A Pediatric Sepsis Protocol Reduced Mortality and Dysfunctions in a Brazilian Public Hospital

Introduction: Few studies in the literature discuss the benefits of compliance with sepsis bundles in hospitals in low- and middle-income countries, where resources are limited and mortality is high.Methods: This is a retrospective cohort study conducted at a public hospital in a low-income region in Brazil. We evaluated whether completion of a sepsis bundle is associated with reduced in-hospital mortality for sepsis, severe sepsis, and septic shock, as well as prevention of septic shock and organ dysfunction. Bundle compliance required the completion of three items: (1) obtaining blood count and culture, arterial or venous blood gases, and arterial or venous lactate levels; (2) antibiotic infusion within the first hour of diagnosis; and (3) infusion of 10–20 ml/kg saline solution within the first hour of diagnosis.Results: A total of 548 children with sepsis, severe sepsis, or septic shock who were treated at the emergency room from February 2008 to August of 2016 were included in the study. Of those, 371 patients were included in the protocol group and had a lower median length of stay (3 days vs. 11 days; p < 0.001), fewer organ dysfunctions during hospitalization (0 vs. 2, p < 0.001), and a lower probability of developing septic shock. According to a propensity score analysis, mortality was lower during the post-implementation period [2.75 vs. 15.4% (RR 95%IC 0.13 (0.06, 0.27); p < 0.001)].Conclusions: A simple and low-cost protocol was feasible and yielded good results at a general hospital in a low-income region in Brazil. Protocol use resulted in decreased mortality and progression of dysfunctions and was associated with a reduced probability of developing septic shock.

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Diagnostic Validity of Ratio between Differences of Central Venous to Arterial CO2 and Arterial to Central Venous O2 Content in Diagnosis of Anaerobic Metabolism among Septic Patients

Journal of Current and Advance Medical Research ◽

10.3329/jcamr.v8i1.52548 ◽

2021 ◽

Vol 8 (1) ◽

pp. 34-38

Author(s):

Subroto Kumar Sarker ◽

Umme Kulsum Choudhury ◽

Mohammad Mohsin ◽

Subrata Kumar Mondal ◽

Muslema Begum

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Anaerobic Metabolism ◽

Venous Blood ◽

Blood Gases ◽

Serum Lactate ◽

Central Venous ◽

College Hospital ◽

Sepsis And Septic Shock

Background: Detection of anaerobic metabolism is very crucial for the management of the septic patients. Objective: The purpose of the present study was to validate the ratio between differences of central venous to arterial CO2 and arterial to central venous O2 content in diagnosis of anaerobic metabolism among septic patients. Methodology: This prospective observational study was conducted in the Intensive Care Unit of the department of Anaesthesia Analgesia, Palliative and Intensive Care Medicine at Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2016 to December 2016. All patients admitted to ICU with the features of severe sepsis and septic shock according to SSC guidelines with the age of more than or equal to 18 years in both sexes were included in this study. The arterial and central venous blood gases were measure simultaneously. At the same time serum lactate was measured. Result: Among the 69 patients, 31(44.9%) were of severe sepsis and 38(55%) were of septic shock patients. In the severe sepsis and septic shock patients the mean P(v-a)CO2/C(a-v)O2 is 1.39±0.41 and 1.11±0.40 respectively. Serum lactate in case of severe sepsis and septic shock patients is 2.85±1.40 and 3.85±1.04 respectively. The ROC analysis showed an area under curve 0.89 and P(v-a)CO2/C(a-v)O2 ratio cutoff value of 1.21 showed sensitivity 0.84 and specificity 0.94. Conclusion: The P(v-a)CO2/C(a-v)O2 ratio is also a another marker of global anaerobic metabolism and it would be used for diagnosis as well as management of septic patient. Journal of Current and Advance Medical Research, January 2021;8(1):34-38

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Utility of venous blood gases in severe sepsis and septic shock

Baylor University Medical Center Proceedings ◽

10.1080/08998280.2018.1460133 ◽

2018 ◽

Vol 31 (3) ◽

pp. 269-275 ◽

Cited By ~ 1

Author(s):

