3,326 research outputs found

    Sepsis Screening Tool Increased the Usage of Sepsis Order Set

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    Introduction: The sepsis screening tool was launched to improve the usage of the sepsis order set. Objectives: The purposes of this study were to determine whether the sepsis screening tool increased the usage of sepsis order set and whether the tool improved the primary outcomes. This study assessed the association between using sepsis order set and the compliance of the SEP-1 measure (represented by achieving total perfect care), and the primary outcomes. Furthermore, this study assessed association between the compliance with SEP-1 and the primary outcomes. The primary outcomes were a) time zero to antibiotics, b) inpatient length of stay, and c) survival at discharge. Material and Methods: Retrospective study collected data 6 months before and 6 months after the launch of sepsis screening tool at a tertiary academic hospital. A total of 632 patients were studied. The sepsis screening tool was incorporated at the nurse station at triage. The sepsis order set contained treatment guidelines based on the SEP-1 measure. Results: Our findings confirmed that the sepsis screening tool increased the usage of the order set, raised an awareness of the emergency department personnel and improved the adherence to the treatment guidelines by showing that the usage of sepsis order set significantly increased in the postintervention group (p = 0.001). However, we did not find the association between the sepsis screening tool and the primary outcomes or the total perfect care. The utilization of sepsis order set streamlined and standardized the sepsis management, shortened time to antibiotic by 54 minutes (p = 0.001) and reduced length of stay by 1.8 days (p = 0.002). However, there was no significant difference in survival between the group that used the order set and the group that did not use the order set. There was a significant association between sepsis order set use and total perfect care (p \u3c 0.001), which indicated that the order set use increased the compliance with SEP-1 measure. The group that achieved total perfect care significantly associated with all primary outcomes; 102.4 minutes shorter average time zero to antibiotic (p \u3c 0.001), 1.5 days shorter average length of stay (p = 0.004), and better survival at discharge (p \u3c 0.001, 95% CI 0.02 – 0.206, OR 0.064) than the group that did not achieve total perfect care. Conclusions: Our study confirmed that adherence to the standard treatment guidelines improved the treatment outcomes. The sepsis screening tool increased the use of the sepsis order set. When the order set was used, the compliance with the SEP-1 measure increased. The group that used sepsis order set had a significantly shorter length of stay and shorter time to antibiotic. The group that met SEP-1 measure compliance significantly received antibiotics earlier, shorter stay as an inpatient, and better survival. However, we need more studies to confirm the significant association between compliance of SEP-1 measure and the outcomes because this study did not adjust for clinical characteristics and severity of illness

    The Importance of Individual Clinical and Laboratory Indicators in the Differential Diagnosis of Postpartum Septic Complications

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    DergiPark: 439373tmsjAims: To perform a comparative analysis of individual clinical and laboratory indicators in the differential diagnosis of conditionally limited and generalized forms of postpartum septic complications.Methods: The study included 34 patients at Gynecology Department of the Zaporizhzhia Regional Clinical Hospital from 2013 to 2016 with postpartum purulent-septic diseases. Patients were divided into 2 groups. Group I consisted of 15 women who were diagnosed with a conditionally limited postpartum purulent-inflammatory disease (endometritis). Group II included 19 women with generalized forms of postpartum purulent-inflammatory diseases (peritonitis, sepsis). For the diagnosis of Multiple Organ Failure due to sepsis, we used the Sequential (Sepsis-Related) Organ Failure Assessment and quick Sequential (Sepsis-Related) Organ Failure Assessment. The differences between the first and second group were assessed by using the Mann-Whitney U test and STATISTICA Version 10. Results: Body temperature was increased in all 34 patients. The average heart rate in group I was 91.6 ± 8.35 beats/ min and 102.26 ± 16.42 beats/min in group II. The average respiratory rate was 19.07 ± 2.49 breaths/min in group I and 24.16 ± 5.09 breaths/min in group II. In group I, none of the patients scored a total of two or more points on the Sequential (Sepsis-Related) Organ Failure Assessment and quick Sequential (Sepsis-Related) Organ Failure Assessment scales; in group II, there were 5 (26.32%) patients who had scored two points or more on the Sequential (Sepsis-Related) Organ Failure Assessment scale; and 2 (10.53%) patients had scored 2 points or more in the quick Sequential (Sepsis-Related) Organ Failure Assessment scale. Conclusion: Clinical cases of postpartum period with inflammation of uterus and signs of multiple organ failure should be; regarded as a septic state, assessed by the Sequential (Sepsis-Related) Organ Failure Assessment scale as they require urgent medical help

