Early Management Of Sepsis Research Articles

Emergency department management of early sepsis: a national survey of emergency medicine and intensive care consultants

ObjectivesEarly goal-directed therapy (EGDT) is recommended for sepsis management in current guidelines, but the underpinning evidence is controversial. Clinician beliefs and the capacity to implement all recommended elements of EGDT...

Acute kidney injury applying pRifle scale in Children of Hospital Universitario del Valle in Cali, Colombia: clinical features, management and evolution

To know the epidemiology of Acute Kidney Injury (AKI) in the pediatric population at Hospital Universitario del Valle (HUV), a tertiary University Hospital in Cali, Colombia. We obtained a series of cases through daily surveillance for a seven-month period (June 1 to December 31, 2009) in patients older than 30 days and under 18 years at HUV. We excluded patients with previous diagnosis of chronic renal failure. The new pRIFLE scale was used to define AKI. 27 patients were detected, with mean age of 36 months. Incidence of AKI was 0.38% from pediatric admissions and 6.2% from the pediatric intensive care unit (pICU) admissions. The pRIFLE scale at study entrance was: Risk: 2 patients, Injury: 8, Failure: 17. Etiology of AKI was: pre-renal in 89%, primary renal disease in 3.7%, and post-renal in 7.4%. There was an association of AKI with sepsis in 66.7% and 48.2% progressed to septic shock. Six patients required renal replacement therapy, all required peritoneal dialysis. The AKI was multi-factorial in 59.3% and associated with systemic multi-organ failure in 59.3%. At study entry, 63% patients were in pICU. The average hospital stay was 21.3 ± 9.2 days. Six children died, 16 resolved AKI, and nine were left with renal sequelae. We recommended pRIFLE scale for early diagnosis of AKI in all pediatric services. Education in pRIFLE scale, prevention of AKI, and early management of sepsis and hypovolemia is recommended.

Early Diagnosis and Evidence-Based Care of Surgical Sepsis

Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.

Principles of Source Control in the Early Management of Sepsis

Source control refers to the spectrum of physical measures that are undertaken to control a focus of infection, and to facilitate restoration of optimal anatomy and physiology. These measures are classified as drainage-the evacuation of infected liquid through the creation of a controlled sinus or fistula, debridement-the physical removal of necrotic infected tissue, device removal, and the definitive measures that comprise the process of reconstruction and rehabilitation. Effective and timely source control is critical to the successful management of life-threatening infection. This article reviews the principles of diagnosis and source-control management, and their application to common infections that result in severe sepsis and septic shock.

Variability in management of early severe sepsis

ObjectiveA study was undertaken to characterise how doctors in emergency medicine (EM), acute medicine (AM) and critical care (ICU) in the UK, USA and Australia and New Zealand (ANZ) approach...

Procalcitonin kinetics within the first days of sepsis: relationship with the appropriateness of antibiotic therapy and the outcome

IntroductionManagement of the early stage of sepsis is a critical issue. As part of it, infection control including appropriate antibiotic therapy administration should be prompt. However, microbiological findings, if any, are generally obtained late during the course of the disease. The potential interest of procalcitonin (PCT) as a way to assess the clinical efficacy of the empirical antibiotic therapy was addressed in the present study.MethodsAn observational cohort study including 180 patients with documented sepsis was conducted in our 15-bed medical intensive care unit (ICU). Procalcitonin measurement was obtained daily over a 4-day period following the onset of sepsis (day 1 (D1) to D4). The PCT time course was analyzed according to the appropriateness of the first-line empirical antibiotic therapy as well as according to the patient outcome.ResultsAppropriate first-line empirical antibiotic therapy (n = 135) was associated with a significantly greater decrease in PCT between D2 and D3 (ΔPCT D2–D3) (-3.9 (35.9) vs. +5.0 (29.7), respectively; P < 0.01). In addition, ΔPCT D2–D3 was found to be an independent predictor of first-line empirical antibiotic therapy appropriateness. In addition, a trend toward a greater rise in PCT between D1 and D2 was observed in patients with inappropriate antibiotics as compared with those with appropriate therapy (+5.2 (47.4) and +1.7 (35.0), respectively; P = 0.20). The D1 PCT level failed to predict outcome, but higher levels were measured in the nonsurvivors (n = 51) when compared with the survivors (n = 121) as early as D3 (40.8 (85.7) and 21.3 (41.0), respectively; P = 0.04). Moreover, PCT kinetics between D2 and D3 were also found to be significantly different, since a decrease ≥ 30% was expected in the survivors (log-rank test, P = 0.04), and was found to be an independent predictor of survival (odds ratio = 2.94; 95% confidence interval 1.22 to 7.09; P = 0.02).ConclusionsIn our study in an ICU, appropriateness of the empirical antibiotic therapy and the overall survival were associated with a greater decline in PCT between D2 and D3. Further studies are needed to assess the utility of the daily monitoring of PCT in addition to clinical evaluation during the early management of sepsis.

