Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle: results from the Portuguese community-acquired sepsis study (SACiUCI study) (original) (raw)

Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study

Indian Journal of Critical Care Medicine

IntroductIon Sepsis is a systemic, deleterious host response to infection leading to severe sepsis and septic shock. Severe sepsis and septic shock are major health-care problems, affecting millions of people around the world each year, killing one in four (and often more), and increasing in incidence. [1-5] According to the World Health Organization estimates, sepsis accounts for 60%-80% of lost lives per year in childhood. [6] Similar to polytrauma, acute myocardial infarction or stroke, the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome. The recommendations of surviving sepsis campaign (SSC) guidelines are intended to provide guidance for the clinician caring for a patient with severe sepsis or septic shock. The outcome improvement can be made through education and process change by SSC guidelines for those caring for severe sepsis patients in the intensive care unit (ICU) and non-ICU settings across the spectrum of acute care. [7] In 2004, the SSC endorsed the early goal-directed therapy for the management of severe sepsis and septic shock. It was aimed at obtaining a 25% reduction in mortality over the following 5 years in patients with septic shock worldwide. [8,9] These guidelines have been summarized by the SSC in sepsis bundles, which represent key elements of care regarding the diagnosis and treatment of patients with septic shock. [10] The Institute for the SSC provides in 2004 two bundles for septic shock patients: The 6-h resuscitation bundle and the 24-h management bundle (http://www.ihi.org/IHI/Topics/ CriticalCare/Sepsis). Many studies showed that implementation of 6-h resuscitation and 24-h management sepsis bundles decreased crude in-hospital or day 28 mortality, reduced the length of stay (in hospital/ICU), reduced the cost of care and Aim: The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock. Methodology: The study was conducted at a tertiary care hospital. Patients aged 1 month-13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged. Results: Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre-and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group. Conclusion: Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.