Assessment of the components of fluid balance in patients with septic shock: a prospective observational study.

BACKGROUND: The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours. METHODS: In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness. RESULTS: We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores. CONCLUSIONS: Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.

Assessment of the components of fluid balance in patients with septic shock: a prospective observational study

Abstract Background: The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours. Methods: In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness. Results: We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores. Conclusions: Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.

Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions. / Disponibilidade de recursos para tratamento da sepse no Brasil: uma amostra aleatória de instituições brasileiras.

OBJECTIVE: To characterize resource availability from a nationally representative random sample of intensive care units in Brazil. METHODS: A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit. RESULTS: A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%). CONCLUSION: Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.

OBJETIVO: Caracterizar a disponibilidade de recursos a partir de amostra aleatória representativa das unidades de terapia intensiva do Brasil. MÉTODOS: Realizou-se um questionário estruturado on-line para ser respondido pelo diretor médico de cada unidade participante do estudo SPREAD (Sepsis PREvalence Assessment Database), um estudo de prevalência de um único dia para avaliar o ônus da sepse no Brasil. RESULTADOS: Uma amostra representativa de 277 das 317 unidades convidadas participou por meio de resposta ao questionário estruturado. Em sua maior parte, os hospitais participantes tinham menos que 500 leitos (94,6%), com mediana de 14 leitos na unidade de terapia intensiva. A principal fonte de recursos financeiros para dois terços das unidades pesquisadas era o atendimento de pacientes do sistema público de saúde. Não havia disponibilidade de laboratório de microbiologia próprio em 26,8% das unidades de terapia intensiva pesquisadas, e 10,5% geralmente não tinham acesso à realização de hemoculturas. Em 10,5% das unidades pesquisadas geralmente não estavam disponíveis antibióticos de amplo espectro, e 21,3% das unidades geralmente não podiam obter mensurações de lactato dentro de 3 horas. As instituições com alta disponibilidade de recursos (158 unidades; 57%) eram, em geral, maiores e atendiam principalmente pacientes do sistema de saúde privado. As unidades sem alta disponibilidade de recursos geralmente não dispunham de antibióticos de amplo espectro (24,4%), vasopressores (4,2%) e cristaloides (7,6%). CONCLUSÃO: Um número importante de unidades não tem condições para realizar intervenções básicas de monitoramento e terapêutica em pacientes sépticos. Nossos resultados salientam importantes oportunidades que o Brasil tem para melhorar, em termos de adesão a intervenções simples, porém eficazes.

Disponibilidade de recursos para tratamento da sepse no Brasil: uma amostra aleatória de instituições brasileiras / Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions

RESUMO Objetivo: Caracterizar a disponibilidade de recursos a partir de amostra aleatória representativa das unidades de terapia intensiva do Brasil. Métodos: Realizou-se um questionário estruturado on-line para ser respondido pelo diretor médico de cada unidade participante do estudo SPREAD (Sepsis PREvalence Assessment Database), um estudo de prevalência de um único dia para avaliar o ônus da sepse no Brasil. Resultados: Uma amostra representativa de 277 das 317 unidades convidadas participou por meio de resposta ao questionário estruturado. Em sua maior parte, os hospitais participantes tinham menos que 500 leitos (94,6%), com mediana de 14 leitos na unidade de terapia intensiva. A principal fonte de recursos financeiros para dois terços das unidades pesquisadas era o atendimento de pacientes do sistema público de saúde. Não havia disponibilidade de laboratório de microbiologia próprio em 26,8% das unidades de terapia intensiva pesquisadas, e 10,5% geralmente não tinham acesso à realização de hemoculturas. Em 10,5% das unidades pesquisadas geralmente não estavam disponíveis antibióticos de amplo espectro, e 21,3% das unidades geralmente não podiam obter mensurações de lactato dentro de 3 horas. As instituições com alta disponibilidade de recursos (158 unidades; 57%) eram, em geral, maiores e atendiam principalmente pacientes do sistema de saúde privado. As unidades sem alta disponibilidade de recursos geralmente não dispunham de antibióticos de amplo espectro (24,4%), vasopressores (4,2%) e cristaloides (7,6%). Conclusão: Um número importante de unidades não tem condições para realizar intervenções básicas de monitoramento e terapêutica em pacientes sépticos. Nossos resultados salientam importantes oportunidades que o Brasil tem para melhorar, em termos de adesão a intervenções simples, porém eficazes.