Heath D. White ◽

Alfredo Vazquez-Sandoval ◽

Pedro F. Quiroga ◽

Juhee Song ◽

Shirley F. Jones ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Venous Blood ◽

Blood Gases ◽

Sepsis And Septic Shock

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The Implementation of Sepsis Bundles on the Outcome of Patients with Severe Sepsis or Septic Shock in Intensive Care Units

International Journal of Gerontology ◽

10.1016/j.ijge.2013.01.016 ◽

2014 ◽

Vol 8 (2) ◽

pp. 60-65 ◽

Cited By ~ 2

Author(s):

Shu-Lien Chou ◽

Khee-Siang Chan ◽

Kuo-Chen Cheng ◽

Willy Chou ◽

Hui-Mei Hung ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Intensive Care Units ◽

Sepsis Bundles

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Lactate levels from arterial, central venous and peripheral venous blood in severe sepsis and septic shock patients

Critical Care ◽

10.1186/cc5612 ◽

2007 ◽

Vol 11 (Suppl 2) ◽

pp. P452 ◽

Cited By ~ 1

Author(s):

M Assuncao ◽

A Nascente ◽

C Guedes ◽

B Mazza ◽

M Jacki ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Venous Blood ◽

Central Venous ◽

Peripheral Venous Blood ◽

Lactate Levels ◽

Sepsis And Septic Shock

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The Use of an Early Alert System to Improve Compliance with Sepsis Bundles and to Assess Impact on Mortality

Critical Care Research and Practice ◽

10.1155/2012/980369 ◽

2012 ◽

Vol 2012 ◽

pp. 1-8 ◽

Cited By ~ 9

Author(s):

Jennifer Anne LaRosa ◽

Noeen Ahmad ◽

Monica Feinberg ◽

Monica Shah ◽

Roseann DiBrienza ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Screening Tool ◽

Severity Of Illness ◽

Antibiotic Administration ◽

Alert System ◽

Sepsis Management ◽

Sepsis Bundles ◽

Improve Compliance ◽

Early Alert

Introduction. Diagnostic and therapeutic guidelines, organized as sepsis bundles, have been shown to improve mortality, but timely and consistent implementation of these can be challenging. Our study examined the use of a screening tool and an early alert system to improve bundle compliance and mortality.Methods. A screening tool was used to identify patients with severe sepsis or septic shock and an overhead alert system known as Code SMART (Sepsis Management Alert Response Team) was activated at the physician’s discretion. Data was collected for 6 months and compliance with bundle completion and mortality were compared between the Code SMART and non-Code SMART groups.Results.Fifty eight patients were enrolled −34 Code SMART and 24 non-Code SMART. The Code SMART group achieved greater compliance with timely antibiotic administration (P<0.001), lactate draw (P<0.001), and steroid use (P=0.02). Raw survival and survival adjusted for age, leucopenia, and severity of illness scores, were greater in the Code SMART group (P<0.05,P=0.03, andP=0.01).Conclusions. A screening tool and an alert system can improve compliance with sepsis bundle elements and improve survival from severe sepsis and septic shock.

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An affordable anti-SARS-COV-2 spike protein ELISA test for early detection of IgG seroconversion suited for large-scale surveillance studies in low-income countries

10.1101/2020.07.13.20152884 ◽

2020 ◽

Cited By ~ 1

Author(s):

Renata G. F. Alvim ◽

Tulio M. Lima ◽

Danielle A. S. Rodrigues ◽

Federico F. Marsili ◽

Vicente B. T. Bozza ◽

...

