Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study*

Unlike other surgical fields, such as cardiac surgery, where many trials have been made about safety, feasibility and outcome of surgical procedures in the elderly, there is lack of literature about emergency abdominal surgery in very old patients, especially in people over 90 years of age. The available data reported survival of about 50% one year after the operation. The aim of the study is to determine the survival rate two years after emergency abdominal surgery in a nonagenarian population and to identify any demographic and surgical parameters that could predict a poor outcome in this type of patient. The study was a retrospective multicenter trial. Patient inclusion criteria were: age 90 years old or older, urgent abdominal surgery. The medical charts reviewed and data collected were: gender, age, the American Society of Anesthesiologists (ASA) score and comorbidities, diagnosis, time elapsed between arrival to the Emergency Room and admission to the Operatory Room, surgical procedures, open versus laparoscopic procedure, type of anesthesia and outcomes with hospital length of stay. Phone call follow-up was performed for patient discharged alive and Kaplan-Meier analysis was used to evaluate survival. We identified 72 (20 males and 52 females) nonagenarian patients who underwent abdominal emergency surgery at 6 Italian hospitals (Parma, Bergamo, Bologna, Brescia, Chiari, Adria). Mean age was 92.5 years [range 90-100, standard deviation (SD) 2.6], median ASA score was 3 (range 2-5, mean 3.32) and only 7 patients were without comorbidities. Mean hospital length of stay was 13 days (range 1-60, SD 11.52); 56 patients (77.7%) were discharged alive; 2 years survival rate was 23% [mean follow-up=10 months (range 1-27)]. Among all the parameters analyzed, only ASA score was significantly correlated with survival. Neither the presence of malignancy nor the absence of comorbidities seems to correlate with survival. Nonagenarian patients undergoing emergent abdominal surgical procedures have a high overall in-hospital mortality rate (23%) and a low 2 years survival rate (51.4%). Except for ASA score, there are no other factors predicting poor outcome. Based on the present study emergency abdominal surgery in frail patients over 90 years of age has to be carefully evaluated: only 1 out 5 patients will be alive after 2 years.

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Impact of Vasopressor Initiation and Discontinuation Sequence on Mortality in Septic Shock: A Retrospective Review

Surgical Case Reports ◽

10.31487/j.scr.2020.01.05 ◽

2020 ◽

pp. 1-7

Author(s):

Cara McDaniel ◽

Andrew Moyer ◽

Cara McDaniel ◽

Judah Brown ◽

Michael Baram

Keyword(s):

Septic Shock ◽

Length Of Stay ◽

Hospital Mortality ◽

Primary Endpoint ◽

Primary Diagnosis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Apache Ii Score ◽

Vasoactive Agent ◽

Intra Abdominal Infection

Background: Little data exists guiding clinicians on how or when to initiate and discontinue the second vasoactive agent in the setting of septic shock refractory to norepinephrine monotherapy. Methods: This retrospective cohort study evaluated patients with a primary diagnosis of septic shock admitted to the intensive care unit receiving norepinephrine in addition to concomitant vasopressors. The primary endpoint was the incidence of all-cause in-hospital mortality when adding adjunctive vasopressors to norepinephrine either before the dose reached 2 mcg/kg/min (early adjunctive vasopressor) or after (late adjunctive vasopressor). Secondary endpoints included the incidence of clinically significant hypotension when discontinuing norepinephrine before or after vasopressin in the same population. Results: Forty-six patients were included (early adjunctive vasopressor [n=36]; late adjunctive vasopressor [n=10]), with a median age of 69 years and APACHE II score of 27. Fewer patients in the early adjunctive vasopressor cohort had malignancy prior to admission (16.7% vs. 60%, p=0.0117), however, more patients were managed in the surgical ICU (44.4% vs. 0%, p=0.0202) with intra-abdominal infection (33.3% vs. 0%, p=0.0439). The primary endpoint of all-cause in-hospital mortality was not statistically different between the early and late adjunctive vasopressor groups (75% vs. 90%, respectively, p=0.4203). Longer ICU and hospital length of stay in the early adjunctive vasopressor cohort was observed (9 days vs 3 days, p=0.0061; 11 days vs 3 days, p=0.0026, respectively). Twenty-two patients were included in analysis of vasopressor discontinuation sequence with no significant differences in mortality, incidence of hypotension, or ICU/hospital length of stay. Conclusion: Among patients with septic shock on multiple vasopressors, addition of adjunctive vasopressor before reaching a norepinephrine dose of 2 mcg/kg/min was associated with longer in-hospital and ICU survival but exhibited no difference in overall mortality. Discontinuation of vasopressin before norepinephrine led to longer total vasopressor duration without a difference in rates of hypotension. Future prospective studies are warranted.

