H Fernandes

The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock

OBJECTIVES This study aimed to assess the impact of the duration of organ dysfunction on the outcome of patients with severe sepsis or septic shock. METHODS Clinical data were collected from hospital charts of patients with severe sepsis and septic shock admitted to a mixed intensive care unit from November 2003 to February 2004. The duration of organ dysfunction prior to diagnosis was correlated with mortality. Results were considered significant if p<0.05. RESULTS Fifty-six patients were enrolled. Mean age was 55.6 ± 20.7 years, mean APACHE II score was 20.6 ± 6.9, and mean SOFA score was 7.9 ± 3.7. Thirty-six patients (64.3%) had septic shock. The mean duration of organ dysfunction was 1.9 ± 1.9 days. Within the univariate analysis, the variables correlated with hospital mortality were: age (p=0.015), APACHE II (p=0.008), onset outside the intensive care unit (p=0.05), blood glucose control (p=0.05) and duration of organ dysfunction (p=0.0004). In the multivariate analysis, only a duration of organ dysfunction persisting longer than 48 hours correlated with mortality (p=0.004, OR: 8.73 (2.37–32.14)), whereas the APACHE II score remained only a slightly significant factor (p=0.049, OR: 1.11 (1.00–1.23)). Patients who received therapeutic interventions within the first 48 hours after the onset of organ dysfunction exhibited lower mortality (32.1% vs. 82.1%, p=0.0001). CONCLUSIONS These findings suggest that the diagnosis of organ dysfunction is not being made in a timely manner. The time elapsed between the onset of organ dysfunction and initiation of therapeutic intervention can be quite long, and this represents an important determinant of survival in cases of severe sepsis and septic shock.

Accuracy of different methods for blood glucose measurement in critically ill patients

CONTEXT AND OBJECTIVE Although glucometers have not been validated for intensive care units, they are regularly used. The aim of this study was to compare and assess the accuracy and clinical agreement of arterial glucose concentration obtained using colorimetry (Agluc-lab), capillary (Cgluc-strip) and arterial (Agluc-strip) glucose concentration obtained using glucometry and central venous glucose concentration obtained using colorimetry (Vgluc-lab). DESIGN AND SETTING Cross-sectional study in a university hospital. METHOD Forty patients with septic shock and stable individuals without infection were included. The correlations between measurements were assessed both in the full sample and in subgroups using noradrenalin and presenting signs of tissue hypoperfusion. RESULTS Cgluc-strip showed the poorest correlation (r = 0.8289) and agreement (-9.87 +/- 31.76). It exceeded the limits of acceptable variation of the Clinical and Laboratory Standards Institute in 23.7% of the cases, and was higher than Agluc-lab in 90% of the measurements. Agluc-strip showed the best correlation (r = 0.9406), with agreement of -6.75 +/- 19.07 and significant variation in 7.9%. For Vgluc-lab, r = 0.8549, with agreement of -4.20 +/- 28.37 and significant variation in 15.7%. Significant variation was more frequent in patients on noradrenalin (36.4% versus 6.3%; P = 0.03) but not in the subgroup with hypoperfusion. There was discordance regarding clinical management in 25%, 22% and 15% of the cases for Cgluc-strip, Vgluc-lab and Agluc-strip, respectively. CONCLUSION Cgluc-strip should be avoided, particularly if noradrenalin is being used. This method usually overestimates the true glucose levels and gives rise to management errors. CLINICAL TRIAL REGISTRATION ACTRN12608000513314 (registered as an observational, cross-sectional study).

Quality Improvement Initiatives in Sepsis in an Emerging Country: Does the Institution’s Main Source of Income Influence the Results? An Analysis of 21,103 Patients

Objective: We aimed to assess the results of a quality improvement initiative in sepsis in an emerging setting and to analyze it according to the institutions’ main source of income (public or private). Design: Retrospective analysis of the Latin American Sepsis Institute database from 2005 to 2014. Settings: Brazilian public and private institutions. Patients: Patients with sepsis admitted in the participant institutions. Interventions: The quality improvement initiative was based on a multifaceted intervention. The institutions were instructed to collect data on 6-hour bundle compliance and outcomes in patients with sepsis in all hospital settings. Outcomes and compliance was measured for eight periods of 6 months each, starting at the time of the enrollment in the intervention. The primary outcomes were hospital mortality and compliance with 6-hour bundle. Measurements and Main Results: We included 21,103 patients; 9,032 from public institutions and 12,071 from private institutions. Comparing the first period with the eigth period, compliance with the 6-hour bundle increased from 13.5% to 58.2% in the private institutions (p < 0.0001) and from 7.4% to 15.7% in the public institutions (p < 0.0001). Mortality rates significantly decreased throughout the program in private institutions, from 47.6% to 27.2% in the eighth period (adjusted odds ratio, 0.45; 95% CI, 0.32–0.64). However, in the public hospitals, mortality diminished significantly only in the first two periods. Conclusion: This quality improvement initiative in sepsis in an emerging country was associated with a reduction in mortality and with improved compliance with quality indicators. However, this reduction was sustained only in private institutions.

