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      Registro observacional y prospectivo de sepsis grave/shock séptico en un hospital terciario de la provincia de Guipúzcoa Translated title: A prospective, observational severe sepsis/septic shock registry in a tertiary hospital in the province of Guipuzcoa (Spain)

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          Abstract

          Objetivo: Conocer las características epidemiológicas y clínicas de los pacientes con sepsis grave/shock séptico ingresados en la unidad de cuidados intensivos del Hospital Donostia, analizar factores pronósticos y compararlos con los datos existentes a nivel nacional. Diseño: Estudio observacional prospectivo durante un periodo consecutivo de 3 años (1 de febrero de 2008-31 de diciembre de 2010). Ámbito: Unidad de cuidados intensivos (UCI) del Hospital Donostia, único hospital de tercer nivel de la provincia de Guipúzcoa, que atiende a una población de 700.000 habitantes. Resultados: A lo largo de este periodo, 6.263 pacientes ingresaron en nuestro servicio; 2.880 fueron pacientes no coronarios y 511 presentaron al ingreso o en su evolución en UCI, un episodio de sepsis grave o shock séptico. Hubo un predominio de varones (66,5%), con una edad media de 63 años y Acute Physiology And Chronic Health Evaluation II (APACHE II) medio de 21. La mayoría fueron de tipo médico (68%), procedentes de planta de hospitalización(53,5%) y el origen más frecuente fue la neumonía (24%). La gran mayoría (73%) presentó shock séptico. La afectación hemodinámica fue la más frecuente, seguida de la renal y respiratoria. En todos los pacientes con shock se utilizó noradrenalina como vasopresor, más de la mitad requirieron ventilación mecánica (VM) y un tercio, hemodiafiltración venovenosa continua (HDFVVC). En el manejo de estos pacientes hubo medidas con aplicación elevada como la realización de hemocultivos o el uso de corticoides pero otros de escasa aplicación como la proteína C activada. La mortalidad en UCI fue del 20,8%, con una estancia media intra-UCI de 14 días. Las variables asociadas a la mortalidad en el análisis multivariante incluyen la presencia de hipoglucemia, la disfunción respiratoria, necesidad de ventilación mecánica, hiperlactacidemia y presencia de trombocitopenia en las primeras 24 horas junto con el origen de la sepsis en UCI o intrahospitalaria. Conclusión: La sepsis grave es una afección frecuente en nuestra unidad, genera elevada morbilidad y tiempo de estancia hospitalaria, además de una alta mortalidad. Las características epidemiológicas y clínicas de nuestros pacientes son similares a las referidas a nivel nacional. Teniendo en cuenta nuestros datos en el cumplimiento de las diferentes medidas de tratamiento, es evidente que quedan aspectos que mejorar.

          Translated abstract

          Objective: To determine the epidemiological and clinical characteristics of the patients with severe sepsis/septic shock admitted to the ICU of Donostia Hospital (Guipuzcoa, Spain), analyzing the prognostic factors and comparing them with the existing data at national level. Design: A prospective observational study was carried out during a consecutive 3-year period (1 Feb. 2008-31 Dec. 2010). Setting: The ICU of Donostia Hospital, the only third level hospital in the province of Guipúzcoa, with a recruitment population of 700,000 inhabitants. Results: In the course of the study period, 6,263 patients were admitted to our Department: 2,880 were non-coronary patients, and 511 suffered a severe sepsis or septic shock episode upon admission or during their stay in the ICU. Males predominated (66.5%), the mean age was 63 years, and the mean Acute Physiology And Chronic Health Evaluation II (APACHE II) score was 21. Most cases were medical (68%) and were admitted from hospital wards (53.5%). The most frequent origin was pneumonia (24%). The great majority of the cases (73%) corresponded to septic shock. Hemodynamic alterations were the most frequent disorders, followed by renal and respiratory impairment. Noradrenalin was used as vasoactive drug in all shock patients; over one-half required mechanical ventilation (MV), and one third required continuous venous-venous hemodiafiltration (CVVHDF). Interventions frequently used in the management of these patients comprised blood cultures or corticosteroid use, while other measures such as activated protein C were little used. The mortality rate in the ICU was 20.8%, with a mean stay in the Unit of 14 days. The parameters associated to mortality in the multivariate analysis included the presence of hypoglycemia, respiratory dysfunction, the need for MV, lactic acid elevation and thrombocytopenia in the first 24hours, together with an origin of sepsis either in the ICU or in the hospital. Conclusions: Severe sepsis is frequent in our unit, generating important morbidity and hospital stay, as well as high mortality. The epidemiological and clinical characteristics of our patients are similar to those described globally at national level. Considering our data in complying with the different treatment measures, it is clear that there is still room for improvement.

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          Most cited references 36

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          Early lactate clearance is associated with improved outcome in severe sepsis and septic shock.