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770. Multimodal Sepsis Performance Improvement Initiative Improves Early and Appropriate Treatment, Reduces Sepsis-related Readmissions, and Reduces Overall Mortality

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.838 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S343-S343

Author(s):

Seife Yohannes

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Length Of Stay ◽

Performance Improvement ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Intervention Period ◽

Post Intervention ◽

Post Intervention Period ◽

Sepsis And Septic Shock

Abstract Background CMS has implemented the SEP-1 Core Measure, which mandates that hospitals implement sepsis quality improvement initiatives. At our hospital, a 900-bed tertiary hospital, a sepsis performance improvement initiative was implemented in April 2016. In this study, we analyzed patient outcomes before and after these interventions. Methods We studied coding data in patients with a diagnosis of Sepsis reported to CMS using a third-party performance improvement database between October, 2015 and July, 2017. The interventions included a hospital-wide education campaign about sepsis; a 24–7 electronic warning system (EWS) using SIRS criteria; a rapid response nursing team that monitors the EWS; a 24–7 mid-level provider team; a database to monitor compliance and timely treatment; and education in sepsis documentation and coding. We performed a before and after analysis of patient outcomes. Results A total of 4,102 patients were diagnosed with sepsis during the study period. 861 (21%) were diagnosed during the pre-intervention period and 3,241 (80%) were diagnosed in the post-intervention period. The overall incidence of sepsis, severe sepsis, and septic shock were 59%, 13%, and 28% consecutively. Regression analysis showed age, admission through the ED, and severity of illness as independent risk factors for increased mortality. Adjusted for these risk factors, the incidence of severe sepsis and septic was reduced by 5.3% and 6.9% in the post-intervention period, while the incidence of simple sepsis increased by 12%. In the post-intervention period, compliance with all 6 CMS mandated sepsis bundle interventions improved from 11% to 37% (P = 0.01); hospital length of stay was reduced by 1.8 days (P = 0.05); length of stay above predicted was less by 1.5 days (P = 0.05); re-admission rate was reduced by 1.6% (P = 0.05); and death from any sepsis diagnosis was reduced 4.5% (P = 0.01). Based on an average of 2000 sepsis cases at our hospital, this amounted to 90 lives saved per year. Death from severe sepsis and septic shock both were also reduced by 5% (P = 0.01) and 6.5% (P = 0.01). Conclusion A multi-modal sepsis performance improvement initiative reduced the incidence of severe sepsis and septic shock, reduced hospital length of stay, reduced readmission rates, and reduced all-cause mortality. Disclosures All authors: No reported disclosures.

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Comparison of culture-negative and culture-positive sepsis or septic shock: a systematic review and meta-analysis

Critical Care ◽

10.1186/s13054-021-03592-8 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Yuting Li ◽

Jianxing Guo ◽

Hongmei Yang ◽

Hongxiang Li ◽

Yangyang Shen ◽

...

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Length Of Stay ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Length Of Stay ◽

