Surviving Sepsis Guidelines Research Articles

Study on Ward-Based Practice of Vasopressor Administration for Patients with Sepsis, in National Hospital of Sri Lanka (NHSL)

Background: Vasopressors are administrated peripherally in hemodynamically unstable patients with sepsis in the initial period. International guidelines are available for peripheral administration of vasopressors, including Surviving Sepsis guidelines 2021.Objective: Assess the ward-based practice regarding peripheral administration of vasopressors in patients with sepsis, in NHSL.Methods: A prospective cross-sectional study, during a period of six weeks in 2022, setting of Medical and surgical wards in NHSL, in a group of 52 patients.Results: Noradrenaline was the vasopressor used for all patients with septic shock. 93% of patients had peripheral noradrenaline infusions for a medium duration of 77.7 hours. Peripheral cannula for noradrenaline was sited in the forearm at 46% and in the dorsum of the hand at 34%. Only 7% had a central line for vasopressors. Other infusions along with noradrenaline in the same cannula were given in 75%. Approximately 90% were monitored hourly during the infusion of vasopressors. ICU referral was done only in 5.7% of patients. Adverse reactions were noted in 38% of patients, all minor complications.Conclusion: Peripheral administration of vasopressors was prolonged compared to standard. Adverse reactions were identified, but all were minor complications.

Comparison between presepsin, procalcitonin, and CRP as biomarkers to diagnose sepsis in critically ill patients.

Mortality associated with sepsis continues to remain high. Early diagnosis and aggressive management may improve outcomes. Biomarkers may help in early diagnosis, but the search for an ideal biomarker continues. Presepsin has been introduced as a new biomarker, however, it still needs validation before its use becomes routine. In this study, we aimed to compare the efficacy of various biomarkers in patients with suspected sepsis. A retrospective analysis of 100 patients with suspected infection, admitted in the medical intensive care unit (ICU) was conducted. Diagnosis of sepsis was made on the basis of the current surviving sepsis guidelines criteria. Out of 100 patients, 70 were diagnosed to have sepsis, and overall ICU mortality was 22%. Overall, C-reactive protein (CRP) was positive in 98, procalcitonin in 75, and presepsin in 64 patients. For diagnosis of sepsis the sensitivity, specificity, and AUC, respectively, for CRP was 98.6%, 3.3%, and 0.725. For procalcitonin (>0.5 ng/ml) it was 87.1%, 53.3%, and 0.776, and for procalcitonin (>1 ng/ml) 70%, 70%, and 0.816, respectively. For presepsin sensitivity, specificity, and AUC, respectively, for diagnosis of sepsis was 77.1%, 66.7%, and 0.734. For ICU mortality, sensitivity and specificity for CRP was 95.5% and 1.3%, for procalcitonin (>0.5) 72.7% and 24.4.%, for procalcitonin (>1) 59.1% and 42.3%, and for presepsin 61.5% and 27.3%, respectively. Inflammatory markers may be raised in a large proportion of ICU patients, even in those without sepsis. Procalcitnonin and presepsin had similar efficacy in diagnosing sepsis. However, none of the three biomarkers studied were accurate in predicting ICU mortality.