ABSTRACT Objective: To characterize resource availability from a nationally representative random sample of intensive care units in Brazil. Methods: A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit. Results: A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%). Conclusion: Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.

Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study.

PURPOSE: To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. METHODS: This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. RESULTS: The proportion of patients who received all the required items for the resuscitation bundle improved from 13% [95% confidence interval (CI) 8-18%] at baseline to 62% (95% CI 54-69%) in the last trimester (p < 0.001). Hospital mortality decreased from 55% (95% CI 48-62%) to 26% (95% CI 19-32%, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95% CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95% CI 23.9-35.4) to 17.5 (95% CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95% CI -18,604 to -5,338). The mean QALY increased from 2.63 (95% CI 2.15-3.14) to 4.06 (95% CI 3.58-4.57). For each QALY, the full compliance saves US$5,383. CONCLUSIONS: A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.

Use of femoral vein catheters for the assessment of perfusion parameters.

The use of central venous oxygen saturation (SvcO2) and arterial lactate in the diagnosis of severe tissue hypoperfusion is well established, and the optimization of these parameters is currently under investigation, particularly in patients with severe sepsis/septic shock. However, the only place for deep venous puncture or the first choice for puncture is often the femoral vein. Although venous saturation obtained from blood sampling from this catheter, instead of SvcO2, has already been used in the diagnosis of severe tissue hypoperfusion, little is known about the accuracy of the results. The venous lactate in place of arterial puncture has also been used to guide therapeutic decisions. We conducted this literature review to seek evidence on the correlation and concordance of parameters obtained by collecting femoral venous blood gases in relation to SvcO2 and arterial lactate. Few studies in the literature have evaluated the use of femoral venous oxygen saturation (SvfO2) or venous lactate. The results obtained thus far demonstrate no adequate agreement between SvfO2 and SvcO2, which limits the clinical use of SvfO2. However, the apparent strong correlation between arterial and peripheral and central venous lactate values suggests that venous lactate obtained from the femoral vein could eventually be used instead of arterial lactate, although there is insufficient evidence on which to base this procedure at this time.

Utilização de cateter em veia femoral para avaliação de parâmetros de perfusão / Use of femoral vein catheters for the assessment of perfusion parameters

A utilização da saturação venosa central de oxigênio (SvcO2) e do lactato arterial no diagnóstico de hipoperfusão tecidual em doentes graves já está bem estabelecida, e a otimização desses parâmetros é buscada principalmente em pacientes com sepse grave/choque séptico. Contudo, em diversas ocasiões, o único sítio para punção venosa profunda ou a primeira escolha para punção é a veia femoral. Embora a saturação venosa obtida da coleta de sangue desse cateter, em substituição a SvcO2, já tenha sido utilizada, pouco se sabe a respeito da acurácia de seus resultados. A utilização do lactato venoso, em substituição da punção arterial, também tem norteado decisões terapêuticas. Realizamos esta revisão de literatura buscando evidências sobre a correlação e a concordância desses parâmetros, obtidos pela coleta de gasometria venosa femoral, em relação à SvcO2 e ao lactato arterial. Existem poucos estudos na literatura avaliando a utilização da saturação venosa femoral de oxigênio (SvfO2) ou de lactato venoso. Os resultados até então obtidos mostram não haver concordância adequada entre SvfO2 e SvcO2, o que limita sua utilidade clínica. No entanto, a aparente correlação forte entre os valores de lactato arterial e venoso, tanto periférico como central, sugere que o lactato venoso obtido da veia femoral poderia, eventualmente, ser utilizado em substituição do lactato arterial, embora não haja evidências suficientes para basear essa conduta no momento.