Mechanical Ventilation Duration ◽

Culture Positive ◽

Culture Negative

Abstract Background Mortality and other clinical outcomes between culture-negative and culture-positive septic patients have been documented inconsistently and are very controversial. A systematic review and meta-analysis was performed to compare the clinical outcomes of culture-negative and culture-positive sepsis or septic shock. Methods We searched the PubMed, Cochrane and Embase databases for studies from inception to the 1st of January 2021. We included studies involving patients with sepsis or septic shock. All authors reported our primary outcome of all-cause mortality and clearly compared culture-negative versus culture-positive patients with clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, mechanical ventilation requirements, mechanical ventilation duration and renal replacement requirements). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Seven studies including 22,655 patients were included. The primary outcome of this meta-analysis showed that there was no statistically significant difference in the all-cause mortality between two groups (OR = 0.95; 95% CI, 0.88 to 1.01; P = 0.12; Chi-2 = 30.71; I2 = 80%). Secondary outcomes demonstrated that there was no statistically significant difference in the ICU length of stay (MD = − 0.19;95% CI, − 0.42 to 0.04; P = 0.10;Chi-2 = 5.73; I2 = 48%), mechanical ventilation requirements (OR = 1.02; 95% CI, 0.94 to 1.11; P = 0.61; Chi2 = 6.32; I2 = 53%) and renal replacement requirements (OR = 0.82; 95% CI, 0.67 to 1.01; P = 0.06; Chi-2 = 1.21; I2 = 0%) between two groups. The hospital length of stay of culture-positive group was longer than that of the culture-negative group (MD = − 3.48;95% CI, − 4.34 to − 2.63; P < 0.00001;Chi-2 = 1.03; I2 = 0%). The mechanical ventilation duration of culture-positive group was longer than that of the culture-negative group (MD = − 0.64;95% CI, − 0.88 to − 0.4; P < 0.00001;Chi-2 = 4.86; I2 = 38%). Conclusions Culture positivity or negativity was not associated with mortality of sepsis or septic shock patients. Furthermore, culture-positive septic patients had similar ICU length of stay, mechanical ventilation requirements and renal replacement requirements as those culture-negative patients. The hospital length of stay and mechanical ventilation duration of culture-positive septic patients were both longer than that of the culture-negative patients. Further large-scale studies are still required to confirm these results.

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Circulating neutrophil-derived microparticles associated with the prognosis of patients with sepsis

10.21203/rs.2.23356/v1 ◽

2020 ◽

Author(s):

Hong-Peng Chen ◽

Xiao-Yan Wang ◽

Xiao-Yan Pan ◽

Wang-Wang Hu ◽

Shu-Ting Cai ◽

...

Keyword(s):

Septic Shock ◽

Length Of Stay ◽

Inflammatory Mediators ◽

Survival Curve ◽

Demographic Data ◽

Magnetic Bead ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Sepsis Severity ◽

Micro Particles

Abstract Background To investigate the relationship between plasma neutrophil-derived micro-particles (NDMPs) and sepsis patients’ prognosis. Methods Eighty eligible patients were classified as the sepsis and septic shock group according to the international guidelines. Their demographic data, pro-inflammatory mediators (TNF-α, IL-6 and sTREM-1) and sepsis severity assessment index (PCT, APACHE-II scores, MODS scores, mechanical ventilation time, ICU length of stay (LOS) and total hospital length of stay (LOS)) of the post-admission day 1, 3, 5 and 7 were harvested. Their plasma NDMPs were determined with magnetic bead sorting and nanoparticle tracking analyser (NTA). Survival curve against the circulation NDMPs was constructed. Results The NDMPs level was higher in the septic shock patients than in the sepsis patients on the post ICU admission day 1, 3 and 5 ( P < 0.05). The NDMPs levels were significantly increased with a parallel increase of pro-inflammatory mediators and sepsis severity ( P <0.05) as well as mortality. Conclusions Our data suggested that NDMP may be a biomarker of sepsis severity and mortality but how its role on sepsis prognosis warrants further study.

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Comparison of Culture-Negative and Culture-Positive Sepsis or Septic Shock: A Systematic Review and Meta-Analysis

10.21203/rs.3.rs-220606/v1 ◽

2021 ◽

Author(s):

Yuting Li ◽

Jianxing Guo ◽

Hongmei Yang ◽

Hongxiang Li ◽

Yangyang Shen ◽

...

