1
|
Ramasco F, Figuerola A, Mendez R, Serrano DR, von Wernitz A, Hernández-Aceituno A, Sáez C, Cardeñoso L, Martin E, García-Vázquez N, de las Cuevas C, Pascual N, Bautista A, Jiménez D, Fernández G, Leal A, Vinuesa M, Pizarro A, di Martino M, Del Campo L, Sanz IG, Chicot M, Barrios A, Rubio MJ. Initial clinical outcomes and prognostic variables in the implementation of a Code Sepsis in a high complexity University Hospital. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:238-245. [PMID: 30968675 PMCID: PMC6609936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To assess the impact of the first months of application of a Code Sepsis in a high complexity hospital, analyzing patient´s epidemiological and clinical characteristics and prognostic factors. METHODS A long-term observational study was carried out throughout a consecutive period of seven months (February 2015 - September 2015). The relationship with mortality of risk factors, and analytic values was analyzed using uni- and multivariate analyses. RESULTS A total of 237 patients were included. The in-hospital mortality was 24% at 30 days and 27% at 60 days. The mortality of patients admitted to Critical Care Units was 30%. Significant differences were found between the patients who died and those who survived in mean levels of creatinine (2.30 vs 1.46 mg/dL, p <0.05), lactic acid (6.10 vs 2.62 mmol/L, p <0.05) and procalcitonin (23.27 vs 12.73 mg/dL, p<0.05). A statistically significant linear trend was found between SOFA scale rating and mortality (p<0.05). In the multivariate analysis additional independent risk factors associated with death were identified: age > 65 years (OR 5.33, p <0.05), lactic acid > 3 mmol/L (OR 5,85, p <0,05), creatinine > 1,2 mgr /dL (OR 4,54, p <0,05) and shock (OR 6,57, P <0,05). CONCLUSIONS The epidemiological, clinical and mortality characteristics of the patients in our series are similar to the best published in the literature. The study has identified several markers that could be useful at a local level to estimate risk of death in septic patients. Studies like this one are necessary to make improvements in the Code Sepsis programs.
Collapse
Affiliation(s)
- Fernando Ramasco
- Anesthesiology and Surgical Critical Care Department, University Hospital of La Princesa, Madrid, Spain.,Correspondence: Fernando Ramasco Anesthesiology and Surgical Critical Care Departament University Hospital of La Princesa, C/ Diego de León 62, Madrid, 28006, Spain. Phone : 639667114 - E-mail:
| | - Angels Figuerola
- Preventive Medicine and Public Health Department, University Hospital of La Princesa, Madrid, Spain
| | - Rosa Mendez
- Anesthesiology and Surgical Critical Care Department, University Hospital of La Princesa, Madrid, Spain
| | - Diego Rodríguez Serrano
- Intensive Care Medicine Department, Universitary Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | | | - Ana Hernández-Aceituno
- Preventive Medicine and Public Health Department, University Hospital of La Princesa, Madrid, Spain
| | - Carmen Sáez
- Internal Medicine and Infectious Disease Departament, University Hospital of La Princesa, Madrid, Spain
| | - Laura Cardeñoso
- Microbiology Department, University Hospital of La Princesa, Madrid, Spain
| | - Elena Martin
- General Surgery Department, University Hospital of La Princesa, Madrid, Spain
| | - Nieves García-Vázquez
- Intensive Care Medicine Departament, University Hospital of La Princesa, Madrid, Spain
| | | | - Natalia Pascual
- Clinical Analysis Department, University Hospital of La Princesa, Madrid, Spain
| | - Azucena Bautista
- Internal Medicine and Infectious Disease Departament, University Hospital of La Princesa, Madrid, Spain
| | - David Jiménez