          Serial lactate concentrations can be used to examine disease severity in the intensive care unit. This study examines the clinical utility of the lactate clearance before intensive care unit admission (during the most proximal period of disease presentation) as an indicator of outcome in severe sepsis and septic shock. We hypothesize that a high lactate clearance in 6 hrs is associated with decreased mortality rate. Prospective observational study. An urban emergency department and intensive care unit over a 1-yr period. A convenience cohort of patients with severe sepsis or septic shock. Therapy was initiated in the emergency department and continued in the intensive care unit, including central venous and arterial catheterization, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, and inotropes when appropriate. Vital signs, laboratory values, and Acute Physiology and Chronic Health Evaluation (APACHE) II score were obtained at hour 0 (emergency department presentation), hour 6, and over the first 72 hrs of hospitalization. Therapy given in the emergency department and intensive care unit was recorded. Lactate clearance was defined as the percent decrease in lactate from emergency department presentation to hour 6. Logistic regression analysis was performed to determine independent variables associated with mortality. One hundred and eleven patients were enrolled with mean age 64.9 +/- 16.7 yrs, emergency department length of stay 6.3 +/- 3.2 hrs, and overall in-hospital mortality rate 42.3%. Baseline APACHE II score was 20.2 +/- 6.8 and lactate 6.9 +/- 4.6 mmol/L. Survivors compared with nonsurvivors had a lactate clearance of 38.1 +/- 34.6 vs. 12.0 +/- 51.6%, respectively (p =.005). Multivariate logistic regression analysis of statistically significant univariate variables showed lactate clearance to have a significant inverse relationship with mortality (p =.04). There was an approximately 11% decrease likelihood of mortality for each 10% increase in lactate clearance. Patients with a lactate clearance> or =10%, relative to patients with a lactate clearance <10%, had a greater decrease in APACHE II score over the 72-hr study period and a lower 60-day mortality rate (p =.007). Lactate clearance early in the hospital course may indicate a resolution of global tissue hypoxia and is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hrs of emergency department intervention have improved outcome compared with those with lower lactate clearance.
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            Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain.

            Concern exists that current guidelines for care of patients with severe sepsis and septic shock are followed variably, possibly due to a lack of adequate education. To determine whether a national educational program based on the Surviving Sepsis Campaign guidelines affected processes of care and hospital mortality for severe sepsis. Before and after design in 59 medical-surgical intensive care units (ICUs) located throughout Spain. All ICU patients were screened daily and enrolled if they fulfilled severe sepsis or septic shock criteria. A total of 854 patients were enrolled in the preintervention period (November-December 2005), 1465 patients during the postintervention period (March-June 2006), and 247 patients during the long-term follow-up period 1 year later (November-December 2006) in a subset of 23 ICUs. The educational program consisted of training physicians and nursing staff from the emergency department, wards, and ICU in the definition, recognition, and treatment of severe sepsis and septic shock as outlined in the guidelines. Treatment was organized in 2 bundles: a resuscitation bundle (6 tasks to begin immediately and be accomplished within 6 hours) and a management bundle (4 tasks to be completed within 24 hours). Hospital mortality, differences in adherence to the bundles' process-of-care variables, ICU mortality, 28-day mortality, hospital length of stay, and ICU length of stay. Patients included before and after the intervention were similar in terms of age, sex, and Acute Physiology and Chronic Health Evaluation II score. At baseline, only 3 process-of-care measurements (blood cultures before antibiotics, early administration of broad-spectrum antibiotics, and mechanical ventilation with adequate inspiratory plateau pressure) we had compliance rates higher than 50%. Patients in the postintervention cohort had a lower risk of hospital mortality (44.0% vs 39.7%; P = .04). The compliance with process-of-care variables also improved after the intervention in the sepsis resuscitation bundle (5.3% [95% confidence interval [CI], 4%-7%] vs 10.0% [95% CI, 8%-12%]; P < .001) and in the sepsis management bundle (10.9% [95% CI, 9%-13%] vs 15.7% [95% CI, 14%-18%]; P = .001). Hospital length of stay and ICU length of stay did not change after the intervention. During long-term follow-up, compliance with the sepsis resuscitation bundle returned to baseline but compliance with the sepsis management bundle and mortality remained stable with respect to the postintervention period. A national educational effort to promote bundles of care for severe sepsis and septic shock was associated with improved guideline compliance and lower hospital mortality. However, compliance rates were still low, and the improvement in the resuscitation bundle lapsed by 1 year.
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              EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units.

               ,  B Vallet,  C Brun-Buisson (2004)
              Ten years ago 8.4% of patients in French intensive care units (ICUs) were found to have severe sepsis or shock and 56% died in the hospital. As novel therapies for severe sepsis are emerging, updated epidemiological information is required. An inception cohort study conducted in 206 ICUs of randomly selected hospitals over a 2-week period in 2001, including all patients meeting criteria for clinically or microbiologically documented severe sepsis (with > or =1 organ dysfunction). Among 3738 admissions, 546 (14.6%) patients experienced severe sepsis or shock, of which 30% were ICU-acquired. The median age of patients was 65 years, and 54.1% had at least one chronic organ system dysfunction. The median (range) Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) at onset of severe sepsis were 48 (2-129) and 9 (1-24), respectively. Mortality was 35% at 30 days; at 2 months the mortality rate was 41.9%, and 11.4% of patients remained hospitalized. The median (range) hospital stay was 25 (0-112) days in survivors and 7 (0-90) days in non-survivors. Chronic liver and heart failure, acute renal failure and shock, SAPS II at onset of severe sepsis and 24-h total SOFA scores were the independent risk factors most strongly associated with death. Although the attack rate of severe sepsis in French ICUs appears to have increased over the past decade, its associated mortality has decreased, suggesting improved management of patients. Severe sepsis incurs considerable resources use, and implementation of effective management strategies and continued research efforts are needed.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                medinte
                Medicina Intensiva
                Med. Intensiva
                Elsevier España, S.L. (, , Spain )
                0210-5691
                May 2012
                : 36
                : 4
                : 250-256
                Affiliations
                San Sebastián orgnameHospital Donostia orgdiv1Unidad de Cuidados Intensivos España
                Article
                S0210-56912012000400003
                10.1016/j.medin.2011.10.006
                22154280
                3d28bdfe-1f84-4813-ae65-887ba099e46d

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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                Figures: 0, Tables: 0, Equations: 0, References: 23, Pages: 7
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