    The 4-Hour Cairns Sepsis Model: a novel approach to predicting sepsis mortality at intensive care unit admission

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    Background: Sepsis commonly causes intensive care unit (ICU) mortality, yet early identification of adults with sepsis at risk of dying in the ICU remains a challenge. Objective: The aim of the study was to derive a mortality prediction model (MPM) to assist ICU clinicians and researchers as a clinical decision support tool for adults with sepsis within 4 h of ICU admission. Methods: A cohort study was performed using 500 consecutive admissions between 2014 and 2018 to an Australian tertiary ICU, who were aged ≄18 years and had sepsis. A total of 106 independent variables were assessed against ICU episode-of-care mortality. Multivariable backward stepwise logistic regression derived an MPM, which was assessed on discrimination, calibration, fit, sensitivity, specificity, and predictive values and bootstrapped. Results: The average cohort age was 58 years, the Acute Physiology and Chronic Health Evaluation III-j severity score was 72, and the case fatality rate was 12%. The 4-Hour Cairns Sepsis Model (CSM-4) consists of age, history of renal disease, number of vasopressors, Glasgow Coma Scale, lactate, bicarbonate, aspartate aminotransferase, lactate dehydrogenase, albumin, and magnesium with an area under the receiver operating characteristic curve of 0.90 (95% confidence interval = 0.84–0.95, p < 0.00001), a Nagelkerke R2 of 0.51, specificity of 0.94, a negative predictive value of 0.98, and almost identical odds ratios during bootstrapping. The CSM-4 outperformed existing MPMs tested on our data set. The CSM-4 also performed similar to existing MPMs in their derivation papers whilst using fewer, routinely collected, and inexpensive variables. Conclusions: The CSM-4 is a newly derived MPM for adults with sepsis at ICU admission. It displays excellent discrimination, calibration, fit, specificity, negative predictive value, and bootstrapping values whilst being easy to use and inexpensive. External validation is required

    Diagnostic utility of Procalcitonin (PCT) for the early detection of sepsis in patients presenting to the emergency department with a qSOFA score of at least one