- Nurse of Intensive Care Medicine Department, University Hospital of La Princesa, Madrid, Spain
| | - Guillermo Fernández
- Admission and Clinical Documentation Department, University Hospital of La Princesa, Madrid, Spain
| | - Ana Leal
- Intensive Care Medicine Departament, University Hospital of La Princesa, Madrid, Spain
| | - Mercedes Vinuesa
- Preventive Medicine and Public Health Department, University Hospital of La Princesa, Madrid, Spain
| | - Alberto Pizarro
- Emergency Department, University Hospital of La Princesa, Madrid, Spain
| | - Marcello di Martino
- General Surgery Department, University Hospital of La Princesa, Madrid, Spain
| | - Lourdes Del Campo
- Radiology Department, University Hospital of La Princesa, Madrid, Spain
| | - Iñigo García Sanz
- General Surgery Department, University Hospital of La Princesa, Madrid, Spain
| | - Marta Chicot
- Intensive Care Medicine Departament, University Hospital of La Princesa, Madrid, Spain
| | - Ana Barrios
- Internal Medicine and Infectious Disease Departament, University Hospital of La Princesa, Madrid, Spain
| | - María José Rubio
- Nurse and Quality and Teaching Supervisor, University Hospital of La Princesa, Madrid, Spain
| | | |
Collapse
|
2
|
Candel FJ, Borges Sá M, Belda S, Bou G, Del Pozo JL, Estrada O, Ferrer R, González del Castillo J, Julián-Jiménez A, Martín-Loeches I, Maseda E, Matesanz M, Ramírez P, Ramos JT, Rello J, Suberviola B, Suárez de la Rica A, Vidal P. Current aspects in sepsis approach. Turning things around. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:298-315. [PMID: 29938972 PMCID: PMC6172679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The incidence and prevalence of sepsis depend on the definitions and records that we use and we may be underestimating their impact. Up to 60% of the cases come from the community and in 30-60% we obtain microbiological information. Sometimes its presentation is ambiguous and there may be a delay in its detection, especially in the fragile population. Procalcitonin is the most validated biomarker for bacterial sepsis and the one that best discriminates the non-infectious cause. Presepsin and pro-adrenomedullin are useful for early diagnosis, risk stratification and prognosis in septic patients. The combination of biomarkers is even more useful to clarify an infectious cause than any isolated biomarker. Resuscitation with artificial colloids has worse results than crystalloids, especially in patients with renal insufficiency. The combination of saline solution and balanced crystalloids is associated with a better prognosis. Albumin is only recommended in patients who require a large volume of fluids. The modern molecular methods on the direct sample or the identification by MALDI-TOF on positive blood culture have helped to shorten the response times in diagnosis, to optimize the antibiotic treatment and to facilitate stewardship programs. The hemodynamic response in neonates and children is different from that in adults. In neonatal sepsis, persistent pulmonary hypertension leads to an increase in right ventricular afterload and heart failure with hepatomegaly. Hypotension, poor cardiac output with elevated systemic vascular resistance (cold shock) is often a terminal sign in septic shock. Developing ultra-fast Point-of-Care tests (less than 30 minutes), implementing technologies based on omics, big data or massive sequencing or restoring "healthy" microbiomes in critical patients after treatment are the main focuses of research in sepsis. The main benefits of establishing a sepsis code are to decrease the time to achieve diagnosis and treatment, improve organization, unify criteria, promote teamwork to achieve common goals, increase participation, motivation and satisfaction among team members, and reduce costs.