QSIRS SCORE IN PREDICTION OF MORTALITY IN PATIENTS WITH SEPSIS: A PROSPECTIVE STUDY

Background: Sepsis is a medical emergency contributing to 1 in 5 deaths worldwide . Both QSOFA score and SIRS criteria are widely used to predict the risk of sepsis and death. But QSOFA score and SIRS criteria has its own limitations. 2022 surviving sepsis guidelines recommend against using QSOFA as a single screening tool. In this study we aim to determine accuracy of predicting mortality with combined SIRS and QS OF Ascore : QSIRS and to compare it with SIRS and Q SOFA. Methodology: It was a prospective observational study. 100 patients with sepsis were included. On admission QSOFA, SIRS, QSIRS were calculated of all patients. Any score of 2 or more was deemed to be a positive score. In hospital mortality was considered as Outcome measure. Receiver Operating Characteristic analyses were performed to determine the Area Under the Curve, along with sensitivity and specicity of various scores were calculated. Results: Out of 100 patients studied 61% was male and 39% were female. Mean age of study participants was 55.7 years. Most common cause of sepsis was pneumonia (43%) followed by urinary tract infections (19 %). 33 deaths were recorded out of 100 patients (33%). In our study we found that QSIRS had the highest sensitivity of (96.96%) in compared to QSOFA(71.6%) and SIRS (84.8%). But the specicity of the QSIRS was low (22.3%). QSOFAhad the highest specicity of 71.6 %, followed by SIRS- 47.7%. AUC in ROC for QSIRS (O.711) was higher compared to QSOFA (0.697), and SIRS (0.588). Conclusion: Our study suggests that QSIRS score is most accurate in predicting mortality in patients with sepsis than SIRS or QSOFAalone. Combinations of QSOFAand SIRS could improve the predictive value for in hospital mortality for patients with sepsis.

63: RESTRICTIVE FLUIDS IN SEPSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: While large-volume fluid resuscitation as a part of early-goal directed therapy (EGDT) for sepsis has been widely adopted and endorsed by the SCCM Surviving Sepsis Guidelines, the risks of volume overload in the critically ill challenge this approach. The objective of this study is to assess the effects of a restrictive fluid resuscitation approach in sepsis given divergent results from randomized studies. Methods: A systematic review using a random effects meta-analysis with trial sequential analysis (TSA) of randomized controlled trials published from 2001 were evaluated. Studies were included if they evaluated adult patients with sepsis or septic shock involving a comparator group with an effective restrictive resuscitation approach. Two blinded reviewers independently assessed studies for inclusion and risk of bias and extracted data using Cochrane Collaborative methodology. The primary outcome was the incidence of mortality at the latest reported study period. Secondary outcomes included rates of acute kidney injury (AKI), ventilator days, intensive care unit (ICU) and hospital length of stay (LOS), duration of vasopressor therapy, and limb ischemia. Results: A total of 2,375 patients were included among the 8 trials analyzed. The risk of bias was high in 6 studies and low in 2 studies. All studies implemented fluid restriction after an initial 30 mL/kg volume. Use of a restrictive resuscitation approach did not significantly reduce mortality in all studies compared to usual care (37% vs 40% with usual care; risk ratio [RR] 0.94, 95% confidence interval [CI] 0.85–1.04, P=0.25, I2 = 24%) and was confirmed by TSA findings. There were no significant differences in rates of AKI (5 studies), LOS in ICU (4 studies) or hospital (2 studies), duration of vasopressor therapy (6 studies), or incidence of limb ischemia (3 studies). However, a restrictive resuscitation strategy significantly reduced ventilator days evaluated in 7 studies (mean difference -1.25 days, 95% CI -0.59 to -1.93 days, P=0.0003, I2 = 90%). Conclusions: This meta-analysis demonstrated that a restrictive fluid resuscitation strategy in sepsis resulted in no difference in mortality but may reduce ventilator days. Larger randomized trials are required to determine the optimal management of fluids in patients with sepsis.