Role of organisational factors on the ‘weekend effect’ in critically ill patients in Brazil: a retrospective cohort analysis

Introduction Higher mortality for patients admitted to intensive care units (ICUs) during the weekends has been occasionally reported with conflicting results that could be related to organisational factors. We investigated the effects of ICU organisational and staffing patterns on the potential association between weekend admission and outcomes in critically ill patients. Methods We included 59 614 patients admitted to 78 ICUs participating during 2013. We defined ‘weekend admission’ as any ICU admission from Friday 19:00 until Monday 07:00. We assessed the association between weekend admission with hospital mortality using a mixed logistic regression model controlling for both patient-level (illness severity, age, comorbidities, performance status and admission type) and ICU-level (decrease in nurse/bed ratio on weekend, full-time intensivist coverage, use of checklists on weekends and number of institutional protocols) confounders. We performed secondary analyses in the subgroup of scheduled surgical admissions. Results A total of 41 894 patients (70.3%) were admitted on weekdays and 17 720 patients (29.7%) on weekends. In univariable analysis, weekend admitted patients had higher ICU (10.9% vs 9.0%, P<0.001) and hospital (16.5% vs 13.5%, P<0.001) mortality. After adjusting for confounders, weekend admission was not associated with higher hospital mortality (OR 1.05, 95% CI 0.99 to 1.12, P=0.095). However, a ‘weekend effect’ was still observed in scheduled surgical admissions, as well as in ICUs not using checklists during the weekends. For unscheduled admissions, no ‘weekend effect’ was observed regardless of ICU’s characteristics. For scheduled surgical admissions, a ‘weekend effect’ was present only in ICUs with a low number of implemented protocols and those with a reduction in the nurse/bed ratio and not applying checklists during weekends. Conclusions ICU organisational factors, such as decreased nurse-to-patient ratio, absence of checklists and fewer standardised protocols, may explain, in part, increases in mortality in patients admitted to the ICU mortality on weekends.

Implementation of sepsis' treatment protocols in an emerging country from 2005-2014: an analysis of 21,103 patients

Methods Retrospective analysis of the Latin America Sepsis Institute (LASI) database, from 2005 to 2014. Participation was voluntary. The implementation process was based on a multifaceted intervention including a local sepsis team, protocols, screening procedures, laboratory and antibiotics flowchart for emergency department (ED), wards and intensive care units (ICU), checklists, physicians and nurses training nd audit/feedback strategies. After the initial training, the institutions collect data on SSC bundles compliance and hospital outcome in patients with severe sepsis or septic shock in all hospital settings. We included only the institutions with at least 80 patients and at least one year of data collection, excluding patients admitted after the first four years of the campaign. All patients were followed until hospital discharge. We define public institutions as those with the major income coming from public sources and private as those coming from private insurances. Results We included 21,103 patients from 65 institutions being 9,032 from public institutions and 12,071 from private ones. Comparing the 1 semester with the 8 semester, compliance with the 6-hours bundle increased from 13.5% to 58.2% in the private institutions while the public ones improved from 7.4% to 15.7%. Mortality rates significantly decreased throughout the program in private institutions (1st semester: 47.6%, 8 semester: 27.2%; odds ratio (OR): 0.45; 95% confidence interval (CI): 0.32-0.64). However, there is no significant reduction in the public institutions throughout the semesters (1 semester: 61.3%; 8 semester: 54.5%, OR: 0.63; 95%CI: 0.39-1.02). The intervention reduced the mortality rates throughout the semesters in patients from all settings (1 semester vs 8 semester: ED OR: 0.55; 95%CI: 0.38 0.79; wards OR: 0.59; 95%CI: 0.42-0.83; ICU OR: 0.46; 95%CI: 0.39 0.54) although the effect was less consistent in the ICU. In patients from private ED, mortality rates decreased from 38.1 to 21.2% (p < 0.001) while in the public institutions this reduction was not significant (56.3% to 49.8%, p = 0.057).