Victor Coba

Early Goal-Directed Therapy in Severe Sepsis and Septic Shock: A Contemporary Review of the Literature

Purpose of review Aggressive approaches to acute diseases such as acute myocardial infarction, trauma, and stroke have improved outcomes. Early goal-directed therapy for severe sepsis and septic shock represents a similar approach. An analysis of the literature assessing external validity and generalizability of this intervention is lacking. Recent findings Eleven peer-reviewed publications (1569 patients) and 28 abstracts (4429 patients) after the original early goal-directed therapy study were identified from academic, community and international settings. These publications total 5998 patients (3042 before and 2956 after early goal-directed therapy). The mean age, sex, APACHE II scores and mortality were similar across all studies. The mean relative and absolute risk reduction was 0.46 ± 26% and 20.3 ± 12.7%, respectively. These findings are superior to the original early goal-directed therapy trial which showed figures of 34% and 16%, respectively. A consistent and similar decrease in healthcare resource consumption was also found. Summary Early goal-directed therapy modulates systemic inflammation and results in significant reductions in morbidity, mortality, and healthcare resource consumption. Early goal-directed therapy has been externally validated and is generalizable across multiple healthcare settings. Because of these robust findings, further emphasis should be placed on overcoming logistical, institutional, and professional barriers to implementation which can save the life of one of every six patients presenting with severe sepsis and septic shock.

The GENESIS Project (GENeralized Early Sepsis Intervention Strategies) A Multicenter Quality Improvement Collaborative

Background: Improved outcomes for severe sepsis and septic shock have been consistently observed with implementation of early best practice intervention strategies or the 6-hour resuscitation bundle (RB) in single-center studies. This multicenter study examines the in-hospital mortality effect of GENeralized Early Sepsis Intervention Strategies (GENESIS) when utilized in community and tertiary care settings. Methods: This study was comprised of 2 strategies to assess treatment. The first was a prospective before-and-after observational comparison of historical controls to patients receiving the RB after implementation of GENESIS in 4 community and 4 tertiary hospitals. The second was a concurrent examination comparing patients not achieving all components of the RB to those achieving all components of the RB in 1 community and 2 tertiary care hospitals after implementation of GENESIS. These 4 subgroups merged to comprise a control (historical controls treated before GENESIS and RB not achieved after GENESIS) group and treatment (patients treated after GENESIS and RB achieved after GENESIS) group for comparison. Results: The control group comprised 1554 patients not receiving the RB (952 before GENESIS and 602 RB not achieved after GENESIS). The treatment group comprised 4801 patients receiving the RB (4109 after GENESIS and 692 RB achieved after GENESIS). Patients receiving the RB (treatment group) experienced an in-hospital mortality reduction of 14% (42.8%-28.8%, P < .001) and a 5.1 day decrease in hospital length of stay (20.7 vs 15.6, P < .001) compared to those not receiving the RB (control group). Similar mortality reductions were seen in the before-and-after (43% vs 29%, P < .001) or concurrent RB not achieved versus achieved (42.5% vs 27.2%, P < .001) subgroup comparisons. Conclusions: Patients with severe sepsis and septic shock receiving the RB in community and tertiary hospitals experience similar and significant reductions in mortality and hospital length of stay. These findings remained consistent when examined in both before-and-after and concurrent analyses. Early sepsis intervention strategies are associated with 1 life being saved for every 7 treated.

The incidence and significance of bacteremia in out of hospital cardiac arrest

BACKGROUND The most common etiology of cardiac arrest is presumed of myocardial origin. Recent retrospective studies indicate that preexisting pneumonia, a form of sepsis, is frequent in patients who decompensate with abrupt cardiac arrest without preceding signs of septic shock, respiratory failure or severe metabolic disorders shortly after hospitalization. The contribution of pre-existing infection on pre and post cardiac arrest events remains unknown and has not been studied in a prospective fashion. We sought to examine the incidence of pre-existing infection in out-of hospital cardiac arrest (OHCA) and assess characteristics associated with bacteremia, the goal standard for presence of infection. METHODS AND RESULTS We prospectively observed 250 OHCA adult patients who presented to the Emergency Department (ED) between 2007 and 2009 to an urban academic teaching institution. Bacteremia was defined as one positive blood culture with non-skin flora bacteria or two positive blood cultures with skin flora bacteria. 77 met pre-defined exclusion criteria. Of the 173 OHCA adults, 65 (38%) were found to be bacteremic with asystole and PEA as the most common presenting rhythms. Mortality in the ED was significantly higher in bacteremic OHCA (75.4%) compared to non-bacteremic OHCA (60.2%, p<0.05). After adjustment for potential confounders, predictive factors associated with bacteremic OHCA were lower initial arterial pH, higher lactate, WBC, BUN and creatinine. CONCLUSIONS Over one-third of OHCA adults were bacteremic upon presentation. These patients have greater hemodynamic instability and significantly increased short-term mortality. Further studies are warranted to address the epidemiology of infection as possible cause of cardiac arrest.

Model Point-of-Care Ultrasound Curriculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management

Objectives. This study was designed to assess the clinical applicability of a Point-of-Care (POC) ultrasound curriculum into an intensive care unit (ICU) fellowship program and its impact on patient care. Methods. A POC ultrasound curriculum for the surgical ICU (SICU) fellowship was designed and implemented in an urban, academic tertiary care center. It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25–50 exams on respective systems or organs for a total not less than 125 studies on ICU. The ICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year. Results. 873 POC ultrasound studies in 203 patients admitted to the surgical ICU were reviewed for analysis. All studies included were done through the POC ultrasound curriculum training. The most common exams performed were 379 lung/pleural exams, 239 focused echocardiography and hemodynamic exams, and 237 abdominal exams. New diagnosis was found in 65.52% of cases (95% CI 0.590, 0.720). Changes in patient management were found in 36.95% of cases (95% CI 0.303, 0.435). Conclusions. Implementation of POC ultrasound in the ICU with a structured fellowship curriculum was associated with an increase in new diagnosis in about 2/3 and change in management in over 1/3 of ICU patients studied.