1242: PEDIATRIC SEPSIS HAS HIGH MORTALITY REGARDLESS OF PATHOGEN IDENTIFICATION

Introduction: Sepsis remains a major cause of morbidity and mortality in critically ill children worldwide. Culture-negative sepsis (CNS) is diagnosed when a patient meets the criteria for sepsis with no causative pathogen identified. The etiology of CNS may be an uncultivable pathogen, treatment with antimicrobials before a culture was drawn, or a non-infectious cause. For adults, CNS is estimated to comprise up to 50% of all ICU admissions for sepsis, but the characteristics of the pediatric population with CNS are poorly understood. Methods: This is a retrospective cohort study of 3 pediatric ICUs within an urban, tertiary children’s hospital. All patients who received piperacillin-tazobactam, the institution’s standard initial broad-spectrum agent, were screened for study inclusion. Patients ≤18 years old who were hospitalized between March 2020 and February 2021 and met the criteria for sepsis defined in the 2020 Pediatric Surviving Sepsis Guidelines were included in the study. Results: Of the 302 patients screened, 61 met the criteria for sepsis. Thirty-two patients (52.5%) had culture-positive sepsis (CPS) and 29 patients (47.5%) had CNS. The median age for CPS was 5 years (interquartile range [IQR] 1-15y) and 3 years (IQR 0.5-15y) for CNS. Both groups had similar numbers of medically complex patients with >3 comorbidities (68.8% for CPS vs 70% for CNS, p=0.98). There was no statistically significant difference in mortality (28.1% CPS vs 17.2% CNS, p=0.32), need for mechanical ventilation (62.5% vs 58.6%, p=0.19), need for vasoactive medication (62.5% vs 55.2%, p=0.41), or median ICU and hospital length of stay (47 vs 27d, p=0.11; 53 vs. 27d, p=0.07) between groups. CPS patients were treated with longer courses of antibiotics (median 10 vs 7d for CNS p=0.03). Conclusions: When compared to CPS, outcomes for patients with CNS were similar though overall rates of mortality in both groups were high compared to previous reports (4-15%). Patients with CNS comprised a considerable proportion of the total number of patients with sepsis. A median ICU length of stay of 27 days for CNS patients represents significant resource utilization for these individual children. Given these findings, further studies are warranted to better understand this population and determine optimal treatment strategies.

439: TIME TO FIRST ANTIBIOTICS ADMINISTRATION IN THE ICU

Introduction: The Surviving Sepsis Guidelines recommend IV antibiotics (ABX) be administered within 1 hour to patients with sepsis or septic shock. Delays in ABX administration in this patient population have been shown to increase mortality. We sought to determine the time to first IV ABX in ICU patients and to identify barriers resulting in delayed IV ABX administration. Methods: This was an IRB-approved retrospective review conducted between May 2021 and July 2021 involving adult patients across three ICUs (2 medical and 1 surgical) at an academic medical center. All patients who received a first-dose IV ABX in the ICU were included. Descriptive statistics were used to characterize the data. Mann-Whitney U test was used to compare the median times to administration between IV ABX dispensed from an automated dispensing cabinet (ADC) versus those from the pharmacy (PHARM). Results: A total of 250 first IV ABX doses (84% MICU and 16% SICU) in 90 patients were included. There were an average of 2.8 first doses of IV ABX per patient during the study period, half of which were dispensed from ADC and half from PHARM. The median time from order input to patient administration (n=211) was 68 min (40-109). The median time from order input to patient administration was longer if the IV ABX was dispensed from PHARM vs ADC [89 min (60-128) vs 54 min (29-76); p< 0.001]. Vancomycin also had a longer median time from order input to administration if dispensed from PHARM vs ADC [92 min (58-154) vs 39 min (24-71); p< 0.001]. A total of 88 IV ABX were dispensed within 60 min, with 82% from ADC vs 18% from PHARM, 81 ABX were dispensed within 60-120 min, with 65% from ADC vs 35% from PHARM, and 42 IV ABX were administered >120 min, with 59% from ADC vs 41% from PHARM (Χ2=9.42; p=0.009). Conclusions: The median time to IV ABX administration in the ICU was near recommendations from guidelines. One limitation was the inability to classify patients as having sepsis or septic shock. Delays in time to IV ABX administration were primarily observed with medications dispensed by PHARM as compared to ADC.

Knowledge, Practice and Attitudes to the Management of Sepsis in Jamaica.

