PARTICIPANTS

A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection.

SETTING

Four university hospitals in California between 2014 and 2016.

MAIN OUTCOMES AND MEASURES

The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen.

KEY RESULTS

Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004).

CONCLUSIONS

Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.

Prognostic models in cirrhotics admitted to intensive care units better predict outcome when assessed at 48 h after admission

BACKGROUND AND AIM

The accuracy of prognostic models in critically ill cirrhotics at admission to intensive care units (ICU) may be unreliable. Predictive accuracy could be improved by evaluating changes over time, but this has not been published. The aim of the present study was to assess the performance of prognostic models in cirrhotics at admission (baseline) and at 48 h to predict mortality in the ICU or within 6 weeks after discharge from the ICU.

METHODS

One hundred and twenty-eight cirrhotics (77 males, mean age 49 +/- 11.3 years) were consecutively admitted and alive 48 h after admission with 89% on mechanical ventilation, 76% on inotrope support, and 42% with renal failure. Prognostic models used were Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), failing organ systems (FOS) at baseline and at 48 h, Deltascore (difference between baseline and at 48 h) and the mean score (MN - score admission + 48 h/2) which were compared by area under the receiver operating characteristic curves (AUC).

RESULTS

Mortality was 54.7% (n = 70) due to multiple organ failure in 55%. CTP, MELD, APACHE II, SOFA and FOS performed better at 48 h (AUC: 0.78, 0.86, 0.78, 0.88 and 0.85, respectively) than at baseline (AUC: 0.75, 0.78, 0.75, 0.81 and 0.79, respectively). The mean score had better discrimination than the baseline score; the Deltascore had poor predictive ability (AUC < 0.70). SOFA score (48 h: 0.88, mean: 0.88) and FOS (mean: 0.88) had the best accuracy, with a SOFA and MN-SOFA > or = 10 predicting mortality in 93% and 91%, respectively, and MN-FOS > or = 1.5 in 98%.

CONCLUSIONS

In cirrhotics, prognostic scores in the ICU at 48 h had better discrimination than baseline scores for short-term mortality. SOFA and FOS models had the best performance.

[Ulysses network: an approach to integral post-ICU treatment of patients with multiple organ dysfunction syndrome]

The concept of continuity of care by intensivists as an element of quality control in the medical care of Intensive Care Unit (ICU) patients surviving multiple organ dysfunction syndrome has led to a rethinking of the ICU model in recent years. We discuss the rationale to design and implement a hospital-based, prospective, randomized, multicenter Intervention/Control study in order to estimate the impact of an interdisciplinary intervention during the post-ICU recovery phase on medium-term medical outcomes in ICU patients with multiple organ dysfunction.

The sequential organ failure assessment score as a useful predictor for estimating the prognosis of systemic inflammatory response syndrome patients being treated with extracorporeal blood purification

Systemic inflammatory response syndrome (SIRS) is a major cause of morbidity and mortality in critically ill patients. Extracorporeal blood purification procedures are becoming important for treating these patients. However, the cost of these procedures is high. Therefore, a prognostic marker would be helpful. To establish the reliability of the Sequential Organ Failure Assessment (SOFA) score as a prognostic indicator, we evaluated daily changes in the SOFA score of 40 SIRS patients who needed blood purification procedures such as continuous renal replacement therapy (CRRT), endotoxin adsorption, bilirubin adsorption, and/or plasma exchange. Twenty patients survived and 20 died. Although the baseline scores of the two groups (survivors and non-survivors) did not differ, both the maximum value of the SOFA score and the DeltaSOFA score (the difference between the maximum SOFA and baseline SOFA scores) were significantly higher in the non-survivor group. The mortality rate among patients with a maximum SOFA score greater than or equal to 18 or a DeltaSOFA score greater than or equal to 3 was higher than for the rest of the patients. The changes in the SOFA score correlated well with the outcomes of the SIRS patients. The maximum SOFA score and the DeltaSOFA score are therefore likely to be useful prognostic markers.