The use of central venous oxygen saturation (SvcO2) and arterial lactate in the diagnosis of severe tissue hypoperfusion is well established, and the optimization of these parameters is currently under investigation, particularly in patients with severe sepsis/septic shock. However, the only place for deep venous puncture or the first choice for puncture is often the femoral vein. Although venous saturation obtained from blood sampling from this catheter, instead of SvcO2, has already been used in the diagnosis of severe tissue hypoperfusion, little is known about the accuracy of the results. The venous lactate in place of arterial puncture has also been used to guide therapeutic decisions. We conducted this literature review to seek evidence on the correlation and concordance of parameters obtained by collecting femoral venous blood gases in relation to SvcO2 and arterial lactate. Few studies in the literature have evaluated the use of femoral venous oxygen saturation (SvfO2) or venous lactate. The results obtained thus far demonstrate no adequate agreement between SvfO2 and SvcO2, which limits the clinical use of SvfO2. However, the apparent strong correlation between arterial and peripheral and central venous lactate values suggests that venous lactate obtained from the femoral vein could eventually be used instead of arterial lactate, although there is insufficient evidence on which to base this procedure at this time.

Diretrizes para tratamento da sepse grave/choque séptico: avaliação da perfusão tecidual / Guidelines for treatment of severe sepsis/septic shock: tissue perfusion assessment

A sepse tem alta incidência, alta letalidade e custos elevados, sendo a principal causa de mortalidade em unidades de terapia intensiva. Está claramente demonstrado que pacientes reconhecidos e tratados precocemente tem melhor prognóstico. A formulação de diretrizes de tratamento é fundamental para a adequação desse tratamento. Pacientes com claros sinais de hipoperfusão devem ser submetidos a otimização hemodinâmica. Assim, o reconhecimento dos sinais de hipoperfusão é um dos principais passos do tratamento. A presente diretriz aborda as evidências disponíveis na literatura em relação aos principais parâmetros hemodinâmicos utilizados atualmente.

Sepsis is a very frequent condition and causes high mortality rates and healthcare costs; it is the main cause of death in intensive care units. Clear, improved prognosis was shown for early diagnosed and treated patients. Treatment guidelines are fundamental for appropriate therapy. It is clear that hypoperfusion patients should be hemodynamically optimized; therefore, recognition of hypoperfusion signs is one of the main therapeutic steps. This guideline discusses the current literature and available data regarding the evaluation of hemodynamic parameters.

Guidelines for treatment of severe sepsis/septic shock: tissue perfusion assessment. / Diretrizes para tratamento da sepse grave/choque séptico: avaliação da perfusão tecidual.

Sepsis is a very frequent condition and causes high mortality rates and healthcare costs; it is the main cause of death in intensive care units. Clear, improved prognosis was shown for early diagnosed and treated patients. Treatment guidelines are fundamental for appropriate therapy. It is clear that hypoperfusion patients should be hemodynamically optimized; therefore, recognition of hypoperfusion signs is one of the main therapeutic steps. This guideline discusses the current literature and available data regarding the evaluation of hemodynamic parameters.