Keyword(s):

Low Income ◽

Large Scale ◽

Low Cost ◽

Venous Blood ◽

Hek293 Cells ◽

Epidemiological Surveillance ◽

Low Income Countries ◽

Serological Tests ◽

S Protein ◽

Surveillance Studies

AbstractBackgroundAccurate serological tests are essential tools to allow adequate monitoring and control of COVID-19 spread. Production of a low-cost and high-quality recombinant viral antigen can enable the development of reliable and affordable serological assays, which are urgently needed to facilitate epidemiological surveillance studies in low-income economies.MethodsTrimeric SARS-COV-2 spike (S) protein was produced in serum-free, suspension-adapted HEK293 cells. Highly purified S protein was used to develop an ELISA, named S-UFRJ test. It was standardized to work with different types of samples: (i) plasma or serum from venous blood samples; (ii) eluates from dried blood spots (DBS) obtained by collecting blood drops from finger prick.FindingsWe developed a cost-effective, scalable technology to produce S protein based on its stable expression in HEK293 cells. Using this recombinant antigen we presented a workflow for test development in the setting of a pandemic, starting from limited amounts of samples up to reaching final validation with hundreds of samples. Test specificity was determined to be 98.6%, whereas sensitivity was 95% for samples collected 11 or more days after symptoms onset. A ROC analysis allowed optimizing the cut-off and confirming the high accuracy of the test. Endpoint titers were shown to correlate with virus neutralization assessed as PRNT90. There was excellent agreement between plasma and DBS samples, significantly simplifying sample collection, storing and shipping. An overall cost estimate revealed that final retail price could be in the range of one US dollar.InterpretationThe S-UFRJ assay developed herein meets the quality requirements of high sensitivity and specificity. The low cost and the use of mailable DBS samples allow for serological surveillance of populations regardless of geographical and socio-economic aspects, with special relevance for public health policy actions in low-income countries.FundingCTG, Senai DN/CETIQT, FAPERJ, CNPq, CAPES and Instituto Serrapilheira.

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Hemodynamic and anti-inflammatory effects of early esmolol use in hyperkinetic septic shock: a pilot study

Critical Care ◽

10.1186/s13054-020-03445-w ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Bruno Levy ◽

Caroline Fritz ◽

Caroline Piona ◽

Kevin Duarte ◽

Andrea Morelli ◽

...

Keyword(s):

Heart Rate ◽

Septic Shock ◽

Cardiac Index ◽

Arterial Pressure ◽

Beta Blockers ◽

Venous Pressure ◽

Venous Blood ◽

Blood Gases ◽

Systolic Arterial Pressure ◽

Increased Risk

Abstract Background Several studies have shown that heart rate control with selective beta-1 blockers in septic shock is safe. In these trials, esmolol was administered 24 h after onset of septic shock in patients who remained tachycardic. While an earlier use of beta-blockers might be beneficial, such use remains challenging due to the difficulty in distinguishing between compensatory and non-compensatory tachycardia. Therefore, the Esmosepsis study was designed to study the effects of esmolol aimed at reducing the heart rate by 20% after the initial resuscitation process in hyperkinetic septic shock patients on (1) cardiac index and (2) systemic and regional hemodynamics as well as inflammatory patterns. Methods Nine consecutive stabilized tachycardic hyperkinetic septic shock patients treated with norepinephrine for a minimum of 6 h were included. Esmolol was infused during 6 h in order to decrease the heart rate by 20%. The following data were recorded at hours H0 (before esmolol administration), H1–H6 (esmolol administration) and 1 h after esmolol cessation (H7): systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, central venous pressure, heart rate, PICCO transpulmonary thermodilution, sublingual and musculo-cutaneous microcirculation, indocyanine green clearance and echocardiographic parameters, diuresis, lactate, and arterial and venous blood gases. Results Esmolol was infused 9 (6.4–11.6) hours after norepinephrine introduction. Esmolol was ceased early in 3 out of 9 patients due to a marked increase in norepinephrine requirement associated with a picture of persistent cardiac failure at the lowest esmolol dose. For the global group, during esmolol infusion, norepinephrine infusion increased from 0.49 (0.34–0.83) to 0.78 (0.3–1.11) µg/min/kg. The use of esmolol was associated with a significant decrease in heart rate from 115 (110–125) to 100 (92–103) beats/min and a decrease in cardiac index from 4.2 (3.1–4.4) to 2.9 (2.5–3.7) l/min/m−2. Indexed stroke volume remained unchanged. Cardiac function index and global ejection fraction also markedly decreased. Using echocardiography, systolic, diastolic as well as left and right ventricular function parameters worsened. After esmolol cessation, all parameters returned to baseline values. Lactate and microcirculatory parameters did not change while the majority of pro-inflammatory proteins decreased in all patients. Conclusion In the very early phase of septic shock, heart rate reduction using fast esmolol titration is associated with an increased risk of hypotension and decreased cardiac index despite maintained adequate tissue perfusion (NCT02068287).

