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.

Factors relating to mortality in septic patients in Vietnamese intensive care units from a subgroup analysis of MOSAICS II study

Sepsis is the most common cause of in-hospital deaths, especially from low-income and lower-middle-income countries (LMICs). This study aimed to investigate the mortality rate and associated factors from sepsis in intensive care units (ICUs) in an LMIC. We did a multicenter cross-sectional study of septic patients presenting to 15 adult ICUs throughout Vietnam on the 4 days representing the different seasons of 2019. Of 252 patients, 40.1% died in hospital and 33.3% died in ICU. ICUs with accredited training programs (odds ratio, OR: 0.309; 95% confidence interval, CI 0.122–0.783) and completion of the 3-h sepsis bundle (OR: 0.294; 95% CI 0.083–1.048) were associated with decreased hospital mortality. ICUs with intensivist-to-patient ratio of 1:6 to 8 (OR: 4.533; 95% CI 1.621–12.677), mechanical ventilation (OR: 3.890; 95% CI 1.445–10.474) and renal replacement therapy (OR: 2.816; 95% CI 1.318–6.016) were associated with increased ICU mortality, in contrast to non-surgical source control (OR: 0.292; 95% CI 0.126–0.678) which was associated with decreased ICU mortality. Improvements are needed in the management of sepsis in Vietnam such as increasing resources in critical care settings, making accredited training programs more available, improving compliance with sepsis bundles of care, and treating underlying illness and shock optimally in septic patients.

Evidence for the Application of Sepsis Bundles in 2021

Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.

Rapid Response System Improves Sepsis Bundle Compliances and Survival in Hospital Wards for 10 Years

Background: Hospitalized patients can develop septic shock at any time. Therefore, it is important to identify septic patients in hospital wards and rapidly perform the optimal treatment. Although the sepsis bundle has already been reported to improve survival rates, the controversy over evidence of the effect of in-hospital sepsis continues to exist. We aimed to estimate the outcomes and bundle compliance of patients with septic shock in hospital wards managed through the rapid response system (RRS). Methods: A retrospective cohort study of 976 patients with septic shock managed through the RRS at an academic, tertiary care hospital in Korea from 2008 to 2017. Results: Of the 976 enrolled patients, the compliance of each sepsis bundle was high (80.8–100.0%), but the overall success rate of the bundle was low (58.3%). The compliance rate for achieving the overall sepsis bundle increased from 26.5% to 70.0%, and the 28-day mortality continuously decreased from 50% to 32.1% over 10 years. We analyzed the two groups according to whether they completed the overall sepsis bundle or not. Of the 976 enrolled patients, 569 (58.3%) sepsis bundles were completed, whereas 407 (41.7%) were incomplete. The complete bundle group showed lower 28-day mortality than the incomplete bundle group (37.1% vs. 53.6%, p < 0.001). In the multivariate multiple logistic regression model, the 28-day mortality was significantly associated with the complete bundle (adjusted odds ratio (OR), 0.61; 95% confidence intervals (CI), 0.40–0.91; p = 0.017). The obtaining of blood cultures (adjusted OR, 0.45; 95% CI, 0.33–0.63; p < 0.001) and lactate re-measurement (adjusted OR, 0.69; 95% CI, 0.50–0.95; p = 0.024) in each component of the sepsis bundle were associated with the 28-day mortality. Conclusions: The rapid response system provides improving sepsis bundle compliances and survival in patients with septic shock in hospital wards.

Rapid Response System Improves Sepsis Bundle Compliances & Survival in Hospital Wards for 10 Years

Background Hospitalized patients can develop septic shock at any time. Therefore, it is important to identify septic patients in hospital wards and rapidly perform the optimal treatment. Although the sepsis bundle has already been reported to improve survival rates, the controversy over evidence of the effect of in-hospital sepsis continues to exist. We aimed to estimate the outcomes and bundle compliance of patients with septic shock in hospital wards managed through the rapid response system (RRS). Methods Retrospective cohort study of 976 patients with septic shock managed through the RRS at an academic, tertiary care hospital in South Korea from 2008 to 2017. Results Of the 976 enrolled patients, the compliance of each sepsis bundle was high (80.8–100.0%), but the overall success rate of the bundle was low (58.3%). The compliance rate for achieving the overall sepsis bundle increased from 26.5–70.0%, and the 28-day mortality continuously decreased from 50–32.1% over 10 years. We analyzed the two groups according to whether they completed the overall sepsis bundle or not. Of the 976 enrolled patients, 569 (58.3%) sepsis bundles were completed, whereas 407 (41.7%) were incomplete. The complete bundle group showed lower 28-day mortality than the incomplete bundle group (37.1% vs. 53.6%, p < 0.001). In the multivariate multiple logistic regression model, the 28-day mortality was significantly associated with the complete bundle (adjusted odds ratio (OR), 0.58; 95% confidence intervals (CI), 0.39–0.87; p = 0.008). Obtention of blood cultures (adjusted OR, 0.45; 95% CI, 0.33–0.63; p < 0.001) and lactate remeasurement (adjusted OR, 0.69; 95% CI, 0.50–0.95; p = 0.024) in each component of the sepsis bundle were associated with the 28-day mortality. Conclusions The rapid response system provides improving sepsis bundle compliances and survival in patients with septic shock in hospital wards.