Sepsis is a life-threatening dysfunction resulting from the dysregulated host response to infection. The mortality of sepsis in Jamaica remains high amid the proven efficacy of the Surviving Sepsis Guidelines implementation in some countries. To evaluate the inter-relationship of healthcare workers' attitude towards, knowledge of and practice of sepsis management in Jamaica. A survey was done using an anonymous self-administered validated questionnaire to healthcare workers across Jamaica. Questions on knowledge, attitude, and practice of sepsis within private and public hospitals were answered. A total of 616 healthcare workers were eligible for analysis. Most respondents agree that healthcare workers need more training on sepsis (93.7%) and that formal sepsis training modules should be implemented at their hospitals or practice (93.2%). Several signs of sepsis as outlined by qSOFA were correctly identified as such by most respondents (60.6% to 76.4%), with the exception of a low PaCO2 (34.9%), which was correctly identified by a minority of respondents. While a majority (69.3%) were able to correctly define sepsis, only 8.8% of respondents knew the annual sepsis mortality rate. Postgraduate training (p<0.01) and formal sepsis training (p<0.05) were both predictive of high correct knowledge and practice scores. Specialization in Anaesthesia/ Critical Care Medicine (p<0.05) or Emergency Medicine (p<0.05) was predictive of high knowledge scores and Internal Medicine predictive of high practice scores (p<0.01). This study revealed that education for healthcare workers on sepsis and the implementation of SSC is needed in Jamaica.

Surviving Sepsis Guideline-Directed Fluid Resuscitation: An Assessment of Practice Patterns and Impact on Patient Outcomes.

IMPORTANCE:Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage.OBJECTIVES:Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation.DESIGN:Large, multisite retrospective cohort study.SETTING AND PARTICIPANTS:The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis.MAIN OUTCOMES AND MEASURES:Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0–29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay.RESULTS:We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight).CONCLUSIONS AND RELEVANCE:IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.

Discrepancy Between Invasive and Noninvasive Blood Pressure Measurements in Patients with Sepsis by Vasopressor Status.

IntroductionBlood pressure (BP) monitoring is an essential component of sepsis management. The Surviving Sepsis Guidelines recommend invasive arterial BP (IABP) monitoring, although the benefits over non-invasive BP (NIBP) monitoring are unclear. This study investigated discrepancies between IABP and NIBP measurement and their clinical significance. We hypothesized that IABP monitoring would be associated with changes in management among patients with sepsis requiring vasopressors.MethodsWe performed a retrospective study of adult patients admitted to the critical care resuscitation unit at a quaternary medical center between January 1–December 31, 2017. We included patients with sepsis conditions AND IABP monitoring. We defined a clinically significant BP discrepancy (BPD) between NIBP and IABP measurement as a difference of > 10 millimeters of mercury (mm Hg) AND change of BP management to maintain mean arterial pressure ≥ 65 mm Hg.ResultsWe analyzed 127 patients. Among 57 (45%) requiring vasopressors, 9 (16%) patients had a clinically significant BPD vs 2 patients (3% odds ratio [OR] 6.4; 95% CI: 1.2–30; P = 0.01) without vasopressors. In multivariable logistic regression, higher Sequential Organ Failure Assessment (SOFA) score (OR 1.33; 95% CI: 1.02–1.73; P = 0.03) and serum lactate (OR 1.27; 95% CI: 1.003–1.60, P = 0.04) were associated with increased likelihood of clinically significant BPD. There were no complications (95% CI: 0–0.02) from arterial catheter insertions.ConclusionAmong our population of septic patients, the use of vasopressors was associated with increased odds of a clinically significant blood pressure discrepancy between IABP and NIBP measurement. Additionally, higher SOFA score and serum lactate were associated with higher likelihood of clinically significant blood pressure discrepancy. Further studies are needed to confirm our observations and investigate the benefits vs the risk of harm of IABP monitoring in patients with sepsis.

Time to recognition, aetiology, antibiotic sensitivity pattern and outcome of sepsis (sepsis 2 definition) in a tertiary care hospital in Sri Lanka

