Surviving Sepsis Campaign Research Articles

The effect of hydrocortisone versus hydrocortisone plus fludrocortisone on duration of shock: A propensity score-weighted analysis.

The 2021 Surviving Sepsis Campaign Guidelines recommend the use of hydrocortisone in patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy. Fludrocortisone has been used concomitantly with hydrocortisone in some studies without a clearly defined role or known clinical benefit. The purpose of this study was to assess the impact of fludrocortisone added to hydrocortisone on shock-free days for septic shock. A single-center, retrospective propensity score-weighted study was conducted to compare hydrocortisone versus hydrocortisone plus fludrocortisone for septic shock. Adults admitted to the medical intensive care unit (ICU) from 2015 to 2020 were included in the study. All patients received ≥200 mg/day hydrocortisone for at least 24 h ± fludrocortisone initiated within 72 h of vasopressors. The primary outcome was shock-free days by day 14. The secondary outcomes included duration of shock, change in Sequential Organ Failure Assessment (SOFA) score, hospital and ICU length of stay, and all-cause inhospital mortality. A total of 228 patients met inclusion criteria with 212 patients retained after propensity score weighting. There was no difference between groups in 14-day shock-free days (6.3 vs. 6.1 days; P = 0.781). Furthermore, no significant differences were observed for the secondary outcomes of ICU/hospital length of stay, duration of shock, change in SOFA score, and all-cause inhospital mortality. The addition of fludrocortisone to hydrocortisone in septic shock did not increase shock-free days by day 14. These results suggest that the use of hydrocortisone alone may be an adequate adjunctive therapy in septic shock. A prospective randomized controlled trial is needed to confirm results.

Impact of a Coordinated Sepsis Response on Time to Treatment in a Pediatric Emergency Department.

Sepsis is responsible for 75 000 pediatric hospitalizations annually, with an associated mortality rate estimated between 11% and 19%. Evidence supports the use of timely fluid resuscitation and antibiotics to decrease morbidity and mortality. Our emergency department did not meet the timeliness goals for fluid and antibiotic administration suggested by the 2012 Surviving Sepsis Campaign. In November 2018, we implemented a sepsis response team utilizing a scripted communication tool and a dedicated sepsis supply cart to address timeliness barriers. Performance was evaluated using statistical process control charts. We conducted observations to evaluate adherence to the new process. Our aim was to meet the Surviving Sepsis Campaign's timeliness goals for first fluid and antibiotic administration (20 and 60 minutes, respectively) within 8 months of our intervention. We observed sustained decreases in mean time to fluids. We also observed a shift in the proportion of patients receiving fluids within 20 minutes. No shifts were observed for timely antibiotic administration. The implementation of a dedicated emergency department sepsis response team with designated roles and responsibilities, directed communication, and easily accessible supplies can lead to improvements in the timeliness of fluid administration in the pediatric population.

Compliance with maternal sepsis guidelines in a tertiary hospital in the Netherlands

ABSTRACT Objectives Sepsis is a common cause of maternal mortality and morbidity. Early detection and rapid management are essential. In this study, we evaluate the compliance with the implemented maternity-specific Early Warning Score (EWS), Rapid Response Team (RRT) protocol and the Surviving Sepsis Campaign (SSC) Hour-1 Bundle in a tertiary hospital in the Netherlands. Methods We performed a retrospective patient chart review from July 2019 to June 2020 at the Leiden University Medical Centre. We included women who received therapeutic antibiotics and were admitted for at least 24 hours. Results We included 240 women: ten were admitted twice and one woman three times, comprising 252 admissions. A clinical diagnosis of sepsis was made in 22 women. The EWS was used in 29% (n = 73/252) of admissions. Recommendations on the follow-up of the EWS were carried out in 53% (n = 46/87). Compliance with the RRT protocol was highest for assessment by a medical doctor within 30 minutes (n = 98/117, 84%) and lowest for RRT involvement (n = 7/23, 30%). In women with sepsis, compliance with the SSC Bundle was highest for acquiring blood cultures (n = 19/22, 85%), while only 64% (n = 14/22) received antibiotics within 60 minutes of the sepsis diagnosis. Conclusion The adherence to the maternity-specific EWS and the SSC Hour-1 bundle was insufficient, even within this tertiary setting in a high-income country.

Real-World Implications of Updated Surviving Sepsis Campaign Antibiotic Timing Recommendations.