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    Background: Early sepsis identification can be achieved with the help of effective screening tools and suitable point-of-care biomarkers. With this objective, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) introduced a new screening instrument in 2016 called the quick Sequential Organ Failure Assessment (qSOFA) score. Since the introduction of the qSOFA score, debate has continued over the lack of sensitivity of the score for sepsis recognition in the Emergency Department (ED). The combination of biomarkers of infection like Procalcitonin (PCT) with the qSOFA score might improve the early identification of septic patients in the ED and could be beneficial as a point-of-care biomarker. Main objective: To investigate whether the early measurement of PCT improves the detection of septic patients in an ED population with elevated qSOFA score. Methods: In this large multicentre cohort study, the LIFE-POC study, adult patients presenting with an elevated qSOFA score (≄1) were identified and prospectively recruited at three tertiary care hospital EDs; the CharitĂ© - UniversitĂ€tsmedizin Berlin Campus Mitte and Campus Virchow as well as the University Hospital of Jena. Exclusion criteria were: trauma, acute ST elevation myocardial infarction; pregnancy; suspected stroke and therapy limitation due to short life expectancy. The current analysis included all (n=742) patients from the study sites of the CharitĂ© - UniversitĂ€tsmedizin Berlin. PCT was measured in all enrolled patients upon ED admission. The primary endpoint was sepsis diagnosis within 96 hours after ED admission. The gold standard diagnosis of sepsis was adjudicated according to the sepsis-3 definition by an expertsÂŽ panel. Results: Within the first 96 hours, 27.4% (n=202) of the total study population were diagnosed with sepsis. The area under the receiver operating characteristics curve (AUC) for PCT for sepsis prediction was 0.857 (95% CI: 0.83–0.89; p < 0.0001). PCT levels were significantly higher in septic patients (1.15”g/L; interquartile range (IQR): 0.25-5.07) as compared with non-septic patients (0.10”g/L; IQR: 0.06-0.20; p<0.0001). The optimal cut-off value of PCT that achieved the highest accuracy was 0.5”g/L. PCT at this cut-off value had a sensitivity of 63.6% (95%-CI: 56.5-70.2%), a specificity of 89.4% (95%-CI: 86.5-91.9%), a positive predictive value (PPV) of 69.4% (95%-CI: 63.4-74.7%) and a negative predictive value (NPV) of 86.7% (84.4-88.7%). Conclusions: This prospective cohort study showed that PCT, measured in an ED population with elevated qSOFA score, improved early sepsis identification. Based on these results, early measurement of PCT could thus be recommended as an additional and important component of sepsis screening in the ED.Hintergrund: Die SepsisfrĂŒherkennung in der Notaufnahme kann mit Hilfe wirksamer Screening-Instrumente und geeigneter Point-of-Care-Biomarker verbessert werden. Aus diesem Grund wurde ĂŒber den „Dritten internationalen Konsens fĂŒr Sepsis“ im Jahr 2016 ein neues Screening-Instrument eingefĂŒhrt, der Quick Sequential Organ Failure Assessment (qSOFA)-Score. Seit der EinfĂŒhrung des qSOFA-Scores wird die mangelnde SensitivitĂ€t des Scores fĂŒr die SepsisfrĂŒherkennung in der Notaufnahme (ED) kritisiert. Die Kombination des qSOFA-Scores mit Infektionsparameter, wie Procalcitonin (PCT), könnte geeignet sein, die frĂŒhe Identifikation von septischen Patient*innen in der Notaufnahme zu verbessern. Ziel der Studie: Ziel der Studie ist die Untersuchung der diagnostischen Wertigkeit von PCT zur FrĂŒherkennung der Sepsis in einer Population von Notaufnahmepatient*innen mit erhöhtem qSOFA-Score. Methodik: Bei der LIFE-POC-Studie handelte es sich um eine multizentrische, prospektive Kohortenstudie, die in den Notaufnahmen von drei KrankenhĂ€usern der tertiĂ€ren Versorgung durchgefĂŒhrt wurde; CharitĂ© - UniversitĂ€tsmedizin Berlin Campus Mitte und Campus Virchow sowie UniversitĂ€tsklinikum Jena. Es wurden erwachsene Patient*innen mit nicht-traumatischen VorstellungsgrĂŒnden mit erhöhtem qSOFA-Score in der Notaufnahme eingeschlossen. Ausschlusskriterien waren: akuter ST-Hebungs-Myokardinfarkt, Schwangerschaft, Verdacht auf Schlaganfall und Therapielimitierung aufgrund einer kurzen Lebenserwartung. In die aktuelle Analyse wurden alle (n=742) Patient*innen aus den Berliner Studienzentren der CharitĂ© – UniversitĂ€tsmedizin Berlin einbezogen. PCT wurde bei Aufnahme gemessen. Der primĂ€re Endpunkt war Sepsis innerhalb von 96 Stunden nach Aufnahme. Die Goldstandard-Diagnose der Sepsis wurde gemĂ€ĂŸ der Sepsis-3-Definition von einem Expert*innengremium gestellt. Ergebnisse: Von allen 742 Patient*innen wurde bei 27,4 % (n=202) innerhalb der ersten 96 Stunden eine Sepsis diagnostiziert. Die FlĂ€che unter der Receiver Operating Characteristics (ROC)-Kurve zur Sepsisdiagnose betrug fĂŒr PCT 0.857 (95% CI: 0.83–0.89; p < 0.0001). PCT war bei Patient*innen mit Sepsis signifikant höher (1,15 ”g/L; IQR: 0,25-5,07) im Vergleich zu nicht-septischen Patient*innen (0,10 ”g/L; IQR: 0,06-0,20; p<0,0001). Der optimale Cut-off-Wert fĂŒr PCT lag bei 0,5 ”g/L. Daraus ergab sich eine SensitivitĂ€t von 63,6% (95%-CI: 56,5-70,2%), eine SpezifitĂ€t von 89,4% (95%-CI: 86,5-91,9%), ein PPV von 69,4% (95%-CI: 63,4-74,7%) und ein NPV von 86,7% (84,4-88,7%) fĂŒr die untersuchte Studienpopulation. Schlussfolgerungen: Diese prospektive Kohortenstudie zeigt einen hohen diagnostischen Nutzen von PCT zur SepsisfrĂŒherkennung bei Patient*innen mit erhöhtem qSOFA-Score in der Notaufnahme. Die frĂŒhe Messung von PCT kann basierend auf diesen Ergebnissen als eine zusĂ€tzliche, wichtige Komponente zum Sepsisscreening in der Notaufnahme empfohlen werden