Introduction: Patients with sepsis or severe sepsis usually present to the Emergency Department (ED). The overall mortality rate for patients admitted with severe sepsis is 35% - approximately five times higher than that of ST-elevation myocardial infarction. Prompt recognition and treatment are essential to improve survival. Our aim was to study the time to recognition, identify aetiology, and obtain antibiotic sensitivity patterns and outcome of patients presenting with suspected sepsis. Methodology: A prospective observational study including all patients suspected of having sepsis was carried out from July 1, 2016, to June 30, 2017, at the Emergency Department (ED) of the Provincial General Hospital Kurunegala, Sri Lanka. The study instrument was a data sheet comprising of the surviving sepsis guidelines (Sepsis 2) of the United Kingdom and demographics and background information from patient records. All the patients were followed up for one month. Results: One hundred and four patients (Age:61 ±17, 54.8% males) were studied. Blood culture results were available in 94 patients (90.4%) of which 19 (20%) were positive. The most common organisms identified were coagulase-negative Staphylococcus (CoNS) (42%) and Escherichia coli (42%). Door to blood culture time was 38.6 ± 26.7 minutes with 98% having blood cultures taken within 45 minutes of admission. Door to antibiotic time was 43.3 ±27.2 minutes. The most common primary foci of infection were pneumonia (34.6%) and cellulitis (28.8%). All CoNS were sensitive to teicoplanin and vancomycin, while all Escherichia coli isolates were sensitive to meropenem. The median (IQR) duration of hospital stay was 6 (3 to 9.1) days. The in-hospital mortality was 30 (28.9%) and 30-day mortality was 36 (34.6%). There was no statistical significance regarding mortality among blood culture positive and negative patients. Conclusion: The sepsis bundle had been activated within 45 minutes in most of our patients. The outcome of sepsis at our hospital is better than data published from other centres around the world.

Update Your Practice With the 2021 Sepsis Guidelines

Persistent hypotension is a parameter in the Centers for Medicare and Medicaid Services core measure sepsis (SEP-1) program. The 2016 sepsis definitions use persistent hypotension requiring vasopressors to maintain mean arterial pressure &gt; 65 mm Hg and having a lactate level &gt; 2 mmol/L after fluid resuscitation to define septic shock. In SEP-1, it is defined as 2 blood pressure readings with a systolic blood pressure of 40 mm Hg in the hour after crystalloid fluids have been infused.1,2 Essentially, persistent hypotension is hypotension that does not improve with fluid resuscitation.The 2017 and 2021 Surviving Sepsis guidelines both suggest the use of dynamic measures such as SV or SVV to assess fluid responsiveness, particularly in complex patients with sepsis. The measurement of SV or SVV in conjunction with a passive leg raise (PLR) or fluid bolus is one method. Fluid responsiveness is determined by an increase in SV of 10% to 15% or an SVV greater than 10% to 15% after PLR or administration of a fluid bolus. However, use of SVV has many limitations; for example, spontaneous respiration, mechanical ventilation with low tidal volumes, open chest, increased abdominal pressure, and dysrhythmia preclude using SVV in many critically ill patients with sepsis. Review your facility procedures for these measures.If there is a mechanism in your computerized provider order entry and in your facility’s guidelines that makes it easy for providers to obtain IBW and use that in the fluid calculation for consistency, then I think it is great. The key is to clearly define the population or target weight and make it easy for order entry. SEP-1 has a procedure for using IBW if the patient is obese with a BMI &gt; 30: the provider documents that the patient is obese and IBW is used, and the value is present in the medical record.1,2

Surviving Sepsis Campaign: Strategies to Implement in Cardiogenic Shock Management

The Surviving Sepsis Guidelines can serve as a structure to help educate and create a set of recommendations on how to care for patients through this complicated pathway of shock. Designing a cardiogenic shock bundle could reduce the variability of care and possibly improve survival. Also, a more standard protocol would allow a review of the outcomes and a system to change practice nationally when new data or technology becomes available. This could create a continuous quality improvement cycle. Creating a “Surviving Cardiogenic Shock” system could help provide awareness for recognition of cardiogenic shock and advanced management alternatives needed at level one and two hospitals. The creation of cardiogenic shock systems of care would support smaller hospitals with a Hub and Spoke structure. Cardiogenic shock is not septic shock, but those in cardiology and cardiac critical care can and should take lessons from the Surviving Sepsis Campaign.

The Effect of Rapid Initiation Versus Delayed Initiation of Antibiotics in Pediatric Patients With Sepsis.