To evaluate real-world implications of updated Surviving Sepsis Campaign (SSC) recommendations for antibiotic timing. Retrospective cohort study. Twelve hospitals in the Southeastern United States between 2017 and 2021. One hundred sixty-six thousand five hundred fifty-nine adult hospitalized patients treated in the emergency department for suspected serious infection. None. We determined the number and characteristics of patients affected by updated SSC recommendations for initiation of antibiotics that incorporate a risk- and probability-stratified approach. Using an infection prediction model with a cutoff of 0.5 to classify possible vs. probable infection, we found that 30% of the suspected infection cohort would be classified as shock absent, possible infection and thus eligible for the new 3-hour antibiotic recommendation. In real-world practice, this group had a conservative time to antibiotics (median, 5.5 hr; interquartile range [IQR], 3.2-9.8 hr) and low mortality (2%). Patients categorized as shock absent, probable infection had a median time to antibiotics of 3.2 hours (IQR, 2.1-5.1 hr) and mortality of 3%. Patients categorized as shock present, the probable infection had a median time to antibiotics 2.7 hours (IQR, 1.7-4.6 hr) and mortality of 17%, and patients categorized as shock present, the possible infection had a median time to antibiotics 6.9 hours (IQR, 3.5-16.3 hr) and mortality of 12%. These data support recently updated SSC recommendations to align antibiotic timing targets with risk and probability stratifications. Our results provide empirical support that clinicians and hospitals should not be held to 1-hour targets for patients without shock and with only possible sepsis.

Assessment of Outcomes in Patients with Heart Failure and End-Stage Kidney Disease after Fluid Resuscitation for Sepsis and Septic Shock

BackgroundSepsis fluid resuscitation is controversial, especially for patients with volume overload risk. The Surviving Sepsis Campaign recommends a 30-mL/kg crystalloid fluid bolus for patients with sepsis-induced hypoperfusion. Criticism of this approach includes excessive fluid resuscitation in certain patients. ObjectiveThe aim of this study was to assess the efficacy and safety of guideline-concordant fluid resuscitation in patients with sepsis and heart failure (HF) or end-stage kidney disease (ESKD). MethodsA retrospective cohort study was conducted in patients with sepsis who qualified for guideline-directed fluid resuscitation and concomitant HF or ESKD. Those receiving crystalloid fluid boluses of at least 30 mL/kg within 3 h of sepsis diagnosis were placed in the concordant group and all others in the nonconcordant group. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS); vasoactive medications and net volume over 24 h; new mechanical ventilation, new or increased volume removal, and acute kidney injury within 48 h; and shock-free survival at 7 days. ResultsOne hundred twenty-five patients were included in each group. In-hospital mortality was 34.4% in the concordant group and 44.8% in the nonconcordant group (p = 0.1205). The concordant group had a shorter ICU LOS (7.6 vs. 10.5 days; p = 0.0214) and hospital LOS (12.9 vs. 18.3 days; p = 0.0163), but increased new mechanical ventilation (37.6 vs. 20.8%; p = 0.0052). No differences in other outcomes were observed. ConclusionsReceipt of a 30-mL/kg fluid bolus did not affect outcomes in a cohort of patients with mixed types of HF and sepsis-induced hypoperfusion.

Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies.

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol

IntroductionEarly sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood...

Surviving Sepsis Campaign Research Priorities 2023.

To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.

A nursing-led sepsis response team guiding resuscitation with point-of-care ultrasound: A review and model for improving bundle compliance while individualizing sepsis care.

A dysregulated host response to infection resulting in life-threatening organ dysfunction defines the onset of sepsis. Unfortunately, sepsis is common, costly, and deadly. The Surviving Sepsis Campaign publishes regularly updated, evidence-informed, detection, and treatment guidelines culminating in time-sensitive care "bundles." The goal of these bundles is to expedite sepsis recognition because it is widely held that early treatment is life-saving. Hospitals are mandated to publicly report their bundle compliance, and this will soon be tied to hospital reimbursement. For these reasons, hospitals are creating sepsis emergency response teams which are a form of a rapid response team consisting of dedicated medical professionals who evaluate patients with suspected sepsis and initiate therapy when appropriate. Evidence to date support sepsis emergency response teams as a mechanism to improve bundle compliance, and potentially, patient outcome. Nevertheless, some elements of bundled sepsis care are controversial (e.g., intravenous fluid administration) as some argue that mandated treatment precludes personalized care. Herein, we briefly describe general sepsis emergency response team structure, review evidence supporting sepsis emergency response teams to improve bundle compliance and patient outcome and report our unique experience incorporating point of care ultrasound-to guide intravenous fluid-into a nursing-led sepsis team. We propose that our sepsis emergency response team approach allays concern that sepsis care is either bundled or personalized. Instead, incorporating point of care ultrasound into a nursing-led sepsis emergency response team increases bundle compliance and individualizes care.