COMPLIANCE TO SURVIVING SEPSIS CAMPAIGN HOUR–1 BUNDLE–A CROSS SECTIONAL STUDY AMONG PHYSICIANS INVOLVED IN CRITICAL CARE IN PAKISTAN

Objective: To determine physician’s compliance to surviving sepsis campaign updated Hour-one bundle incritically ill patients in Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: Department of Anaesthesiology, Combined Military Hospital Lahore MedicalCollege, from Jun to Aug 2019. Methodology: This study was carried out among physicians managing critical patients in intensive care units.Participants were asked to fill out a 16-questions survey (work experience, qualification and individual components of surviving sepsis campaign hour-1 bundle. Data was collected using online access to survey and by sending hard copies. Results: Questionnaire was sent to 230 physicians while only 63 responses were received (response rate 27%).Only 45 (71%) respondents were aware of the updated Hour-1 bundle. There was no institutional protocolfor compliance to sepsis bundles in thirty three (55%) responses. 52% respondents used Systemic inflammatoryresponse syndrome (SIRS) criteria to diagnose sepsis while quick Sequential Organ Failure Assessment (qSOFA)was used by 36% respondents. Overall compliance to hour-1 bundle components was only 60%. Lactate levelswas not measured by 35 (55%) respondents while 24 (38%) did not obtain blood cultures before administeringantibiotics. Crystalloid and nor epinephrine was used by all respondents. Overall compliance with all the components of sepsis bundle had strong correlation with post-graduate qualification (p-value 0.001-0.049). Conclusion: Poor compliance to updated sepsis guidelines was one of the major reasons of high sepsis relatedmortality in Pakistan.

Advances in the Approaches Using Peripheral Perfusion for Monitoring Hemodynamic Status

Measures of peripheral perfusion can be used to assess the hemodynamic status of critically ill patients. By monitoring peripheral perfusion status, clinicians can promptly initiate life-saving therapy and reduce the likelihood of shock-associated death. Historically, abnormal perfusion has been indicated by the observation of pale, cold, and clammy skin with increased capillary refill time. The utility of these assessments has been debated given that clinicians may vary in their clinical interpretation of body temperature and refill time. Considering these constraints, current sepsis bundles suggest the need to revise resuscitation guidelines. New technologies have been developed to calculate capillary refill time in the hopes of identifying a new gold standard for clinical care. These devices measure either light reflected at the surface of the fingertip (reflected light), or light transmitted through the inside of the fingertip (transmitted light). These new technologies may enable clinicians to monitor peripheral perfusion status more accurately and may increase the potential for ubiquitous hemodynamic monitoring across different clinical settings. This review will summarize the different methods available for peripheral perfusion monitoring and will discuss the advantages and disadvantages of each approach.

Septic shock in children

Chapter 1 begins by examining the definitions of sepsis and septic shock as subsets of the systemic inflammatory response syndrome, discusses the epidemiology of paediatric sepsis, and provides a structured approach to the assessment of a child with suspected sepsis. The evidence for and limitation of investigations, such as lactate measurement and attempted quantification of cardiac function in paediatric sepsis, is examined. Optimal management strategies for paediatric sepsis remain much studied and debated. This chapter addresses the use of inotropes—both early inotropes and choice of inotropes, intravenous fluids, including the current evidence base for choice of fluids, and the increasingly studied areas of fluid overload and fluid removal (de-resuscitation) following the initial phases of resuscitation. The evidence base for use and timing of antibiotics and steroids is discussed, along with the roles of the supportive therapies renal replacement therapy and extracorporeal membrane oxygenation. Finally, the chapter examines some of the key aspects of the care of patients with sepsis of relevance to intensivists: early goal-directed therapy; sepsis bundles; and the Surviving Sepsis Campaign.