Krista L. Turner

Validation of a screening tool for the early identification of sepsis.

BACKGROUND Sepsis is the leading cause of mortality in noncoronary intensive care units. Recent evidence based guidelines outline strategies for the management of sepsis and studies have shown that early implementation of these guidelines improves survival. We developed an extensive logic-based sepsis management protocol; however, we found that early recognition of sepsis was a major obstacle to protocol implementation. To improve this, we developed a three-step sepsis screening tool with escalating levels of decision making. We hypothesized that aggressive screening for sepsis would improve early recognition of sepsis and decrease sepsis-related mortality by insuring early appropriate interventions. METHODS Patients admitted to the surgical intensive care unit were screened twice daily by our nursing staff. The initial screen assesses the systemic inflammatory response syndrome parameters (heart rate, temperature, white blood cell count, and respiratory rate) and assigns a numeric score (0-4) for each. Patients with a score of > or = 4 screened positive proceed to the second step of the tool in which a midlevel provider attempts to identify the source of infection. If the patients screens positive for both systemic inflammatory response syndrome and an infection, the intensivist was notified to determine whether to implement our sepsis protocol. RESULTS Over 5 months, 4,991 screens were completed on 920 patients. The prevalence of sepsis was 12.2%. The screening tool yielded a sensitivity of 96.5%, specificity of 96.7%, a positive predictive value of 80.2%, and a negative predictive value of 99.5%. In addition, sepsis-related mortality decreased from 35.1% to 23.3%. CONCLUSIONS The three step sepsis screening tool is a valid tool for the early identification of sepsis. Implementation of this tool and our logic-based sepsis protocol has decreased sepsis-related mortality in our SICU by one third.

The epidemiology of sepsis in general surgery patients

BACKGROUND Sepsis is increasing in hospitalized patients. Our purpose is to describe its current epidemiology in a general surgery (GS) intensive care unit (ICU) where patients are routinely screened and aggressively treated for sepsis by an established protocol. METHODS Our prospective, Institutional Review Board-approved sepsis research database was queried for demographics, biomarkers reflecting organ dysfunction, and mortality. Patients were grouped as sepsis, severe sepsis, or septic shock using refined consensus criteria. Data are compared by analysis of variance, Students t test, and χ test (p<0.05 significant). RESULTS During 24 months ending September 2009, 231 patients (aged 59 years ± 3 years; 43% men) were treated for sepsis. The abdomen was the source of infection in 69% of patients. Several baseline biomarkers of organ dysfunction (BOD) correlated with sepsis severity including lactate, creatinine, international normalized ratio, platelet count, and d-dimer. Direct correlation with mortality was noted with particular baseline BODs including beta natriuretic peptide, international normalized ratio, platelet count, aspartate transaminase, alanine aminotransferase, and total bilirubin. Most patients present with severe sepsis (56%) or septic shock (26%) each with increasing multiple BODs. Septic shock has prohibitive mortality rate (36%), and those who survive septic shock have prolonged ICU stays. CONCLUSION In general surgery ICU patients, sepsis is predominantly caused by intra-abdominal infection. Multiple BODs are present in severe sepsis and septic shock but are notably advanced in septic shock. Despite aggressive sepsis screening and treatment, septic shock remains a morbid condition.

Computer Protocol Facilitates Evidence-Based Care of Sepsis in the Surgical Intensive Care Unit