    Improved diagnosis and management of sepsis and bloodstream infection

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    Sepsis is a severe organ dysfunction triggered by infections, and a leading cause of hospitalization and death. Concurrent bloodstream infection (BSI) is common and around one third of sepsis patients have positive blood cultures. Prompt diagnosis and treatment is crucial, but there is a trade-off between the negative effects of over diagnosis and failure to recognize sepsis in time. The emerging crisis of antimicrobial resistance has made bacterial infections more difficult to treat, especially gram-negative pathogens such as Pseudomonas aeruginosa. The overall aim with this thesis was to improve diagnosis, assess the influence of time to antimicrobial treatment and explore prognostic bacterial virulence markers in sepsis and BSI. The papers are based on observational data from 7 cohorts of more than 100 000 hospital episodes. In addition, whole genome sequencing has been performed on approximately 800 invasive P. aeruginosa isolates collected from centers in Europe and Australia. Paper I showed that automated surveillance of sepsis incidence using the Sepsis-3 criteria is feasible in the non-ICU setting, with examples of how implementing this model generates continuous epidemiological data down to the ward level. This information can be used for directing resources and evaluating quality-of-care interventions. In Paper II, evidence is provided for using peripheral oxygen saturation (SpO2) to diagnose respiratory dysfunction in sepsis, proposing the novel thresholds 94% and 90% to get 1 and 2 SOFA points, respectively. This has important implications for improving sepsis diagnosis, especially when conventional arterial blood gas measurements are unavailable. Paper III verified that sepsis surveillance data can be utilized to develop machine learning screening tools to improve early identification of sepsis. A Bayesian network algorithm trained on routine electronic health record data predicted sepsis onset within 48 hours with better discrimination and earlier than conventional NEWS2 outside the ICU. The results suggested that screening may primarily be suited for the early admission period, which have broader implications also for other sepsis screening tools. Paper IV demonstrated that delays in antimicrobial treatment with in vitro pathogen coverage in BSI were associated with increased mortality after 12 hours from blood culture collection, but not at 1, 3, and 6 hours. This indicates a time window where clinicians should focus on the diagnostic workup, and proposes a target for rapid diagnostics of blood cultures. Finally, Paper V showed that the virulence genotype had some influence on mortality and septic shock in P. aeruginosa BSI, however, it was not a major prognostic determinant. Together these studies contribute to better understanding of the sepsis and BSI populations, and provide several suggestions to improve diagnosis and timing of treatment, with implications for clinical practice. Future works should focus on the implementation of sepsis surveillance, clinical trials of time to antimicrobial treatment and evaluating the prognostic importance of bacterial genotype data in larger populations from diverse infection sources and pathogens

    Sepsis Team Organizational Model to Decrease Mortality for Intra-Abdominal Infections: Is Antibiotic Stewardship Enough?

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    Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms “sepsis” AND “intra-abdominal infections” AND (“antibiotic therapy” OR “antibiotic treatment”). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient’s characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI

    Separator fluid volume requirements in multi-infusion settings

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    INTRODUCTION. Intravenous (IV) therapy is a widely used method for the administration of medication in hospitals worldwide. ICU and surgical patients in particular often require multiple IV catheters due to incompatibility of certain drugs and the high complexity of medical therapy. This increases discomfort by painful invasive procedures, the risk of infections and costs of medication and disposable considerably. When different drugs are administered through the same lumen, it is common ICU practice to flush with a neutral fluid between the administration of two incompatible drugs in order to optimally use infusion lumens. An important constraint for delivering multiple incompatible drugs is the volume of separator fluid that is sufficient to safely separate them. OBJECTIVES. In this pilot study we investigated whether the choice of separator fluid, solvent, or administration rate affects the separator volume required in a typical ICU infusion setting. METHODS. A standard ICU IV line (2m, 2ml, 1mm internal diameter) was filled with methylene blue (40 mg/l) solution and flushed using an infusion pump with separator fluid. Independent variables were solvent for methylene blue (NaCl 0.9% vs. glucose 5%), separator fluid (NaCl 0.9% vs. glucose 5%), and administration rate (50, 100, or 200 ml/h). Samples were collected using a fraction collector until <2% of the original drug concentration remained and were analyzed using spectrophotometry. RESULTS. We did not find a significant effect of administration rate on separator fluid volume. However, NaCl/G5% (solvent/separator fluid) required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). Also, G5%/G5% required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). The significant decrease in required flushing volume might be due to differences in the viscosity of the solutions. However, mean differences were small and were most likely caused by human interactions with the fluid collection setup. The average required flushing volume is 3.7 ml. CONCLUSIONS. The choice of separator fluid, solvent or administration rate had no impact on the required flushing volume in the experiment. Future research should take IV line length, diameter, volume and also drug solution volumes into account in order to provide a full account of variables affecting the required separator fluid volume