The purpose of this study was to determine if administration of antibiotics within 1 hour of meeting sepsis criteria improved patient outcomes versus antibiotics administered greater than 1 hour after meeting sepsis criteria in pediatric patients. The Surviving Sepsis Campaign's international guidelines recommend appropriate antimicrobial therapy be administered within 1 hour of recognition of severe sepsis or septic shock. Data regarding outcomes in pediatric patients with sepsis regarding antibiotic timing are currently limited. This was a retrospective chart review of 69 pediatric patients admitted between July 1, 2013, and June 30, 2016, with a diagnosis of sepsis. The primary outcome of in-hospital mortality was 7.1% in the within 1 hour group versus 14.6% in the greater than 1 hour group (p = 0.3399). Median hospital length of stay was significantly shorter in the within 1 hour group (15.4 versus 39.2 days, p = 0.0022). Median intensive care unit length of stay was also significantly shorter in the within 1 hour group (3.1 versus 33.6 days, p = 0.0191). There were no differences between groups for pediatric intensive care unit admission, end organ dysfunction, time to intubation, or time on the ventilator. Pediatric patients who receive antimicrobial therapy within 1 hour of meeting sepsis criteria had improved hospital and intensive care unit length of stay. This study supports the Surviving Sepsis Guidelines recommendation to administer antibiotics within 1 hour in pediatric patients with sepsis or septic shock.

The new 2021 Surviving Sepsis Guidelines: an emergency department perspective may be more effective.

The new 2021 Surviving Sepsis Guidelines: an emergency department perspective may be more effective.

204 A Higher Initial VExUS Score Is Associated With Inferior Outcomes in Septic Emergency Department Patients

Early recognition, antibiotic therapy, and fluid resuscitation are integral components of the management of patients with sepsis and septic shock. Historically, emergency department (ED) management of these patients has been guided by the Surviving Sepsis guidelines, however, with advances in point-of-care ultrasound, more precise fluid management has become a realistic possibility. More recently, the venous excess ultrasound (VExUS) scoring system has been used to stratify intravascular volume status, but the prognostic value of VExUS scores has yet to be determined.

In-house intensivist presence does not affect mortality in select emergency general surgery patients.

This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. Therapeutic, level III.

How Robust are the Evidences that Formulate Surviving Sepsis Guidelines? An Analysis of Fragility and Reverse Fragility of Randomized Controlled Trials that were Referred in these Guidelines.

Objectives“Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” provides guidelines in regard to prompt management and resuscitation of sepsis or septic shock. The study is aimed to assess the robustness of randomized controlled trials (RCTs) that formulate these guidelines in terms of fragility index and reverse fragility index.MethodRCTs that contributed to these guidelines having parallel two-group design, 1:1 allocation ratio, and at least one dichotomous outcome were included in the study. The median fragility index was calculated for RCTs with significant statistical outcomes, whereas the median reverse fragility index was calculated for RCTs with nonsignificant statistical results.ResultsHundred RCTs that met the inclusion criteria were analyzed. The median fragility index was 5.5 [95% confidence interval (CI) 1–30] and median reverse fragility index was 13 (95% CI 12.07–16.8) at a p value of 0.05. The median reverse fragility index was 16 (95% CI 10–26) at a p value of 0.01. Most of the RCTs included in this analysis were of good quality, having a median Jadad score of 6.ConclusionThis analysis found that the surviving sepsis guidelines were based on highly robust RCTs with statistically insignificant results and on some moderately robust RCTs with statistically significant results. RCTs with statistically insignificant results were more robust than RCTs with statistically significant results in regard to these guidelines.HighlightsThe study assessed the robustness of randomized controlled trials (RCTs) that were used to formulate surviving sepsis guidelines. Most RCTs showed statistically nonsignificant results. RCTs with statistically significant results were moderately fragile whereas RCTs with nonsignificant results were more robust.How to cite this articleChoupoo NS, Das SK, Saikia P, Dey S, Ray S. How Robust are the Evidences that Formulate Surviving Sepsis Guidelines? An Analysis of Fragility and Reverse Fragility of Randomized Controlled Trials that were Referred in these Guidelines. Indian J Crit Care Med 2021;25(7):773–779.

