Empiric Antibiotic Treatment Reduces Mortality in Severe Sepsis and Septic Shock from the First Hour: Results from a Guideline-Based Performance Improvement Program. Ferrer R, Loeches IM, Phillips G, Osborn TM, Townsend S, Dellinger RP, Artigas A, Schorr C, Levy MM. Crit. Care Med. 2014 Aug;42(8):1749-55.
This study was a retrospective review of the Society of Critical Care Medicine’s Surviving Sepsis campaign database. This database is a prospectively entered dataset accounting for over 28 thousand patients over a 5 year period (2005-2010) with severe sepsis and septic shock in 165 intensive care units throughout the USA, South America, and Europe. The authors compared timing of antibiotic administration from onset of severe sepsis or septic shock to mortality while controlling for severity using the sepsis severity score, location prior to ICU admission (ED, ward, ICU), and geographic location.
The results revealed a linear relationship between risk of mortality and each hour delay in antibiotic administration from the time of severe sepsis or septic shock onset to drug infusion. The conclusions of this study support the notion that delays in appropriate antibiotic coverage in septic patients and patients with septic shock increases mortality.
The authors investigated several sub-populations and the findings held true. This included sources of sepsis inclusive of nosocomial infections, pneumonias, UTI, and abdominal sources. Overall, the odds ratios for mortality increased significantly after a 2 hour delay in antibiotic administration.
An Empirical Comparison of Key Statistical Attributes Among Potential ICU Quality Indicators. Brown S, Ratcliffe SJ, Halpern SD. Crit Care Med. 2014 Aug;42(8):1821-31.
Common ICU quality indicators such as mortality, ICU length of stay, need for ICU readmission, the use of commonly accepted prophylaxis regimens such as stress ulcer and venous thromboembolism prophylaxis are often used by hospital administration and other third parties to evaluate performance of the ICU and subsequently the institution. Quality indicators should measure processes of care and indirectly the quality of care provided. Therefore, this study seeks to evaluate the effectiveness of commonly used ICU quality indicators.
This study was a retrospective cohort study of the Project IMPACT database. Project IMPACT was a prospectively entered database of a nationally representative, voluntary, fee-based ICU clinical information system. 138 ICU’s in the USA contributed data over 7 years (2001-2008) and included data from 268,824 patients.
Using a host of statistical methods and adjusting for severity, correlations between risk adjusted quality indicators was performed. Large ranges among the quality indicators was noted and none of the 10 indicators was clearly and consistently correlated with a majority of the other nine. Thus, the authors concluded that no indicator performed optimally and further work is needed to define and operationalize better ICU quality metrics.
Albumin Replacement in Patients with Severe Sepsis or Septic Shock. Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, Fanizza C, Caspani L, Faenza S, Grasselli G, Iapichino G, Antonelli M, Parrini V, Fiore G, Latini R, Gattinoni L. N. Engl J. Med. 2014 Apr 10;370(15):1412-21.
The use of Human Albumin has been a controversial topic in the literature over the past 2 decades starting with a Cochrane review indicating potential harmful effects. However the SAFE study of 2004 found no ill effects. Beyond this, the SAFE study suggested (not in a statistically significant way) that there may be a survival benefit with Albumin use in the setting of severe sepsis. This current study, therefore, intended to determine this relationship in septic patients.
The study was performed as a multi-center trial across 100 different ICUs where patients were randomized to either 20% Albumin or crystalloid solution. The Albumin group received enough albumin per day to maintain a serum albumin level of 30g/L or more. Crystalloid was administered to the crystalloid group when clinically indicated. Outcome measures included mortality, incidence of organ dysfunction, degree of dysfunction, and length of stay.
The results showed a lower net fluid balance and higher mean arterial pressure in the Albumin group in the first 7 days. No differences in mortality or any other secondary outcomes was observed throughout the study period. The authors concluded Albumin derived no survival benefit and that further analysis of sub-groups was needed.
Effect of Erythropoietin and Transfusion Threshold on Neurological Recovery After Traumatic Brain Injury A Randomized Clinical Trial. Robertson CS, Hannay J, Yamal JM, Gopinath S, Goodman C, Tilley BC. JAMA. 2014 Jul 2;312(1):36-47.
Blood transfusion after traumatic injury is controversial in hemodynamically stable patients with moderate anemia. Blood transfusion has been associated with increased risk of infection, multi-organ failure, thromboembolic events, and even death. This has led to the creation of transfusion threshold triggers, most popularly 7g/dL as noted by the TRICC trial. However, in Traumatic Brain Injury, concern for cerebral oxygen delivery has generated concern for too low a transfusion threshold. The current study looks to evaluate transfusion threshold and the effects of erythropoietin and outcomes after TBI.
The authors randomized 200 patients with closed head injuries within 6 hours of injury to either erythropoietin or placebo and transfusion threshold of 7 vs. 10 g/dL. Main outcome measures were Glasgow Outcome Scale (GOS) at 6 months post injury. Ultimately, the authors found no interaction between erythropoietin or hemoglobin thresholds. Erythropoietin was found to be futile as compared to placebo. With no difference in GOS for transfusion triggers, the authors did find that the 10g/dL group had a higher incidence of thromboembolic events.
The Impact of Meeting Donor Management Goals on the Number of Organs Transplanted per Expanded Criteria Donor. Pate MS, Zatarain J, De La Cruz S, Sally MB, Ewing T, Crutchfield M, Enestvedt CK, Malinoski D. JAMA Surg. 2014 Sep;149(9):969-75.
The gap between organ donors and the transplant waiting list continues to grow. Expanded criteria donors (ECD) have increased the available pool of donors. Donor management guidelines (DMG) have the intended purpose of improving the number of transplantable organs per donor. The current study seeks to evaluate the effect of DMG on ECDs with the hypothesis that the average number of transplanted organs per donor will increase.
The study was a prospective interventional study involving the implementation of a DMG that consisted of 9 components. The number of DMG components at goal prior to organ donation was recorded and compared to the number of transplanted organs from each donor. The components included MAP, CVP, ejection fraction, pH, P/F ratio, serum sodium, Urine output, glucose, and need for pressor goals. The study was performed in the southwestern USA encompassing 8 different organ procurement organizations from 2010 through 2013.
The authors results showed that the higher the number of DMG components that were achieved in ECDs, the higher the chances of having 3 or more transplanted organs per donor. The authors concluded that the ECD population was in need of physiologic optimization and would receive particular benefit from DMGs.