Racial differences in vasopressor requirements for septic shock.

ABSTRACT Objective: The objective of this study was to compare vasopressor requirements between African American (AA) patients and white patients in septic shock. Methods: This was a retrospective cohort review conducted over a 2-year period measuring total and mean dosage of various vasopressors used between two racial groups during the treatment of patients admitted with septic shock. The study included patients admitted to the intensive care unit with septic shock at an 805-bed tertiary, academic center. All septic shock patients were managed with vasopressors. Vasopressor selection, dosage, and duration were at the discretion of the treating physician. Total, mean, and duration of vasopressor dosing requirements were obtained for study participants. Comorbidities, prehospitalization antihypertensive medication requirements, intravenous fluids given during the septic shock phase, and source of infection were analyzed. Results: One hundred fifty-nine patients with septic shock were analyzed, of which 96 (60.4%) were AAs (P < 0.059). African Americans had higher rates of end-stage renal disease and hypertension compared with whites, 85.7% vs. 14.3% (P < 0.011; odds ratio [OR], 15.684) and 68.3% vs. 31.7% (P < 0.007; OR, 3.357), respectively. Norepinephrine (NE) was administered to 150 patients, 57.2% of which were AAs (P < 0.509). Thirteen patients received dopamine (5% AAs, P < 0.588), 40 patients received phenylephrine (15.7% AAs, P < 0.451), and five patients received epinephrine (1.9% AAs, P < 0.660). Comparing vasopressors between races, only NE showed statistical significance via logistic regression modeling for the AA race in terms of total dosage (AAs 736.8 [SD, 897.3] &mgr;g vs. whites 370 [SD, 554.2] &mgr;g, P < 0.003), duration of vasopressor used (AAs 38.38 [SD, 34.75] h vs. whites 29.09 [SD, 27.11] h, P < 0.037), and mean dosage (AAs 21.08 [SD, 22.23] &mgr;g/h vs. whites 12.37 [SD, 13.86] &mgr;g/h, P < 0.01). Mortality between groups was not significant. Logistic regression identified discrepancy of the mean dose NE in AAs compared with whites, with OR of 1.043 (P = 0.01). Conclusions: African American patients with septic shock were treated with higher doses of NE and required longer duration of NE administration compared with white patients.

Using Ultrasound to Identify the Central Venous Catheter Tip in the Superior Vena Cava

In this case series of 5 patients, ultrasound was used to verify the position of the central venous catheter in the superior vena cava using the supraclavicular approach. In all patients, the position of the catheter in the superior vena cava could be verified and the results compared with a postprocedure chest X ray.

Sepsis Response Team

The transition from sepsis to severe life-threatening disease frequently develops well before admission to an intensive care unit (ICU), often in the pre-hospital setting, the emergency department (ED), general medical-surgical floors, operating room or the outpatient clinic setting. One would hope that as soon as possible after the sepsis syndrome occurs, treatment with resuscitation fluids, restoration of adequate oxygen delivery to the tissues, and antimicrobial therapy would begin. However, optimal care may be delayed for many reasons, including lack of recognition, ED overcrowding and long wait times for ICU beds. Delays to medical emergency teams (MET) and rapid response team involvement may further hinder the availability of expert care to prevent morbidity and mortality. For years we have recognized that delay in care negatively impacts outcome for trauma, myocardial infarction, and stroke.1–3 There is now robust evidence that treatment delay can also negatively impact outcome in sepsis.4–7 This chapter will review the evidence for early intervention in sepsis, models of delivery, and potential obstacles. While a specific team response is not required, a Rapid Response System with a trained efferent limb may provide one mechanism for providing a rapid, coordinated team response to patients presenting to the hospital with signs of sepsis.

Ultrasound Diagnosis of Central Line Guidewire Entrapment With an Inferior Vena Cava Filter

Introduction. Guidewire entrapment with an inferior vena cava (IVC) filter during internal jugular vein central line placement is a rare complication. The diagnosis is made by abdominal X-ray or fluoroscopy, and in the majority of cases, the guidewire is removed by interventional radiology, seldom requiring operative removal. Objective. To describe a case of diagnosing central line guidewire entrapment with an IVC by bedside ultrasound. Data source/Case summary. During the placement of a central venous catheter (CVC) in a 63-year-old man—on postoperative day 7 from small bowel resection with presumed peripherally inserted central catheter sepsis—the authors were unable to remove the guidewire. Bedside ultrasound was used to quickly identify the guidewire entrapment down the IVC to the IVC filter. Conclusion. Bedside ultrasound may aid in the diagnosis and expedite the management of guidewire entrapment with IVC filter, which is on the CVC placement complications.

Recurrent Chyle Aspiration Secondary to a Bronchopleural Fistula Communicating With a Chylothorax

Persistent pneumonia and pulmonary infiltrates are commonly encountered in the intensive care unit. Thorough investigation is needed to uncover and confirm the diagnosis. This report presents a case of persistent pulmonary infiltrate and pleural effusion, which did not resolve despite multiple courses of antibiotics and several attempts of thoracostomy tube drainage. A bronchoscopy was performed that identified chyle aspiration from a persistent chylothorax through a postsurgical bronchopleural fistula.