Nepal Paediatric Society Clinical Guidance for Management of Sepsis and Septic Shock in the Paediatric Intensive Care Units in Nepal

&#x0D; &#x0D; &#x0D; &#x0D; Justification: Sepsis is a major cause of morbidity and mortality in Nepal. There is a lack of standardisation in the management of severe sepsis and septic shock. Additionally, international guidelines may not be completely applicable to resource limited countries like Nepal.&#x0D; Objective: Create a collaborative standardised protocol for management of severe sepsis and septic shock for Nepal based on evidence and local resources.&#x0D; Process / Methods: Paediatricians representing various paediatric intensive care units all over Nepal gathered to discuss clinical practice and delivery of care of sepsis and septic shock under the aegis of Nepal Paediatric Society. After three meetings and several iterations a standardised protocol and algorithm was developed by modifying the existing Surviving Sepsis Guidelines to suit local experience and resources.&#x0D; Recommendations: Paediatric sepsis and septic shock definitions and management in the early hours of presentation are outlined in text and flow diagram format to simplify and standardise delivery of care to children in the paediatric intensive care setting. These are guidelines and may need to be modified as necessary depending on the resources availability and lack thereof. It is recommended to analyse data moving forward and revise every few years in the advent of additional data.&#x0D; &#x0D; &#x0D; &#x0D;

Improving sepsis recognition and management

Sepsis is a major contributor to morbidity and mortality world-wide, with over half of the cases occurring in the pediatric population. The World Health Organization has challenged healthcare providers and organizations to improve the prevention, diagnosis, and management of sepsis.1 While the pediatric definition for sepsis was first introduced in 2005, it has not changed since that time, and does not fully represent what occurs during sepsis. The updated adult definition focuses on the dysregulation of the host response to infection leading to life-threatening organ dysfunction. Aligning with this definition, the new Pediatric Surviving Sepsis guidelines target sepsis with end-organ dysfunction and septic shock. Recommendations include utilizing automated trigger tools embedded in the electronic health record to improve timing of recognition, as well as utilization of a standardized approach to the management, and early escalation to critical care if the patient is not responding to interventions. Rapid fluid resuscitation utilizes lactated ringers rather than normal saline due to potential concerns of worse outcomes with a large chloride infusion. 40-60 ml/kg is the recommended fluid goal in the first hour, watching for development of fluid overload which can also lead to increased morbidity and mortality. Broad-spectrum antibiotics should be initiated by the end of the first hour, especially in cases of septic shock. Implementation of systems capitalizing on the ability of the electronic health record to constantly screen patients, paired with rapid response teams who can assess and approach sepsis with a standardized algorithm can significantly improve the recognition and management of patients with sepsis, and save lives.11-13.

Guideline-Concordant Insulin Infusion Initiation Among Critically Ill Patients With Sepsis

ObjectiveOur objective was to benchmark rates of guideline-concordant insulin infusion initiation, identify factors associated with guideline-concordant insulin practices, and examine the association between hospital-level guideline concordance and mortality among critically ill patients with sepsis. MethodsWe performed a multicenter retrospective cohort study of intensive care patients with sepsis who were eligible for insulin infusion initiation according to American Diabetes Association and Surviving Sepsis guidelines (persistent blood sugar ≥180 mg/dL). We then identified patients who were initiated on insulin infusions within 24 hours of eligibility. We examined patient- and hospital-level factors associated with guideline-concordant insulin infusion initiation and explored the association between the hospital-level proportion of patients who received guideline-concordant insulin infusions and hospital mortality. ResultsAmong 5453 guideline-eligible patients with sepsis, 13.4% were initiated on insulin infusions. Factors most strongly associated with guideline-concordant insulin infusion initiation were mechanical ventilation and hospital of admission. The hospital-level proportion of patients who received guideline-concordant insulin infusions were not associated with mortality. Among 1501 intensive care unit patients with sepsis who were started on insulin infusions, 37.0% were initiated at a blood glucose level below 180 mg/dL, the guideline-recommended starting threshold. ConclusionGuideline-concordant insulin infusion initiation was uncommon among patients with sepsis admitted to U.S. intensive care units and was determined in large part by hospital of admission. The degree to which hospitals were guideline-concordant were not associated with mortality.