    Acute lung injury in paediatric intensive care: course and outcome

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    Introduction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) carry a high morbidity and mortality (10-90%). ALI is characterised by non-cardiogenic pulmonary oedema and refractory hypoxaemia of multifactorial aetiology [1]. There is limited data about outcome particularly in children. Methods This retrospective cohort study of 85 randomly selected patients with respiratory failure recruited from a prospectively collected database represents 7.1% of 1187 admissions. They include those treated with High Frequency Oscillation Ventilation (HFOV). The patients were admitted between 1 November 1998 and 31 October 2000. Results: Of the 85, 49 developed acute lung injury and 47 had ARDS. There were 26 males and 23 females with a median age and weight of 7.7 months (range 1 day-12.8 years) and 8 kg (range 0.8-40 kg). There were 7 deaths giving a crude mortality of 14.3%, all of which fulfilled the Consensus I [1] criteria for ARDS. Pulmonary occlusion pressures were not routinely measured. The A-a gradient and PaO2/FiO2 ratio (median + [95% CI]) were 37.46 [31.82-43.1] kPa and 19.12 [15.26-22.98] kPa respectively. The non-survivors had a significantly lower PaO2/FiO2 ratio (13 [6.07-19.93] kPa) compared to survivors (23.85 [19.57-28.13] kPa) (P = 0.03) and had a higher A-a gradient (51.05 [35.68-66.42] kPa) compared to survivors (36.07 [30.2-41.94]) kPa though not significant (P = 0.06). Twenty-nine patients (59.2%) were oscillated (Sensormedics 3100A) including all 7 non-survivors. There was no difference in ventilation requirements for CMV prior to oscillation. Seventeen of the 49 (34.7%) were treated with Nitric Oxide including 5 out of 7 non-survivors (71.4%). The median (95% CI) number of failed organs was 3 (1.96-4.04) for non-survivors compared to 1 (0.62-1.62) for survivors (P = 0.03). There were 27 patients with isolated respiratory failure all of whom survived. Six (85.7%) of the non-survivors also required cardiovascular support.Conclusion: A crude mortality of 14.3% compares favourably to published data. The A-a gradient and PaO2/FiO2 ratio may be of help in morbidity scoring in paediatric ARDS. Use of Nitric Oxide and HFOV is associated with increased mortality, which probably relates to the severity of disease. Multiple organ failure particularly respiratory and cardiac disease is associated with increased mortality. ARDS with isolated respiratory failure carries a good prognosis in children

    Modern approaches to sepsis - evolving definitions, clinician roles, and AI-based diagnostic aids

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    Sepsis is an ongoing concern in critical care. It is hard to quickly detect, and rapid deterioration of a patient into septic shock causes death in around 30% - 50% of patients, while survivors may live with organ damage and shorter lifespans. Traditional methods of detection require long laboratory tests and clinician vigilance, which put a strain on hospital resources. New advances in machine learning offer an alternative – using algorithmic analysis in real-time to watch for a deteriorating patient state. The use of readily available data – heart rate, respiratory rate – combined with electronic medical records and fast laboratory tests presents an opportunity for early detection of sepsis, which can potentially make great strides in minimizing damage to patients. A variety of algorithmic methods have been proposed by researchers, and research so far has been promising. Algorithms inretrospective studies have performed equal or better to standard protocols such as SIRS or SOFA. Some promising research even presents the opportunity to approach sepsis diagnosis and treatment in an entirely new manner. At the present stage, however, the field is at too early a stage for use in a clinical environment. This review intends to review some prominent types of machine learning algorithms, as well as discuss current concerns regarding machine learning-based detection support systems (ML-DSS)
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