Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data

This research by Heldens and colleagues was published in the Medical Journal of Australia in September 2018.
Objectives:  To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology.
Design, Setting, Participants:  Prospective inception cohort study (3-month inception period, 1 October – 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU.
Main Outcomes:  Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days).
Results:  Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the clinical diagnosis group (13/83, 16%) than in the database group (18/49, 37%; P = 0.006).
Conclusions:  When compared with the reference standard – prospective clinical diagnosis – ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.
The full text of this article is freely available via this link.

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Red blood cell distribution width predicts long-term outcomes in sepsis patients admitted to the intensive care unit

This research by Han and colleagues was published in Clinica chimica acta; international journal of clinical chemistry September 2018 issue.
Background:  Although some underpowered studies have proven that increased red blood cell distribution width (RDW) may be associated with short-term prognosis of sepsis, the long-term prognostic value of RDW remains largely unknown.
Methods:  This retrospective observational study was based on the Medical Information Mart for Intensive Care III (MIMIC III), a large critical care database. Baseline RDW and conventional disease severity scores were extracted along with data on 4-year mortality, of adult patients with severe sepsis upon first admission to the intensive care unit (ICU). The prognostic value of RDW was analysed with Kapan-Meier cure, Cox model, receiver operating characteristic (ROC) curve analysis, net reclassification index (NRI) and integrated discriminatory index (IDI).
Results:  A total of 4264 subjects were included. The area under ROC curve of RDW for predicting 4-year mortality was 0.64 (95% CI: 0.63-0.66). In multivariable Cox model, increased RDW was independently associated with all-cause mortality, irrespective of anemia. With conventional severity scores as reference, RDW had continuous NRI comprised between 0.18 and 0.20, and IDI comprised between 0.30 and 0.40.
Conclusions:  RDW values significantly predicts long-term all-cause mortality in critically ill patients with severe sepsis beyond conventional severity scores.
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Automated monitoring for the early detection of sepsis in patients receiving care in intensive care units

Review question:  Can automated systems for the early detection of sepsis reduce the time to treatment and improve outcomes in patients in the intensive care unit (ICU), in comparison to standard care?
cochrane-57-1Background:  Sepsis happens when a person develops an infection and their immune system overreacts to it. If sepsis is not managed it can quickly develop into septic shock, which causes organs such as the liver and heart to stop working properly. People can be affected by sepsis at any time but people in intensive care settings are more likely to be affected by it. Septic shock is fatal for 20% to 70% of people admitted to intensive care in Europe. There is no single diagnostic test that can tell if someone has sepsis or not. Instead, the results of several tests (such as blood tests) have to be reviewed along with other information about the patient (such as their medical history), and clinical observations (such as heart rate, temperature, and blood pressure). This process can be time consuming and complicated to do. People already admitted to intensive care are likely to be very unwell and it can be difficult to tell if abnormal results are because of the problem that caused them to be admitted to intensive care, or because of sepsis.
Automated monitoring systems are electronic systems that can collect and analyse information from different sources, and can be used to alert staff when the signs and symptoms of sepsis have been identified. This may mean that sepsis is diagnosed at the earliest possible time, enabling treatment to begin before organ damage happens. However, there is the possibility that automated monitoring systems don’t help, or even cause harm. This might happen if the systems are unable to correctly detect sepsis (meaning that treatment is not started when it should be, or it is started when it shouldn’t be), or health care staff may not respond to alerts quickly enough, especially if the systems give too many false alarms.
Study characteristics:  We conducted a search to identify evidence published before September 2017. Studies were eligible for inclusion if they compared automated sepsis monitoring to standard care (such as paper‐based systems) in people admitted to intensive or critical care units for critical illness. We did not include non‐randomized studies (studies where participants were not allocated to treatment groups by chance), quasi‐randomized studies (studies where participants were allocated to treatment groups by a method that is not truly down to chance, such as date of birth or medical number), and cross‐over studies (where participants first receive one treatment and then cross over to receive the other treatment). Studies including people already diagnosed with sepsis were also excluded.
Key results:  We included three randomized controlled trials (studies where participants were allocated to treatment groups by chance), involving 1199 participants in this review. Overall there were no significant differences in time to start of antimicrobial therapy (such as antimicrobial and antifungal treatments, very low‐quality evidence), length of stay in the intensive care setting (very low‐quality evidence), or in mortality at 14 days, 28 days or discharge (very low‐quality evidence) when automated monitoring systems were compared to standard care. Very low‐quality evidence was available on failed detection of sepsis but data reporting was too unclear to enable us to analyse this in a meaningful way. Other outcomes that we wished to assess like time to initiation of fluid resuscitation (the process of increasing the amount of fluids in the body), mortality at 30 days, and quality of life were not reported in any of the studies.
Quality of the evidence:  Results of this review show limited, very low‐quality evidence, which has prevented us from drawing meaningful conclusions. It is unclear what effect automated systems for monitoring sepsis have on any outcomes included in this review, and therefore we are uncertain if automated sepsis monitoring is beneficial or not. Additional, high‐quality evidence is needed to help address our review question.
The full text of this Cochrane Review is freely available via this link.

A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection

This research by Redfern and colleagues was published in Critical Care Medicine in August 2018.
Objectives:  The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection.
Design:  Retrospective cohort study.  Setting:  Large U.K. General Hospital.
Patients:  Adults hospitalized between January 1, 2010, and February 1, 2016.
Measurement and main results:  We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825-0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680-0.695]; primary infection, National Early Warning Score 0.805 [0.799-0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670-0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without.
Conclusions:  The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be re-evaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials

The secondary research was published in the journal Critical Care in August 2018 by Wirz and others.
Background:  The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection.
Methods:  For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the “procalcitonin-guided” group) or the current standard of care (the “controls”). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay.
Results:  Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001).
Conclusion:  Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.
The full text of this article is freely available via this link.

Critical Care Reviews Newsletter 348 12th August 2018

The 348th Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature during the last week.  “The highlights of this week’s edition are randomised controlled trials on terlipressin versus noradrenaline for AKI in acute-on-chronic liver failure, restricted fluid bolus volume in early paediatric septic shock & early CPAP in acute respiratory failure in children with impacritcal care reviewsired immunity; systematic reviews and meta analyses on complications and failures of central vascular access devices & laryngeal injury and upper airway symptoms after intubation during critical care; and guidelines and position statements on steroid therapy for sepsis, disorders of consciousness & spinal motion restriction in trauma.”

The full text of the newsletter can be accessed via this link.