Collapse
Affiliation(s)
| | - Marcio Borges Sá
- Multidisciplinar Sepsis Unit. Intensive Care Unit. Hospital Son Llatzer. Palma de Mallorca
| | - Sylvia Belda
- Department of Intensive Pediatrics. Maternal and Child Health and Development Network. Hospital 12 de Octubre. Madrid
| | - Germán Bou
- Clinical Microbiology Department. Complejo Hospitalario Universitario. La Coruña
| | - José Luis Del Pozo
- Clinical Microbiology and Infectious Diseases Department. Clinica Universitaria Navarra
| | - Oriol Estrada
- Clinical Innovation Management, Germans Trias i Pujol University Hospital. Barcelona
| | - Ricard Ferrer
- Department of Intensive Care. Shock, Organ Dysfunction and Resuscitation Research Group. CIBERES Instituto de Salud Carlos III. Vall d’Hebron University Hospital. Barcelona
| | | | | | - Ignacio Martín-Loeches
- Multidisciplinary Intensive Care Research Organization. CIBERES Instituto de Salud Carlos III. Department of Intensive Care Medicine. St James’s Hospital. Trinity Centre for Health Sciences. Dublin. Ireland
| | - Emilio Maseda
- Department of Anesthesia and Surgical Intensive Care, Hospital Universitario La Paz. Madrid
| | - Mayra Matesanz
- Department of Internal Medicine. Hospital Clínico San Carlos. Madrid
| | - Paula Ramírez
- Critical Care Department. University Hospital la Fe. Valencia
| | - José Tomás Ramos
- José T. Ramos. Department of Public and Mother-Child Health. Hospital Clínico San Carlos, IdISSC Health Research Institute. Universidad Complutense. Madrid
| | - Jordi Rello
- Clinical Research/epidemiology In Pneumonia & Sepsis (CRIPS). CIBERES Instituto de Salud Carlos III. Vall d’Hebron University Hospital. Barcelona
| | - Borja Suberviola
- Critical Care Department. Hospital Universitario Marqués de Valdecilla. Santander
| | | | - Pablo Vidal
- Intensive Care Unit. Complexo Hospitalario Universitario de Ourense
| |
Collapse
|
3
|
Rello J, Valenzuela-Sánchez F, Ruiz-Rodriguez M, Moyano S. Sepsis: A Review of Advances in Management. Adv Ther 2017; 34:2393-2411. [PMID: 29022217 PMCID: PMC5702377 DOI: 10.1007/s12325-017-0622-8] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Indexed: 12/28/2022]
Abstract
Infections represent a common health problem in people of all ages. Usually, the response given to them is appropriate and so little treatment is needed. Sometimes, however, the response to the infection is inadequate and may lead to organ dysfunction; this is the condition known as sepsis. Sepsis can be caused by bacteria, fungi or viruses and at present there is no specific treatment; its management basically focuses on containing the infection through source control and antibiotics plus organ function support. This article reviews key elements of sepsis management, focusing on diagnosis, biomarkers and therapy. The main recent advance in therapy is the strategy of personalized medicine, based on a precise approach using biomarkers to identify specific individuals who are likely to benefit from more personalized attention.
Collapse
Affiliation(s)
- Jordi Rello
- CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain.
| | | | | | - Silvia Moyano
- CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain
| |
Collapse
|
4
|
Maslove DM, Lamontagne F, Marshall JC, Heyland DK. A path to precision in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:79. [PMID: 28366166 PMCID: PMC5376689 DOI: 10.1186/s13054-017-1653-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Precision medicine is increasingly touted as a groundbreaking new paradigm in biomedicine. In the ICU, the complexity and ambiguity of critical illness syndromes have been identified as fundamental justifications for the adoption of a precision approach to research and practice. Inherently protean diseases states such as sepsis and acute respiratory distress syndrome have manifestations that are physiologically and anatomically diffuse, and that fluctuate over short periods of time. This leads to considerable heterogeneity among patients, and conditions in which a “one size fits all” approach to therapy can lead to widely divergent results. Current ICU therapy can thus be seen as imprecise, with the potential to realize substantial gains from the adoption of precision medicine approaches. A number of challenges still face the development and adoption of precision critical care, a transition that may occur incrementally rather than wholesale. This article describes a few concrete approaches to addressing these challenges. First, novel clinical trial designs, including registry randomized controlled trials and platform trials, suggest ways in which conventional trials can be adapted to better accommodate the physiologic heterogeneity of critical illness. Second, beyond the “omics” technologies already synonymous with precision medicine, the data-rich environment of the ICU can generate complex physiologic signatures that could fuel precision-minded research and practice. Third, the role of computing infrastructure and modern informatics methods will be central to the pursuit of precision medicine in the ICU, necessitating close collaboration with data scientists. As work toward precision critical care continues, small proof-of-concept studies may prove useful in highlighting the potential of this approach.
Collapse
Affiliation(s)
- David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada. .,Department of Medicine, Queen's University, Kingston, ON, Canada. .,Department of Critical Care Medicine, Kingston General Hospital, Davies 2, 76 Stuart St., Kingston, Ontario, K7L 2V7, Canada.
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| |
Collapse
|