BACKGROUND Care of sepsis has been the focus of intense research and guideline development for more than two decades. With ongoing success of computer protocol (CP) technology and with publication of Surviving Sepsis Campaign (SSC) guidelines, we undertook protocol development for management of sepsis of surgical intensive care unit patients in mid-2006. METHODS A sepsis protocol was developed and implemented in The Methodist Hospital (TMH) (Houston, TX) surgical intensive care unit (27 beds) together with a sepsis research database. We compare paper-protocol (PP) (2008) and CP (2009) performance and results of the SSC guideline performance improvement initiative (2005-2008). TMH surgical intensive care unit sepsis protocol was developed to implement best evidence and to standardize decision making among surgical intensivists, nurse practitioners, and resident physicians. RESULTS The 2008 and 2009 sepsis protocol cohorts had very similar number of patients, age, % male gender, Acute Physiology and Chronic Health Evaluation scoring system II, and Sequential Organ Failure Assessment scores. The 2008 PP patients had greater baseline lactate concentration consistent with greater mortality rate. Antibiotic agents were administered to 2009 CP cohort patients sooner than 2008 PP cohort patients. Both cohorts received similar volume of intravenous fluid boluses. Comparing 6-hour resuscitation bundle compliance, the 2009 CP cohort was substantially greater than SSC eighth quarter and 2008 PP cohorts (79% vs. 31% vs. 29%), and mortality rate was much less when using the CP (14% vs. 31% vs. 24%). CONCLUSIONS Our comprehensive sepsis protocol has enabled rapid and consistent implementation of evidence-based care, and, implemented as a bedside CP, contributed to decreased mortality rate for management of surgical sepsis.

Update on postinjury nutrition.

Purpose of reviewNutritional supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma, many areas of clinical nutrition remain controversial and not well defined. The benefit of early enteral nutrition in the care of injured patients has been well established, with further benefit derived by the administration of immune-enhancing formulas supplemented with glutamine, arginine, nucleotides, and omega-3-fatty acids. A new paradigm of pharmaconutrition has been developed that separates the administration of immunomodulatory nutrients from that of nutritional support. The optimal utilization and benefit of pharmaconutrients, however, remains unclear, as does the need for full caloric provision in the early postinjury phase. Recent findingsNutrition studies with the greatest reduction in morbidity and mortality are those utilizing specific nutrients. The use of pharmaconutrients to modulate the inflammatory and immune response associated with critical illness seems to provide benefit to critically ill and injured patients. Additionally, studies at least suggest that trauma patients derive comparable if not additional benefit from hypocaloric feeding during the acute phase of injury. SummaryBuilding upon previous well performed studies in trauma patients, the current focus of nutritional investigations center on the use of pharmaconutrients to modulate the inflammatory response and the use of hypocaloric feeds. These practices will be reviewed and evidence presented for their use in critically ill and injured patients.

Antipsychotic use and diagnosis of delirium in the intensive care unit

IntroductionDelirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU.MethodsThis was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU.ResultsDelirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004).ConclusionsThe incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.

Availability of acute care surgeons improves outcomes in patients requiring emergent colon surgery

BACKGROUND The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome. METHODS We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients. RESULTS Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%). CONCLUSIONS Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival.

Computerized clinical decision support improves mortality in intra abdominal surgical sepsis.

BACKGROUND The management of surgical sepsis is challenging because of the complexity of interventions. The authors therefore created a computerized clinical decision support program to facilitate this process, with the goal of improving abdominal sepsis mortality. METHODS The authors evaluated a prospective database for all patients requiring surgery for abdominal sepsis. Patient demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained. Observed mortality was compared with predicted mortality using Fishers exact test. RESULTS Eighty-seven patients met the inclusion criteria. The average age was 59 ± 17.0 years, and 39% were men. The most common source of infection was the colon (45%). The average Acute Physiology and Chronic Health Evaluation II score was 27.6 ± 9.72. The overall actual mortality rate for the cohort was 24% compared with a predicted Acute Physiology and Chronic Health Evaluation II mortality of 62.5% (P < .0001). CONCLUSION The use of computerized clinical decision support results in significantly improved survival in patients with intra-abdominal surgical sepsis.