56: Early Sepsis Management: A Meta-analysis of Published Studies

56: Early Sepsis Management: A Meta-analysis of Published Studies

Canadian Association of Emergency Physicians Sepsis Guidelines: the optimal management of severe sepsis in Canadian emergency departments

Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an evidence-based grading system. Key areas in the management of septic patents were determined by members of the CAEP Critical Care Interest Group (C4). Members of C4 were assigned a question to be answered after literature review, based on the Oxford grading system. After completion, each section underwent a secondary review by another member of C4. A tertiary review was conducted by additional external experts, and modifications were determined by consensus. Grading was based on peer-reviewed publications only, and where evidence was insufficient to address an important topic, a "practice point" was provided based on group opinion. The project was initiated in 2005 and completed in December 2007. Key areas which were reviewed include the definition of sepsis, the use of invasive procedures, fluid resuscitation, vasopressor/inotrope use, the importance of culture acquisitionin the ED, antimicrobial therapy and source control. Other areas reviewed included the use of corticosteroids, activated protein C, transfusions and mechanical ventilation. Early sepsis management in the ED is paramount for optimal patient outcomes. The CAEP Critical Care Interest Group Sepsis Position Statement provides a framework to improve the ED care of this patient population.

Validating the use of the APACHE II score in a tertiary South African ICU

Background. In order to evaluate both outcome of intensive care unit (ICU) patients and ICU care, the riskadjusted mortality can be calculated using the APACHE II equation. Our aim was to: (i) describe the case mix of admissions to our ICU; (ii) investigate the impact of such variation on outcome; and (iii) validate the use of the APACHE II risk prediction model in a developing country. Methods. Prospective data collection of consecutive adult admissions over 13 months in a tertiary, predominantly medical, ICU. Survivors and non-survivors were compared for age, sex and diagnoses. ICU mortality was calculated for diagnostic categories and for the whole group. Risk of death was calculated according to the APACHE II method. The goodness of fit of the APACHE II equation was assessed with a calibration curve. The discrimination of the model was assessed with a receiver operator characteristic (ROC) curve. Results. There were 304 admissions with an average APACHE II score of 17.4 and 37% ICU mortality. Diagnostic groups with high ICU mortalities included medical patients (42%), severe sepsis (59.4%), community-acquired pneumonia (CAP) (53%), pulmonary tuberculosis (45%) and immunocompromised patients (62%). A calibration curve for the APACHE II equation, applied to our data, shows that the predicted ICU mortality was within the 95% confidence interval (CI) of the actual mortality. The only exception was the group with a 70% predicted risk of ICU death. The area under the ROC curve was 0.83 (95% CI: 0.78 - 0.88). The standardised mortality ratio was 0.98 (95% CI: 0.79 - 1.17). Conclusions. This study validates the use of the APACHE II model to accurately describe the risk of ICU death of the patient population in a tertiary ICU in a developing country. Patients with severe sepsis and/or CAP had a significantly higher mortality. The main reason for this appeared to be a high risk of death at ICU admission. The principles of appropriate management of early sepsis should be taught to all doctors through continuing medical education. SAJCC Vol. 21 (1) 2005: pp. 46-54