Early Versus Late Initiation of Hydrocortisone in Patients With Septic Shock: A Prospective Study.

Introduction The optimal timing of corticosteroid initiation in septic shock patients is debatable. The Surviving Sepsis Campaign Guidelines recommended adding hydrocortisone to septic shock patients who require a vasopressor with a dose of norepinephrine ≥ 0.25 mcg/kg/min for at least four hours. Nevertheless, the best time to initiate hydrocortisone remains uncertain. Objective Assessing the impact of early (≤3 hours) versus late (>3 hours) initiation of hydrocortisone in septic patients. Methodology We compared the outcomes of septic shock patients who received hydrocortisone within three hours versus those who started treatment after three hours. The inclusion criteria encompassed septic shock patients aged 18 or older who received at least one dose of hydrocortisone. Exclusion criteria included pregnancy, do-not-resuscitate orders, the absence of empirical intravenous antibiotics, recent corticosteroid use, recent cardiac arrest, and a history of adrenal insufficiency. Results Eighty-one patients were included (54% were males). The mean age was 59 years, and 56.8% of patients were in the early group. The time needed to discontinue vasopressors was 25 and 37 hours for the early and late groups, respectively (p = 0.009), and more patients achieved reversal of shock (35 vs. 24 patients) and had shorter ICU stays (17 days vs. 20 days). Conclusion Initiating hydrocortisone early, within three hours, reduced the time needed to discontinue vasopressors among the study population. However, both early and late initiation strategies yielded comparable outcomes in terms of ICU mortality, ICU length of stay, and shock reversal.

Time Is Survival: Continuing Education on Sepsis for Neurosurgical Critical Care Nurses.

Early identification of sepsis among neurosurgical critical care patients is a significant challenge because of the many possible confounding variables that lead to altered mental status in this specific patient population. Nurses' knowledge, attitudes, confidence, and practices related to the early identification and management of sepsis are crucial to patients' survival. This evidence-based intervention project implemented continuing education for neurosurgical critical care nurses on the early signs and symptoms of sepsis and the management of sepsis according to the Surviving Sepsis Campaign (SSC) Guidelines. Continuing education on sepsis increased neurosurgical critical care nurses' knowledge of the SSC 1-hour sepsis bundle, reported confidence in the management of sepsis, and likelihood of assessing for sepsis. Continuing education for neurosurgical critical care nurses on the signs and symptoms of sepsis and the SSC Guidelines is necessary and may improve patient outcomes. [J Contin Educ Nurs. 2024;55(5):224-230.].

Argipressin-norepinephrine association in the treatment of septic shock: the use of the polydistrectual resistance index as an assessment of vascular compliance

IntroductionThe hemodynamic management of septic patients involves initial fluid therapy, followed by the use of vasoconstrictors in case of treatment failure. The latest Surviving Sepsis Campaign guidelines suggest the synergistic use of argipressin in addition to norepinephrine when hemodynamic optimization is not achieved with norepinephrine alone.MethodsIn our single-center retrospective observational study, the primary endpoint is the safety of initial norepinephrine-argipressin association treatment, assessed through a reduction in Resistance Index. Our secondary endpoint includes the efficacy of this combination, measured by an increase in Mean Arterial Pressure and a reduction in Resistance Index as an indicator of organ perfusion. The Resistance Index (RI) is evaluated through Power Doppler ultrasound. RI is crucial for assessing multi-district vascular tone and multiorgan perfusion. Patients were categorized into three groups based on their treatment. In Group 1, we analyzed patients treated with norepinephrine alone in incremental doses; in Group 2, we analyzed patients receiving the initial norepinephrine-argipressin association treatment (norepinephrine 0.05 mcg/kg/min-argipressin 0.03 IU/min); in the third group (Group 3), we analyzed patients given argipressin (0.03 IU/min) after norepinephrine (<0.10–0.25≥ mcg/kg/min) to stabilize their hemodynamics (MAP > 65 mmHg). RI measurements were taken in the Renal Artery (ARE), Radial Artery (AR), Central Retinal Artery (CRA), and Superior Mesenteric Artery (AMS) at four different time points: T0 before vasopressor therapy, T1 at 1 h, T2 at 24 h, and T3 at 48 h after vasopressor infusion.ResultsA total of 48 patients were divided into three groups: 17 patients in Group 1, 16 in Group 2, and 15 in Group 3. In Group 1, an increase in Mean Arterial Pressure (MAP) was observed, but there was an increase in RIs in the right CRI and left ARE. In Group 2, there was an improvement in MAP and a reduction in RIs in the right/left CRI, left ARE, AMS, and right AR. In Group 3, there was an increase in MAP and a reduction in RIs in the right/left CRI, left ARE, AMS, and right AR.ConclusionEarly norepinephrine-argipressin association treatment appears to be a valid strategy for hemodynamic optimization in this patient population.