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Additional Telemedicine Rounds as a Successful Performance-Improvement Strategy for Sepsis Management: Observational Multicenter Study (Preprint)

10.2196/preprints.11161 ◽

2018 ◽

Cited By ~ 1

Author(s):

Robert Deisz ◽

Susanne Rademacher ◽

Katrin Gilger ◽

Rudolf Jegen ◽

Barbara Sauerzapfe ◽

...

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Length Of Stay ◽

Performance Improvement ◽

Multicenter Study ◽

Sepsis Management ◽

Sepsis Bundles ◽

Improvement Programs ◽

Sepsis And Septic Shock ◽

Effective Component

BACKGROUND Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians. OBJECTIVE Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. METHODS We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated. RESULTS In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046). CONCLUSIONS Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management.

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Development and Large-Scale Validation of A Highly Accurate SARS-COV-2 Serological Test Using Regular Test Strips for Autonomous and Affordable Finger-Prick Sample Collection, Transportation, and Storage

10.21203/rs.3.rs-668316/v1 ◽

2021 ◽

Author(s):

Renata G.F. Alvim ◽

Tulio M. Lima ◽

Danielle A. S. Rodrigues ◽

Federico F. Marsili ◽

Vicente B. T. Bozza ◽

...

Keyword(s):

Low Income ◽

Large Scale ◽

Serological Test ◽

Low Cost ◽

Venous Blood ◽

Hek293 Cells ◽

Epidemiological Surveillance ◽

Sample Collection ◽

S Protein ◽

Finger Prick

Abstract Accurate serological tests are essential tools to allow adequate monitoring and control of COVID-19 spread. Production of a low-cost and high-quality recombinant viral antigen can enable the development of reliable and affordable serological assays, which are urgently needed to facilitate epidemiological surveillance studies in low-income economies. Trimeric SARS-COV-2 spike (S) protein was produced in serum-free, suspension-adapted HEK293 cells. Highly purified S protein was used to develop an ELISA, named S-UFRJ test. It was standardized to work with different types of samples: (i) plasma or serum from venous blood samples; (ii) eluates from dried blood spots (DBS) obtained by collecting blood drops from a finger prick. We developed a cost-effective, scalable technology to produce S protein based on its stable expression in HEK293 cells. Using this recombinant antigen, we presented a workflow for test development in the setting of a pandemic, starting from limited amounts of samples up to reaching final validation with hundreds of samples. Test specificity was determined to be 98.6%, whereas sensitivity was 95% for samples collected 11 or more days after symptoms onset. A ROC analysis allowed optimizing the cut-off and confirming the high accuracy of the test. Endpoint titers were shown to correlate with virus neutralization assessed as PRNT90. There was excellent agreement between plasma and DBS samples, significantly simplifying sample collection, storing, and shipping. An overall cost estimate revealed that the final retail price could be in the range of one US dollar. The S-UFRJ assay developed herein meets the quality requirements of high sensitivity and specificity. The low cost and the use of mailable DBS samples allow for serological surveillance and follow-up of SARS-CoV-2 vaccination of populations regardless of geographical and socio-economic aspects. We hope the detailed guidelines for the development of an affordable and accurate anti-spike SARS-COV-2 ELISA, such as S-UFRJ described here, will stimulate governmental and non-governmental health agencies in other countries to engage in much-needed large-scale studies monitoring the spread and immunity to SARS-COV-2 infection.

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