Sepsis and septic shock are life-threatening conditions which may be difficult to diagnose. This poses challenges for clinicians because the early recognition and management of sepsis is crucial in terms of morbidity and mortality. Although published Australian epidemiologic studies of sepsis are scant, a Victorian study (Sundararajan et al 2005 ) conducted over a four year period July 1999 – June 2003 suggests that the overall incidence of sepsis was 1.1 per cent of hospital overnight admissions. This study identifies a mortality rate of 18.4 per cent. Twenty-three point eight per cent of the patients with sepsis received care in an intensive care unit (ICU). Recent literature suggests that 11.8 per hundred admissions to ICU were associated with severe sepsis, with an in-hospital mortality rate of 37.5 per cent increasing to 60 per cent mortality in patients with septic shock. (ARISE 2007). Sepsis has been identified by the NSW RCA Review Committee as an emerging theme, with many of the SAC11 Root Cause Analysis (RCA) reports reflecting a failure to recognise sepsis early or treat adequately. The committee agreed that the issue warranted a more detailed review of RCAs and exploration of IIMS data to identify the extent of the problem. The following example demonstrates the type of incident identified. Weniger anzeigen

Objective: Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in eight countries. Design: Retrospective review of existing national administrative data. We identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible. Setting: United States, France, United Kingdom, Canada, Belgium, Germany, The Netherlands, and Spain. Patients: Not available. Interventions: None. Measurements and main results: No standard definition existed for acute care hospital or intensive care unit beds across countries. Hospital beds varied three-fold from 221/100,000 population in the United States to 593/100,000 in Germany. Adult intensive care unit beds also ranged seven-fold from 3.3/100,000 population in the United Kingdom to 24.0/100,000 in Germany. Volume of intensive care unit admissions per year varied ten-fold from 216/100,000 population in the United Kingdom to 2353/100,000 in Germany. The ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90). There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = -.82). Conclusions: Absolute critical care services vary dramatically between countries with wide differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality. These findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services. Weniger anzeigen

Receipt of fluid and vasopressors, common treatments in septic shock, may affect cardiac function. We sought to determine whether a liberal or restrictive fluid resuscitation strategy was associated with changes in cardiac function. We prospectively studied a subset of patients enrolled in the Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial, performing echocardiography at baseline and at 24 hours after randomization. Among patients who had an echocardiogram performed at 24 hours, we measured left ventricular global longitudinal strain (LV GLS) and right ventricular free-wall longitudinal strain (RVFWLS). We performed linear regressions with dependent variables of LV GLS, change in LV GLS (ΔLV GLS), and RVFWLS using treatment assignment as an independent variable. We adjusted for ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity, mean arterial pressure, and history of congestive heart failure and myocardial infarction. Emergency department and ICUs. Adults with sepsis enrolled in the CLOVERS trial. We enrolled 180 patients. Our analytic cohort comprised 131 patients with an echocardiogram performed at 24 hours. We observed no differences between treatment arms with respect to demographic, clinical, or echocardiographic data at baseline. We observed no association between restrictive fluid assignment and LV GLS (coefficient, 1.22; p = 0.23), ΔLV GLS (-1.97; p = 0.27), or RVFWLS (2.33; p = 0.19). In a subset of patients enrolled in CLOVERS, we observed no association between receipt of fluid and vasopressors and short-term changes in cardiac function. Decreased enrollment may limit inferences. Weniger anzeigen

For hospitalized critically ill adults with suspected sepsis, procalcitonin (PCT) and C-reactive protein (CRP) monitoring protocols can guide the duration of antibiotic therapy, but the evidence of the effect and safety of these protocols remains uncertain. To determine whether decisions based on assessment of CRP or PCT safely results in a reduction in the duration of antibiotic therapy. A multicenter, intervention-concealed randomized clinical trial, involving 2760 adults (≥18 years), in 41 UK National Health Service (NHS) intensive care units, requiring critical care within 24 hours of initiating intravenous antibiotics for suspected sepsis and likely to continue antibiotics for at least 72 hours. From January 1, 2018, to June 5, 2024, 918 patients were assigned to the daily PCT-guided protocol, 924 to the daily CRP-guided protocol, and 918 assigned to standard care. The primary outcomes were total duration of antibiotics (effectiveness) and all-cause mortality (safety) to 28 days. Secondary outcomes included critical care unit data and hospital stay data. Ninety-day all-cause mortality was also collected. Among the randomized patients (mean age 60.2 [SD, 15.4] years; 60.3% males), there was a significant reduction in antibiotic duration from randomization to 28 days for those in the daily PCT-guided protocol compared with standard care (mean duration, 10.7 [SD, 7.6] days for standard care and 9.8 [SD, 7.2] days for PCT; mean difference, 0.88 days; 95% CI, 0.19 to 1.58, P = .01). For all-cause mortality up to 28 days, the daily PCT-guided protocol was noninferior to standard care, where the noninferiority margin was set at 5.4% (19.4% [170 of 878] of patients receiving standard care; 20.9% [184 of 879], PCT; absolute difference, 1.57; 95% CI, -2.18 to 5.32; P = .02). No difference was found in antibiotic duration for standard care vs daily CRP-guided protocol (mean duration, 10.6 [7.7] days for CRP; mean difference, 0.09; 95% CI, -0.60 to 0.79; P = .79). For all-cause mortality, the daily CRP-guided protocol was inconclusive compared with standard care (21.1% [184 of 874] for CRP; absolute difference, 1.69; 95% CI, -2.07 to 5.45; P = .03). Care guided by measurement of PCT reduces antibiotic duration safely compared with standard care, but CRP does not. All-cause mortality for CRP was inconclusive. isrctn.org Identifier: ISRCTN47473244. Weniger anzeigen