Analysis of pathogenic factors on the death rate of sepsis patients

Background The Surviving Sepsis Campaign (SSC) believed that early identification of septic shock, aggressive fluid resuscitation and maintenance of effective perfusion pressure should be carried out. However, some of the current research focused on a single death factor for sepsis patients, based on a limited sample, and the research results of the relationship between comorbidities and sepsis related death also have some controversies. Method Therefore, our study used data from a large sample of 9,544 sepsis patients aged 18–85 obtained from the MIMIC-IV database, to explore the risk factors of death in patients with sepsis. We used the general clinical information, organ dysfunction scores, and comorbidities to analyze the independent risk factors for death of these patients. Results The death group had significantly higher organ dysfunction scores, lower BMI, lower body temperature, faster heart rate and lower urine-output. Among the comorbidities, patients suffering from congestive heart failure and liver disease had a higher mortality rate. Conclusion This study helps to identify sepsis early, based on a comprehensive evaluation of a patient’s basic information, organ dysfunction scores and comorbidities, and this methodology could be used for actual clinical diagnosis in hospitals.

Promoting Antibiotic Stewardship and Implementation of Sepsis Pathway in the Emergency Department: A Quality Improvement Initiative.

Introduction Sepsis is a preventable cause of mortality and presents challenges in triage and management. The Surviving Sepsis Campaign care bundles improve patient outcomes; however, non-compliance with guidelines, understaffing, and scarcity of training opportunities undermine care quality in resource-limited countries. We aimed to implement the sepsis hour-1 care bundle in the emergency department of a tertiary-care hospital in Pakistan and develop hospital antimicrobial guidelines. Methods The baseline assessment included a survey of knowledge and confidence in sepsis management and a retrospective audit of inpatient medical records. The inclusion criteria were age ≥ 18 years with a systemic inflammatory response score ≥ 2 or a National Early Warning Score ≥ 3. Improvement strategies included(a) educational intervention, (b) adult sepsis screening tool and sepsis 1-hour bundle checklist, and (c) recommendations for empirical antibiotics. These were implemented and assessed via Plan-Do-Study-Act (PDSA) cycles: (a) multi-tiered educational campaigns, (b) implementation of hospital protocols/guidelines, and (c) antimicrobial policy and sustainability. The process measures were hour-1 bundle components and the outcome measures were in-hospital mortality, ICU admission, length of hospital stay, and ICU stay. Results The baseline survey revealed that the majority of participants had formal training and felt confident in managing septic patients but none of the respondents had used a sepsis scoring system, and only 29.4% had used an hour-1 bundle previously. There was a sustained improvement in bundle compliance from 0% at baseline to 57.7% at PDSA-3. Inappreciable variation (p > 0.05) was reflected in the length of hospital and ICU stay and in-hospital mortality, whereas ICU admission decreased insignificantly (p > 0.05). The antimicrobial therapy practice, as per the guidelines, increased remarkably (p < 0.05). Conclusion Regular training and feedback are pivotal for practice change, yet integrating structured screening tools and bundled checklists into current workflows can significantly improve compliance.

