Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluationReport as inadecuate




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Critical Care

, 15:R229

First Online: 27 September 2011Received: 18 June 2011Revised: 30 August 2011Accepted: 27 September 2011

Abstract

IntroductionImplementation of the Surviving Sepsis Campaign SSC guidelines has been associated with improved outcome in patients with severe sepsis. Resolution of lactate elevations or lactate clearance has also been shown to be associated with outcome. The purpose of the present study was to examine the compliance and effectiveness of the SSC resuscitation bundle with the addition of lactate clearance.

MethodsThis was a prospective cohort study over 18 months in eight tertiary-care medical centers in Asia, enrolling adult patients meeting criteria for the SSC resuscitation bundle in the emergency department. Compliance and outcome results of a multi-disciplinary program to implement the Primary SSC Bundle with the addition of lactate clearance Modified SSC Bundle were examined. The implementation period was divided into quartiles, including baseline, education and four quality improvement phases.

ResultsA total of 556 patients were enrolled, with median 25th to 75th percentile age 63 50 to 74 years, lactate 4.1 2.2 to 6.3 mmol-l, central venous pressure 10 7 to 13 mmHg, mean arterial pressure MAP 70 56 to 86 mmHg, and central venous oxygen saturation 77 69 to 82%. Completion of the Primary SSC Bundle over the six quartiles was 13.3, 26.9, 37.5, 45.9, 48.8, and 54.5%, respectively P <0.01. The Modified SSC Bundle was completed in 10.2, 23.1, 31.7, 40.0, 42.5, and 43.6% patients, respectively P <0.01. The ratio of the relative risk of death reduction for the Modified SSC Bundle compared with the Primary SSC Bundle was 1.94 95% confidence interval = 1.45 to 39.1. Logistic regression modeling showed that the bundle items of fluid bolus given, achieve MAP >65 mmHg by 6 hours, and lactate clearance were independently associated with decreased mortality - having odds ratios 95% confidence intervals 0.47 0.23 to 0.96, 0.20 0.07 to 0.55, and 0.32 0.19 to 0.55, respectively.

ConclusionsThe addition of lactate clearance to the SSC resuscitation bundle is associated with improved mortality. In our study patient population with optimized baseline central venous pressure and central venous oxygen saturation, the bundle items of fluid bolus administration, achieving MAP >65 mmHg, and lactate clearance were independent predictors of outcome.

AbbreviationsAPACHEAcute Physiology and Chronic Health Evaluation

CVPcentral venous pressure

EDemergency department

EGDTearly goal-directed therapy

MAPmean arterial pressure

PaO2-FiO2partial pressure of oxygen-fraction of inspired oxygen

ScvO2central venous oxygen saturation

SSCSurviving Sepsis Campaign.

Electronic supplementary materialThe online version of this article doi:10.1186-cc10469 contains supplementary material, which is available to authorized users.

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Author: H Bryant Nguyen - Win Sen Kuan - Michael Batech - Pinak Shrikhande - Malcolm Mahadevan - Chih-Huang Li - Sumit Ray - Anna

Source: https://link.springer.com/







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