Advertisement
Protocol-Based Care for Septic Shock

Protocol-Based Care for Septic Shock

Until recently, the hospital mortality of patients with severe sepsis and septic shock was 50%. In 2001, a single-center ED study found that mortality in patients with severe sepsis or septic shock was significantly lower among those treated according to a 6-hour protocol of early goal-directed therapy (EGDT) than for those receiving standard therapy. That study involved a specific protocol in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets. “Many wondered if all the EGDT steps were needed and if changes in critical illness care have since altered the impact of the catheter-guided sepsis care,” says Donald M. Yealy, MD. To address this question, Dr. Yealy and colleagues designed a multicenter trial comparing alternative resuscitation strategies in patients with septic shock. Published in the New England Journal of Medicine, the study tested whether protocol-based resuscitation was superior to usual care. They also tested whether a protocol with central hemodynamic monitoring to guide treatments was superior to a simpler protocol that used bedside exams to trigger care. “We wanted to see if we could achieve better outcomes by simply recognizing septic shock early and treating it aggressively with fluids and vasopressors absent a catheter-based algorithm,” says Dr. Yealy. Key Findings Conducted in 31 U.S. EDs and in 1,351 enrollees, Dr. Yealy and colleagues randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: 1. Protocol-based EGDT given by a dedicated two-person team. 2. Protocol-based standard therapy by the same team that did not require the placement of a central venous catheter, administration ofninotropes, or blood transfusions. 3....

Improving Sepsis Care in the ED

For patients with severe sepsis and septic shock in the ED, studies have shown that goal-directed therapy is effective. However, many EDs throughout the country have not implemented such protocols. In a recent study, a survey was conducted by investigators in New York. The purposes were to identify and address specific barriers to optimal sepsis treatment and to maximize benefits of implementing a planned sepsis treatment initiative. According to findings, several barriers to a quantitative resuscitation protocol for sepsis were identified, including: The inability to perform central venous pressure monitoring. The inability to perform central venous oxygen saturation monitoring. Limited physical space in the ED. Lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians. For physicians, a delay in availability of ICU beds and nursing delays were the greatest barriers. The majority of respondents reported that written protocols would be helpful, even with these perceptions. The authors concluded that the knowledge gaps and procedural hurdles identified by their survey can help inform educational and process components for initiatives to improve sepsis care in the ED. Abstract: Journal of Emergency Nursing, November...

Admission Site Tied to Mortality in Sepsis

Admission for sepsis through the ED, when compared with direct admission to the hospital, appears to be associated with lower early and overall inpatient mortality. Results from a large national sample of hospitalizations with a principal diagnosis of sepsis showed that overall sepsis inpatient mortality was 17.1% for ED admissions, compared with a 19.7% rate for direct admissions. Patients admitted through the ED: Had a greater proportion of comorbid conditions. Were more likely to have Medicaid or be uninsured. Were more likely to be admitted to urban, large bed-size, or teaching hospitals. Abstract: American Journal of Emergency Medicine, March...

Procalcitonin & Antibiotic Decisions

The advent of antibiotic therapy has led to dramatic reductions in mortality and morbidity due to bacterial infections and sepsis. The overuse of antibiotics to treat infections, however, may expose patients to adverse events resulting from use of these agents and by increasing the risk of developing bacterial resistance. To fight the emergence of bacterial resistance to antimicrobial agents, more effective efforts are needed to reduce the inappropriate or unnecessarily prolonged use of antibiotics. A novel approach for determining the need and optimal duration of antibiotic therapy is to use biomarkers of bacterial infections (see also, Procalcitonin: A Biomarker for Early Sepsis Intervention). One such biomarker is procalcitonin (PCT), which has been shown to become up-regulated during bacterial infections. It also appears to mirror the extent and severity of infections. Measuring PCT levels may help physicians more rationally decide on prescriptions and duration of antibiotic therapy in patients with infections. Previous studies have suggested that using clinical algorithms based on PCT levels results in less antibiotic use without negatively affecting clinical outcomes. However, various trials using such algorithms have been conducted largely in European healthcare settings. New Data from Procalcitonin Algorithms In the August 8, 2011 Archives of Internal Medicine, my colleagues and I performed a systematic review of 14 randomized controlled trials that investigated PCT algorithms for antibiotic treatment decisions in adults with respiratory tract infections and sepsis from primary care, ED, and ICU settings. The aim was to summarize the evidence for using PCT measurements and to propose clinical algorithms for use in future trials in the United States. Our analysis revealed no significant differences in mortality...

Sepsis Care Improved in the ED

Sepsis is a life-threatening condition that requires immediate medical attention. The condition occurs when the body’s overwhelming immune response to infection triggers widespread inflammation that drops blood pressure and may lead to shock. Each year, about 750,000 people in the United States get sepsis, and it’s increasingly affecting the elderly population. When patients receive appropriate care in a timely fashion, the death rate associated with sepsis decreases substantially. However, if these patients go into shock, as many as 50% will die from it. Patients can present with sepsis in many ways and are either admitted through the ED or directly admitted to the hospital. While early aggressive resuscitation in patients with severe sepsis can decrease mortality, this requires extensive time and resources (see also, Procalcitonin: A Biomarker for Early Sepsis Intervention). In the February 2011 American Journal of Emergency Medicine, Emilie Powell, MD, MBA, my colleagues, and I had a study published in which we analyzed if patients with sepsis admitted through the ED have lower inpatient mortality than those admitted directly to the hospital . Comparing Inpatient Mortality for Sepsis In our analysis, we analyzed 2008 data from the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample from the AHRQ. The cross-sectional analysis examined hospitalizations with a principal diagnosis of sepsis in institutions with an annual minimum of 25 ED and 25 direct admissions for sepsis. The study controlled for patient and hospital characteristics. We also assessed the likelihood of early inpatient mortality—defined as within 2 days of the admission—and overall inpatient mortality. Nearly 100,000 hospitalizations with a principal diagnosis of sepsis were examined from 290 hospitals. Because...
Page 1 of 212
[ HIDE/SHOW ]