EGS P33 Audit of Serial Lactate Measurement in Septic Patients Admitted in Acute General Surgery Department

Abstract Background Timely and effective resuscitation is crucial for the stabilisation of sepsis-induced tissue hypo-perfusion. Elevated serum lactate is associated with increase mortality and longer hospital stays. A reduction in lactate levels towards normal during acute resuscitation is therefore associated with improved clinical outcomes. Surviving sepsis campaign 2021 therefore recommends using lactate as quantitative measure of resuscitation in patient with sepsis and has advised serum lactate levels to be measured within three hours of admission and repeated within 4-6 hours if ≥2mmol. This audit aims to evaluate efficiency of our surgical department in serial lactate measurement in septic patients. Methods This was a single centre retrospective audit of patients admitted to general surgical ward between October 2022 to January 2023 with sepsis and Lactate ≥2mmol. Patients were identified electronic handover database. Data was collected for demographics, initial time and value of lactate, NEWS score and time and value of subsequent lactate measurements. All patients with initial Lactate ≥ 2mmol were included in the study, although our laboratory upper limit of normal Lactate is 2.4mmol. This audit was registered with Clinical Quality Project ID: 14730. Results Sixty-nine patients were included; median age was 70 years (IQR 58-82) and 35 (50.7%) were female. Median Charlson Comorbidity Index was 4 (IQR 2-6). 56 (81.2%) patients were admitted to acute surgical ward and 13 (18.8%) to the ICU/HDU. 51 (73.9%) patients had first lactate level was between 2-4mmol and 18 (26.1%) had ≥4. 16 (28.6%) patients admitted to surgical ward with high lactate was repeated and 9 (56%) of these were ≥ 8 hours. In HDU/ICU 12 (92%) patients had their lactate repeated in targeted time. Conclusions This audit highlights the standards not being achieved. This is likely due to unawareness of the recommendations as well as time pressure. Awareness of the latest guidelines is paramount in improving the adherence to the guidelines.

Impact of emergency medicine clinical pharmacist practitioner-driven sepsis antibiotic interventions

BackgroundThe 2021 Surviving Sepsis Campaign Guidelines recommend administration of antimicrobials within the first hour of recognition of sepsis. Over the last decade, several studies have demonstrated improved time-to-antibiotic administration and antibiotic appropriateness when a pharmacist was involved in the care of patients with sepsis. To our knowledge, no studies evaluating the appropriate use of antibiotics in sepsis driven entirely by an Emergency Medicine (EM) Clinical Pharmacist Practitioner (CPP) have been published. The purpose of this study is to evaluate the impact of an EM CPP-driven protocol on antimicrobial interventions in patients with sepsis in the emergency department (ED). MethodsThis was a retrospective comparison of patients with sepsis for whom antimicrobials were ordered in the ED without pharmacist intervention to patients whose antimicrobials were ordered by an EM CPP via a sepsis consult to pharmacy. An EM CPP reviewed individual patient profiles for pertinent historical admissions, culture data, and allergy profiles to guide antimicrobial selection for the suspected source of infection and entered orders under their scope of practice with formal documentation in the electronic medical record (EMR). The primary objective of this study was to compare the rates of appropriate empiric antibiotic utilization in septic patients admitted from the ED pre- and post-protocol implementation. Secondary endpoints included the following, broadening of ED-initiated empiric antibiotics on hospital admission, time-to-antibiotic administration, in-hospital mortality, Rapid Emergency Medicine Score (REMS) association with in-hospital mortality, and hospital length of stay. ResultsA total of 144 patients were included: 80 patients prescribed antibiotics without pharmacist intervention and 64 prescribed antibiotics by an EM CPP. Appropriate empiric antibiotic selection in the ED improved from 57.5% (46/80) to 86% (55/64) with EM CPP intervention (difference 28.5%; p < 0.01). Time-to-first antibiotic administration decreased by 64 min (p < 0.01). Administration of antibiotics within 60 min, broadening of antibiotics on admission, hospital length of stay, and in-hospital mortality did not significantly differ across groups. ConclusionsIn this small, single-center study, an EM Clinical Pharmacist Practitioner-driven protocol for patients with sepsis in the emergency department improved the rate of appropriate empiric antimicrobial selection and time-to-antibiotic administration.

Abstract 11912: Temporal Trends in the Incidence of Non-Shockable In-Hospital Cardiac Arrest in Septic Patients