Intubação orotraqueal: avaliação do conhecimento médico e das práticas clínicas adotadas em unidades de terapia intensiva / Orotracheal intubation: physicians knowledge assessment and clinical practices in intensive care units

OBJETIVOS: Avaliar o conhecimento médico sobre as técnicas de intubação e identificar as práticas mais realizadas. MÉTODOS: Estudo prospectivo, envolvendo três diferentes unidades de terapia intensiva de um hospital universitário: da anestesiologia (ANEST), da pneumologia (PNEUMO) e do pronto socorro (PS). Todos os médicos que trabalham nessas unidades e que concordaram em participar do estudo, responderam um questionário contendo dados demográficos e questões sobre intubação orotraqueal. RESULTADOS: Foram obtidos 85 questionários (90,42 por cento dos médicos). ANEST teve maior média de idade (p = 0,001), com 43,5 por cento sendo intensivistas. Foi referido uso da associação hipnótico e opióide (97,6 por cento) e pré oxigenação (91,8 por cento), mas apenas 44,6 por cento referiram utilização de coxim suboccipital, sem diferença entre as UTIs. Na ANEST, referiu-se maior uso de bloqueador neuromuscular (p < 0,000) e maior cuidado com estômago cheio (p = 0,002). O conhecimento sobre sequência rápida foi restrito (nota média - 2,20 ± 0,89, com p = 0,6 entre as unidades de terapia intensiva. A manobra de Sellick era conhecida por (97,6 por cento), mas 72 por cento usaram-na inapropriadamente. CONCLUSÕES: O conhecimento médico sobre intubação orotraqueal em terapia intensiva não é satisfatório, mesmo entre profissionais qualificados para tal procedimento. É necessário avaliar se há concordância entre as respostas dos questionários e as práticas clínicas efetivamente adotadas.

OBJECTIVES: To assess the physician’s knowledge on intubation techniques and to identify the common practices. METHODS: This was a prospective study, involving three different intensive care units within a University hospital: Anesthesiology (ANEST), Pulmonology (PULMO) and Emergency Department (ED). All physicians working in these units and consenting to participate in the study completed a questionnaire with their demographic data and questions on orotracheal intubation. RESULTS: 85 completed questionnaires were retrieved (90.42 percent of the physicians). ANEST had the higher mean age (p=0.001), being 43.5 percent of them intensivists. The use of hypnotic and opioid association was reported by 97.6 percent, and pre-oxygenation by 91.8 percent, but only 44.6 percent reported sub-occipital pad use, with no difference between the ICUs. On ANEST an increased neuromuscular blockade use was reported (p<0.000) as well as increased caution with full stomach (p=0.002). The rapid sequence knowledge was restricted (mean 2.20 ± 0.89), p=0.06 between the different units. The Sellick maneuver was known by 97.6 percent, but 72 percent used it inappropriately. CONCLUSIONS: Physicians knowledge on orotracheal intubation in the intensive care unit is unsatisfactory, even among qualified professionals. It is necessary to check if the responses to the questionnaire and actual clinical practices agree.

Orotracheal intubation: physicians knowledge assessment and clinical practices in intensive care units. / Intubação orotraqueal: avaliação do conhecimento médico e das práticas clínicas adotadas em unidades de terapia intensiva.

OBJECTIVES: To assess the physician’s knowledge on intubation techniques and to identify the common practices. METHODS: This was a prospective study, involving three different intensive care units within a University hospital: Anesthesiology (ANEST), Pulmonology (PULMO) and Emergency Department (ED). All physicians working in these units and consenting to participate in the study completed a questionnaire with their demographic data and questions on orotracheal intubation. RESULTS: 85 completed questionnaires were retrieved (90.42% of the physicians). ANEST had the higher mean age (p=0.001), being 43.5% of them intensivists. The use of hypnotic and opioid association was reported by 97.6%, and pre-oxygenation by 91.8%, but only 44.6% reported sub-occipital pad use, with no difference between the ICUs. On ANEST an increased neuromuscular blockade use was reported (p<0.000) as well as increased caution with full stomach (p=0.002). The rapid sequence knowledge was restricted (mean 2.20 ± 0.89), p=0.06 between the different units. The Sellick maneuver was known by 97.6%, but 72% used it inappropriately. CONCLUSIONS: Physicians knowledge on orotracheal intubation in the intensive care unit is unsatisfactory, even among qualified professionals. It is necessary to check if the responses to the questionnaire and actual clinical practices agree.