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Length Of Stay ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Length Of Stay ◽

Mechanical Ventilation Duration ◽

Culture Positive ◽

Culture Negative

Abstract Background: Mortality and other clinical outcomes between culture-negative and culture-positive septic patients have been documented inconsistently and are very controversial. A systematic review and meta-analysis was performed to compare the clinical outcomes of culture-negative and culture-positive sepsis or septic shock.Methods: We searched the PubMed, Cochrane, and Embase databases for studies from inception to the 1st of January 2021. We included studies involving patients with sepsis or septic shock. All authors reported our primary outcome of all-cause mortality and clearly comparing culture-negative versus culture-positive patients with clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, mechanical ventilation requirements, mechanical ventilation duration and renal replacement requirements). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI).Results: Seven studies including 22655 patients were included. The primary outcome of this meta-analysis showed that there was no statistically significant difference in the all-cause mortality between two groups (OR=0.95; 95% CI, 0.88 to 1.01; P=0.12; Chi2=30.71; I2=80%) . Secondary outcomes demonstrated that there was no statistically significant difference in the ICU length of stay(MD=-0.19;95% CI, -0.42 to 0.04; P=0.10;Chi2=5.73; I2=48%), mechanical ventilation requirements(OR=1.05; 95% CI, 0.93 to 1.18; P=0.41; Chi2=5.89; I2=66%) and renal replacement requirements(OR=0.82; 95% CI, 0.67 to 1.01; P=0.06; Chi2=1.21; I2=0%) between two groups. The hospital length of stay of culture-positive group was longer than that of the culture-negative group(MD=-3.48;95% CI, -4.34 to -2.63; P<0.00001;Chi2=1.03; I2=0%). The mechanical ventilation duration of culture-positive group was longer than that of the culture-negative group(MD=-0.64;95% CI, -0.88 to -0.4; P<0.00001;Chi2=4.86; I2=38%).Conclusions: Culture positivity or negativity was not associated with mortality of sepsis or septic shock patients. Furthermore, culture-positive septic patients had similar ICU length of stay, mechanical ventilation requirements and renal replacement requirements as those culture-negative patients. The hospital length of stay and mechanical ventilation duration of culture-positive septic patients were both longer than that of the culture-negative patients. Further large-scale studies are still required to confirm these results.

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Time to First Antimicrobial Administration After Onset of Sepsis in Critically Ill Children

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-20.1.37 ◽

2015 ◽

Vol 20 (1) ◽

pp. 37-44 ◽

Cited By ~ 1

Author(s):

Nicholas M. Fusco ◽

Kristine A. Parbuoni ◽

Jill A. Morgan

Keyword(s):

Intensive Care Unit ◽

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Critically Ill Children ◽

Sepsis And Septic Shock ◽

Antimicrobial Administration

OBJECTIVES: Delay of antimicrobial administration in adult patients with severe sepsis and septic shock has been associated with a decrease in survival to hospital discharge. The primary objective of this investigation was to determine the time to first antimicrobial administration after the onset of sepsis in critically ill children. Secondary objectives included appropriateness of empiric antimicrobials and microbiological testing, fluid resuscitation during the first 24 hours after onset of sepsis, intensive care unit and hospital length of stay, and mortality. METHODS: Retrospective, chart review of all subjects less than or equal to 18 years of age admitted to the pediatric intensive care unit (PICU) with a diagnosis of sepsis between January 1, 2011, and December 31, 2012. RESULTS: A total of 72 subjects met the inclusion criteria during the study period. Median time to first antimicrobial administration by a nurse after the onset of sepsis was 2.7 (0.5–5.1) hours. Cultures were drawn prior to administration of antimicrobials in 91.7% of subjects and were repeated within 48 hours in 72.2% of subjects. Empiric antimicrobial regimens were appropriate in 91.7% of cases. The most common empiric antimicrobial regimens included piperacillin/tazobactam plus vancomycin in 19 subjects (26.4%) and ceftriaxone plus vancomycin in 15 subjects (20.8%). Median PICU length of stay was 129 (64.6–370.9) hours, approximately 5 days, and median hospital length of stay was 289 (162.5–597.1) hours, approximately 12 days. There were 4 deaths during the study period. CONCLUSIONS: Time to first antimicrobial administration after onset of sepsis was not optimal and exceeded the recommendations set forth in international guidelines. At our institution, the process for treating pediatric patients with severe sepsis and septic shock should be modified to increase compliance with national guidelines.