Background: Owing to increased awareness of the timely recognition and treatment of sepsis in the USA, sepsis care has improved over time with better outcomes. Hypothesis: We hypothesized that the incidence of non-shockable in-hospital cardiac arrest (IHCA) has also improved over time with improving sepsis care. Aims: The primary objective was to evaluate temporal trends of non-shockable IHCA in septic patients. The secondary objective was to evaluate these trends stratified by age, sex, and race. Methods: Using the National Inpatient Sample, we studied all adult patients hospitalized with sepsis from 2005 to 2019. We used multivariate logistic regression for trend analysis. Results: Of 26 million adult patients admitted with sepsis from 2005 to 2019 in the USA, with a mean age of 66 ±0.043 years, 50% were females. The mean age decreased from 68 years in 2005 to 65 years in 2019. The risk-adjusted rates of non-shockable IHCA in septic patients decreased from 2.4% in 2005 to 1.1% in 2019 (Figure 1, Panel A) after accounting for differences in age, sex, and comorbidity burden. The risk-adjusted rates were highest in the age group 45-64 and lowest in the oldest age group ≥85 years (Panel B). Furthermore, the sex-stratified analysis showed consistently higher rates of non-shockable IHCA in males than in females throughout our study (Panel C). Finally, the risk-adjusted rates of non-shockable IHCA were consistently highest in Black patients compared to other races throughout our study period (Panel D). Conclusions: The incidence of non-shockable IHCA in septic patients has significantly improved with increased awareness and improved care of sepsis. Initiatives like Surviving Sepsis Campaign need continued implementation in hospitals, with constant monitoring of compliance with these guidelines to further improve the incidence of non-shockable IHCA in septic patients.

Association between corticosteroid use and 28-day mortality in septic shock patients with gram-negative bacterial infection: a retrospective study.

Although corticosteroids are recommended in the 2021 Surviving Sepsis Campaign (SSC) guidelines, evidence with respect to their effects on short-term mortality remains conflicting. We conducted this study to identify whether corticosteroids alter 28-day mortality in septic shock patients with gram-negative bacterial infection. A total of 621 patients with septic shock and gram-negative bacterial culture results were identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Propensity score matching (PSM) was performed, and Kaplan-Meier survival curve analyses with log-rank tests were used to determine the relationship between corticosteroid use and the risk of 28-day mortality. Subgroup analyses were conducted to assess whether the conclusions were stable and reliable. Corticosteroid administration was associated with increased 28-day mortality in septic shock patients with gram-negative bacterial infection (log-rank test P = 0.028). The incidence of Stage 2 or 3 AKI and the rate of hospital mortality were higher among patients who received corticosteroids. The incidence of Stage 2 or 3 AKI in the early period significantly mediated the relationship between corticosteroid use and 28-day mortality [P =0.046 for the average causal mediation effect (ACME)]. Interaction tests indicated that the effect of corticosteroid use was maintained in patients with a neutrophil-to-lymphocyte ratio (NLR) of <20 (P-value for interaction = 0.027). Systemic corticosteroid use could be harmful in septic shock patients with gram-negative bacterial infection, especially in patients with relatively low NLR.

Patient diversity and author representation in clinical studies supporting the Surviving Sepsis Campaign guidelines for management of sepsis and septic shock 2021: a systematic review of citations

BackgroundThe generalizability of the Surviving Sepsis Campaign (SSC) guidelines to various patient populations and hospital settings has been debated. A quantitative assessment of the diversity and representation in the clinical evidence supporting the guidelines would help evaluate the generalizability of the recommendations and identify strategic research goals and priorities. In this study, we evaluated the diversity of patients in the original studies, in terms of sex, race/ethnicity, and geographical location. We also assessed diversity in sex and geographical representation among study first and last authors.MethodsAll clinical studies cited in support of the 2021 SSC adult guideline recommendations were identified. Original clinical studies were included, while editorials, reviews, non-clinical studies, and meta-analyses were excluded. For eligible studies, we recorded the proportion of male patients, percentage of each represented racial/ethnic subgroup (when available), and countries in which they were conducted. We also recorded the sex and location of the first and last authors. The World Bank classification was used to categorize countries.ResultsThe SSC guidelines included six sections, with 85 recommendations based on 351 clinical studies. The proportion of male patients ranged from 47 to 62%. Most studies did not report the racial/ ethnic distribution of the included patients; when they did so, most were White patients (68–77%). Most studies were conducted in high-income countries (77–99%), which included Europe/Central Asia (33–66%) and North America (36–55%). Moreover, most first/last authors were males (55–93%) and from high-income countries (77–99%).ConclusionsTo enhance the generalizability of the SCC guidelines, stakeholders should define strategies to enhance the diversity and representation in clinical studies. Though there was reasonable representation in sex among patients included in clinical studies, the evidence did not reflect diversity in the race/ethnicity and geographical locations. There was also lack of diversity among the first and last authors contributing to the evidence.

Vasopressin in Sepsis and Other Shock States: State of the Art.

This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.