Sven-Olaf Kuhn

Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study.

Objective: To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated. Design: Prospective observational before-after cohort study. Setting: Tertiary university hospital in Germany. Patients: All adult medical and surgical ICU patients with severe sepsis and septic shock. Intervention: Implementation of a quality improvement program over 7.5 years. Measurements: The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements. Main Results: A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p < 0.001). Hospital length of stay decreased from 44 to 36 days (p < 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p < 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60–0.84; p < 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53–0.75; p < 0.001), 1–2 L crystalloids within the first 6 hours (hazard ratio 0.67–0.97; p = 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64–0.95; p = 0.012) as predictors for improved survival. Conclusions: The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.

Capnography vs. bronchoscopy for percutaneous tracheostomy placement.

I read the letter regarding the impending collapse of academic anaesthesia with considerable interest (Jackson et al. Anaesthesia 2003; 58: 911–2). As I am a clinical anaesthetist who does quite a bit of research ‘on the side’, I feel I can speak with a certain amount of authority on the issues raised, and perhaps suggest alternative solutions to the rather drastic measures proposed. In any case, their proposals are, in my view, impractical and unlikely to improve the lot of academic departments. There is no doubt that clinical academic departments in all specialties are suffering as a result of changes in funding, training, and the focus of Universities. There is also no doubt that anaesthesia has suffered disproportionately. One does not have to look very far to see why. The collective perception of research by anaesthetists themselves must take some of the blame. The following views are repeatedly expressed to me: 1 Anaesthesia is a service speciality and doesn’t have time for research 2 Anaesthesia is very safe and cannot be improved upon, so clinical research is pointless 3 Basic science is too difficult for anaesthetists to understand 4 Trainees have no interest in research, and in any case it is no longer a career issue. I will deal with each of these in turn. If you think of yourself as a servant, you will be treated as a servant. There is no doubt that the more assertive approach in recent years by the Royal College of Anaesthetists and the Association of Anaesthetists has vastly improved ‘in-theatre’ standards. Trivial operations are no longer performed at bizarre times of night, and consultant cover for trainees has improved beyond recognition in the past 20 years. Nevertheless, Trusts view anaesthetists simply as a means to an end – getting the patients to lie still long enough for the surgeon to perform the operation and thereby reduce the waiting lists. If we offer ourselves up merely as ‘bums on seats’, and perform no other extracurricular activity apart from occasional College activities, we can hardly expect our peers, the local hospital management, major research-funding bodies, or even the Government, to take much notice of what we say. ‘Nobody asked the anaesthetists’ is a frequent complaint. The current controversy surrounding the means of insertion of central lines is a good example. Did anyone from NICE ask you what you thought about it? We only have ourselves to blame. Anaesthesia of itself causes very little major morbidity or mortality in this country. However, in my view, this does not mean we can sit back and let the surgeons take all the blame, tempting as that may be. I have attended several national surgical meetings, and it always strikes me that the surgeons are continually frustrated by complex perioperative issues that limit the type of patient that can undergo a particular operation, and ⁄ or affect outcome. By this I mean such things as nutritional status, preand postoperative fluid balance, pulmonary embolus, wound infection and dehiscence, and MRSA to name but a few. You may think surgeons are a law unto themselves and should sort out their own problems, but I would contend that we are all professionals who have a collective responsibility for the welfare of any patient that we take to theatre. We need to work out how to provide the most relevant pre-operative care, how to maximise intra-operative management, and how to speed their recovery. We are part of the team that brought them into hospital. We have an obligation to get them out., The excuse that basic science is too difficult for anaesthetists to understand is put to me very frequently, and is possibly the scariest. With a very few notable exceptions, the majority of anaesthetic Specialist Registrars are convinced that science is an impenetrable jungle. Many of their consultant colleagues express similar views. In these attitudes, we are no better than the general public. The standard of scientific knowledge and understanding in this country is a national disgrace. Why are we following this herd? Medical schools recruit people with the highest science A-level grades in the country. We need to find out what happens next that turns these bright young people into trainees that are happy to give potent vasopressors without having the faintest idea how they work. Jackson et al. are quite right that we are in danger of turning

Use of the qSOFA Score in the Emergency Department

The quick Sequential Organ Failure Assessment (qSOFA) score is much simpler and faster to accomplish than other screening tools and does not require results from laboratory analyses or invasive monitoring. It represents a useful score for the emergency department and ward. The study by Dr Freund and colleagues1 concluded that “qSOFA resulted in greater prognostic accuracy for in-hospital mortality than did either SIRS [systemic inflammatory response syndrome] or severe sepsis.”

Dexmedetomidine in Patients With Sepsis Requiring Mechanical Ventilation

dic or plastic surgery) with a mean cost of

Discrepant post filter ionized calcium concentrations by common blood gas analyzers in CRRT using regional citrate anticoagulation.

2060 (95% CI,

Is the Method of Modified Percutaneous Tracheostomy Without Bronchoscopic Guidance Really Simple and Safe

1787

Prevalence and clinical implications of anti-PF4/heparin antibodies in intensive care patients: a prospective observational study

2333). Mean fees for MOC were

Fluid Resuscitation in Sepsis: "Get the Balance Right".

257 annually (95% CI,

Do Sepsis-3 criteria facilitate earlier recognition of sepsis and septic shock? A retrospective cohort study

205

Sepsis-3 Is a Positive Evolution in Discrimination Between Septic and Nonseptic Patients As Well As Sepsis Entities, Not a Step Backward

309) (Table 1). In FY 2013, member boards reported