QUALI RISULTATI VORRESTI E QUALI HAI

Journal Club ‘Sopravvivere alla Sepsi: i primi 5 anni’

2 dicembre 2010

SURGICAL - “SEPTIC” ICU (01/2005-12/2008)

307 patients severe sepsis/septic shock

195 patients

66 Severe sepsis

129 Septic shock

112 excluded:- cirrhosis waiting list OLT- OLT- Pediatrics

ICU (2005-2009) severe sepsis/septic shock

I. I. Management of Severe SepsisManagement of Severe Sepsis• Initial ResuscitationInitial Resuscitation• DiagnosisDiagnosis• Antibiotic therapyAntibiotic therapy• Source ControlSource Control• FluidsFluids• VasopressorVasopressor• Inotropic TherapyInotropic Therapy• SteroidsSteroids• rhAPCrhAPC• Blood Product Blood Product

adiministartionadiministartion50 Strong Recommendations (1 A-C)

19 Weak Recommendations (2 B-D)

II. II. Supportive Therapy of SepsisSupportive Therapy of Sepsis• Mechanical VentilationMechanical Ventilation• SedationSedation• Glucose controlGlucose control• Renal replacementRenal replacement• Bicarbonate TherapyBicarbonate Therapy• Deep Vein Thrombosis Deep Vein Thrombosis

ProphylaxisProphylaxis• Stress Ulcer ProphylaxisStress Ulcer Prophylaxis• SDDSDD• Limitation of SupportLimitation of SupportIII. III. Pediatric Consideration in Pediatric Consideration in

severe sepsissevere sepsis

GUIDELINES

PartnershipSSC and Institute for Healthcare Improvement

PartnershipSSC and Institute for Healthcare Improvement

SEPSIS BUNDLES

ICU (2005-2007) severe sepsis/septic shock

BUNDLES COMPLIANCE

Jan 05

Jun 05

July 05

Dec 05

July 06

Dec 06

Jan 06

Jun 06

Jan 07

Jun 07

% p

ati

ents 6-Hours6-Hours

24-Hours24-Hours

All bundlesAll bundles

EDUCATION

PROCESS CHANGES

ICU (2005-2008) severe sepsis/septic shock

BUNDLES COMPLIANCE

6H bundle

24 H bundle

n =195

Perc

en

tag

e o

f p

ati

en

ts

Perc

en

tag

e o

f p

ati

en

ts

GIViTI

Septic Shock

year SAPS II Mort.H

2005 55±18 62,1

2009 55±18 59,0

SAPS II

50±16 58±2764±2

456±1

661±1

656±21 66±22 53±14 60±16 57±17

EDUCATION

SEPSIS TEAM

SAPS II

hospital

30 days

TI (2005-2008) severe sepsis/septic shock

BUNDLES COMPLIANCE

ICU (2005-2008) severe sepsis/septic shock

MORTALITY

Septic shock n = 129

TI (2005-2008) severe sepsis/septic shock

BUNDLES COMPLIANCE

ICU (2005-2008) severe sepsis/septic shock

MORTALITY (f) BUNDLES

Multivariate Logistic Regression

30-d MortalityConfounders: age, sex, SAPS II, SOFA, Shock,

Semester

Independent: 9 sepsis interventions* + IgGAM

n =129

ICU (2005-2008) severe sepsis/septic shock

mortality (f) sepsis interventions

Hosmer-Lemeshow = 0,565

* sepsis Interventions1. Blood Cultures2. Antibiotic < 3h3. Source control4. Fluids5. SvO2> 70%

6. Glycamia 7. Steroids8. rhAPC9. PIP<30cmH20

OR 95% CI p

Source Control 0,245 0,069-0,871 0,030

Antibiotic 0,119 0,024-0,592 0,009

Fluids 5,007 1,260-19,90 0,022

6 H Bundles 0,274 0,065-1,152 0,077

Steroids 4,238 1,13-15,82 0,032

rhAPC 0,226 0,064-0,803 0,021

IgGAM 0,094 0,019-0,774 0,014

77 Spanish ICUs

2804 patients severe sepsis/septic shock

Before and after 2 months educational program

WHICH INTERVENTION ?