A multidisciplinary protocol improves electrolyte replacement and its effectiveness

BACKGROUND We implemented a multidisciplinary electrolyte replacement protocol in a tertiary referral center surgical intensive care unit. The purpose of this study was to evaluate its efficacy. METHODS This was a retrospective study. The electrolyte replacement protocol was designed for the replacement of potassium, magnesium, and phosphorous and was nurse driven. Data evaluated included patient demographics and details specific to electrolyte replacement. Univariate analyses were performed by using the Student t test and the Fisher exact test. A P value of <.05 was considered significant. RESULTS After implementation of the protocol, overall electrolyte replacement improved from 70% to 79% (P = .03), and its overall effectiveness increased from 50% to 65% (P = .01). Individual electrolyte replacement, effectiveness, and dosing varied. CONCLUSIONS The implementation of a multidisciplinary electrolyte replacement protocol in a tertiary referral center surgical intensive care unit significantly improved both overall electrolyte replacement and its effectiveness.

Nucleated Red Blood Cells Are Associated with a Higher Mortality Rate in Patients with Surgical Sepsis

BACKGROUND Nucleated red blood cells (NRBCs) are present in certain non-oncologic disease states and are associated with a poor prognosis. The purpose of this study was to evaluate NRBCs as an early prognostic marker for death in patients with surgical sepsis. METHODS Retrospective evaluation of data collected prospectively from 275 patients from our Investigational Review Board-approved surgical sepsis database over a 27-mo period. The NRBC values were correlated with patient outcomes. The χ(2) test was used for testing of categorical variables and the Mann-Whitney U was used for testing of continuous variables. The level of significance was set at 0.05. RESULTS At sepsis recognition, 48 patients (17.5%) were NRBC-positive. The mortality rate was greater in patients who were NRBC positive while in the intensive care unit (ICU); (27% vs. 12%; p=0.007) and during the hospital stay (35.4% vs. 15%; p=0.001). When NRBC-values at all time points are considered, 116 patients (42.2%) were NRBC-positive. The mortality rate was greater in patients who were NRBC-positive in both the ICU (23.3% vs. 8.2%; p<0.001) and during the hospital stay (31% vs. 9.4%; p<0.001). In-hospital and ICU mortality rates increased with increasing NRBC-concentration. For the 153 patients with severe sepsis, NRBC positivity at any time was associated with a higher ICU mortality rate (20% vs. 3.2%; p=0.001). Significant mortality differences did not occur between NRBC-positive and NRBC-negative patients with sepsis (n=48) or septic shock (n=74). CONCLUSIONS Surgical sepsis patients with detectable NRBCs are at higher risk of ICU and in-hospital death than those with non-detectable NRBCs. The mortality difference is underscored in surgical patients with severe sepsis. This study suggests NRBCs may be a biomarker of outcomes in patients with surgical sepsis.

The identification of thyroid dysfunction in surgical sepsis.

BACKGROUND Studies have documented a correlation between hypothyroxinemia and mortality in critically ill patients; however, there are limited data in sepsis. The objective of this study was to assess baseline thyroid function studies and their association with mortality in surgical sepsis. We hypothesized that the relatively decreased levels of free thyroxine (T4), decreased levels of triiodothyronine (T3), and increased thyrotropin-stimulating hormone levels would be associated with mortality. METHODS This was a retrospective review of prospectively collected data in a surgical intensive care unit. Data evaluated included patient demographics, baseline thyroid function studies, and mortality. Patients were categorized as having sepsis, severe sepsis, or septic shock. A value of p < 0.05 was considered significant. RESULTS Within 24 months, 231 septic patients were accrued. The mean age was 59 ± 3 years, and 43% were male. Thirty-nine patients were diagnosed as having sepsis, 131 as having severe sepsis, and 61 as having septic shock. There were no statistically significant differences between the T3, free T4, or thyrotropin-stimulating hormone levels at baseline and the different categorizations of sepsis. T4 levels were increased in all patients but to a significantly lesser extent in those who died. Similarly, T3 levels were significantly decreased in patients who died. CONCLUSION In surgical sepsis, decreased T3 levels at baseline are associated with mortality. These data do not support the administration of levothyroxine (T4) because it is already elevated and would preferentially be converted to reverse T3 (inactive) in critical illness; however, replacement with liothyronine (T3) might be rational. LEVEL OF EVIDENCE Epidemiologic study, level III.