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Duodenum-preserving pancreatic head resections for surgical treatment of paraduodenal pancreatitis

Herald of Pancreatic Club ◽

10.33149/vkp.2020.04.04 ◽

2020 ◽

Vol 49 (4) ◽

pp. 51-54

Author(s):

O. Yu. Usenko ◽

V. M. Kopchak ◽

I. V. Khomiak ◽

A. I. Khomiak ◽

A. V. Malik

Keyword(s):

Surgical Treatment ◽

Length Of Stay ◽

Pain Score ◽

Pain Control ◽

Pancreatic Head ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Study Group ◽

Paraduodenal Pancreatitis

Introduction. Up to date, no consensus exists on the surgical treatment of paraduodenal pancreatitis (PDP). Most authors prefer to perform pancreaticoduodenectomy when surgical treatment is indicated. However, such an aggressive approach may not always be justified for the treatment of benign disease. The aim of our study was to investigate the results of duodenum-preserving pancreatic head resections (DPPHR) for the treatment of PDP. Materials and methods. We performed a retrospective analysis of a database consisting of 112 patients with PDP treated in Shalimov National Institute of Surgery and Transplantology from 2014 to 2019. A total of 45 patients after DPPHR were included to the study. Such modifications of DPPHR as Frey’s, Beger’s and Berne’s procedures were used. The primary study endpoint was pain control assessed according to the Izbicki pain score before surgery and at follow-up visits. Secondary endpoints were defined as complication rate (Clavien — Dindo >2), hospital length of stay and 90-day mortality. All patients were followed-up for the assessment of pain cessation with a median of 33 months (range 8–54 months). Results. There were 42 males (93.3%) and 3 females (6.7%) in the study group. Preoperative Izbicki pain score result was 52.6 points. Follow-up pain score results were significantly lower at 11.7 points. Postoperative complication rate (Clavien — Dindo >2) was measured at 8.9%. Median hospital length of stay was 17.4 days. No mortality was recorded in the study group. All results were statistically significant (p<0.05). Conclusion. Application of DPPHR for the surgical treatment of PDP allows to achieve excellent results in terms of pain control (52.6 and 11.7 points on the Izbicki pain score before surgical intervention and at follow-up), while maintaining low complication (8.9%) and mortality (0%) rates.

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Abstract W P351: A Stroke Above the Rest: A Reengineering of the Interdisciplinary Plan of Care

Stroke ◽

10.1161/str.46.suppl_1.wp351 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Noella J West

Keyword(s):

Length Of Stay ◽

Patient Participation ◽

Stroke Survivor ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Steady Increase ◽

Quality Enhancement ◽

Phone Calls ◽

Stroke Team

Background and Purpose: Patients who are newly diagnosed with a stroke are often overwhelmed due to the devastating nature of their condition. The post-acute phase frequently involves a significant amount of education regarding new medications, treatments, recovery and follow up. Ineffective education may be associated with poor outcomes; therefore information from healthcare professionals should be easily understood by patients and their families. The purpose of this evidence based nursing practice and quality enhancement initiative was to improve the patient outcomes and provide tools to assist patients for reentry into the community. Methods: The reengineered plan of care was implemented by the interdisciplinary Stroke Team. Individual education packets were developed based on diagnosis and specific comorbidities, and took into consideration the concept of health literacy. Communication with the primary care provider as well as providing patients with a thirty-day filled prescription prior to discharge assisted with continuity of care. Follow up phone calls reinforced education. Creation of a listserv provided notification of monthly stroke support group meetings and our yearly stroke retreat. Both programs are tailored to the stroke survivor and caregiver, and have been beneficial to the community. Results: This interdisciplinary initiative contributed to a steady increase in patient’s ratings of communication with doctors, and with a decrease in hospital length of stay for patients who were treated by the Interdisciplinary Stroke Team. In addition, patient participation in the annual Stroke Retreat and patient participation in community stroke programs have increased.Conclusions : Reengineering of the interdisciplinary plan of care improved not only the patient experience, but also better prepared patients and their caregivers for discharge. This quality enhancement initiative was vital in decreasing length of stay and quality of care in the stroke population.

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