Thromboelastometry analysis of thrombocytopenic dengue patients: a cross-sectional study.

BACKGROUND: Dengue virus infection (DVI) is a prevalent and potentially fatal viral disease associated with coagulopathy. So far, the coagulation profile of DVI patients with thrombocytopenia has not been assessed through a viscoelastic test such as rotational thromboelastometry. We aimed to describe the prevalence and characteristics of coagulation abnormalities in dengue fever outpatients with thrombocytopenia, addressed by both rotational thromboelastometry and conventional coagulation tests. METHODS: This was a cross-sectional study conducted between April 6th and May 5th 2015 in São Paulo, Brazil during a dengue outbreak. Thromboelastometry (ROTEM®) and the conventional coagulation tests prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), thrombin time (TT), platelet count and fibrinogen levels were performed in 53 patients with DVI and thrombocytopenia. RESULTS: Despite a median interquartile range (IQR) platelet count of 77 (63-88) x 109/L in DVI patients, conventional coagulation tests and plasma fibrinogen levels were within the normal range. Subjects demonstrated hypocoagulability in 71.7% (38/53) in INTEM and 54.7% (29/53) in EXTEM DVI patients. FIBTEM analyses detected only 5.7% (3/53) with hypocoagulability among this population. The median (IQR) clotting time (CT), clot formation time (CFT) and maximum clot firmness (MCF) on INTEM were, respectively, 177 (160-207) sec, 144 (108-178) sec and 48 (42-52) mm. On EXTEM, median (IQR) CT, CFT and MCF were, respectively, 69 (65-78) sec, 148 (126-198) sec and 49 (44-55) mm. Median (IQR) MCF on FIBTEM was 15 (13-18) mm. CONCLUSION: Thromboelastometry impairment is highly prevalent in DVI patients with thrombocytopenia, particularly in INTEM and EXTEM analyses, while standard coagulation tests are normal in this setting. Clinical implications remain to be established.

The cost-effectiveness ratio of a managed protocol for severe sepsis.

PURPOSE: Severe sepsis is a time-dependent disease, and implementation of early treatment has been associated with mortality rate reduction. However, the literature is controversial regarding cost-effectiveness analysis of this intervention. The aim was to assess the cost-effectiveness of a managed protocol for the treatment of severe sepsis. MATERIALS AND METHODS: This is a prospective cohort study involving a historical comparison (before and after the implementation of the protocol) of patients who had been hospitalized with severe sepsis and septic shock. The group of patients who were treated before the assistance routine was implemented was considered to be the control. The case-managed nurse involved with assistance protocol performed the data collection. This nurse received special training to ensure the quality of the data and to measure the intervention throughout the implementation process. RESULTS: A total of 414 patients were analyzed. The mortality rates were 57% in the control group and 38% in the protocol group (P=.002). After the implementation of the protocol, the absolute risk reduction was 18%; and the relative risk reduction was 31.8%. There was a tendency for a reduction in the cost of the full hospitalization, but this trend did not reach statistical significance. Nevertheless, the cost of hospitalization in the intensive care unit was reduced significantly from US $138,237±$202,418 in the control group to US $85,484±$127,471 in the protocol group (P=.003). The managed protocol for sepsis resulted in an average gain of 3.2 life-years after being discharged from the hospital (8.8±13.3 years in the control group and 12.0±14.0 years in the protocol group, P=.01). CONCLUSIONS: Given that the incremental cost was lower than or equal to zero, the effectiveness of the protocol was justified by the significant increase in the life-years saved and the reduced mortality.

Decreasing mortality in severe sepsis and septic shock patients by implementing a sepsis bundle in a hospital setting.

BACKGROUND: The Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis (SS) and septic shock (SSh) have been recommended to reduce morbidity and mortality. MATERIALS AND METHODS: A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize SS and SSh shock patients' clinical outcomes were performed by applying sepsis bundles (6- and 24-hour) in May 2006. We compared bundle compliance and patient outcomes before (July 2005-April 2006) and after (May 2006-December 2009) implementation of the interventions. RESULTS: A total of 564 SS and SSh patients were identified. Prior to the intervention, compliance with the 6 hour-sepsis resuscitation bundle was only 6%. After the intervention, compliance was as follows: 8.2% from May to December 2006, 9.3% in 2007, 21.1% in 2008 and 13.7% in 2009. For the 24 hour-management bundle, baseline compliance was 15.0%. After the intervention, compliance was 15.1% from May to December 2006, 21.4% in 2007, 27.8% in 2008 and 44.4% in 2009. The in-hospital mortality was 54.0% from July 2005 to April 2006, 41.1% from May to December 2006, 39.3% in 2007, 41.4% in 2008 and 16.2% in 2009. CONCLUSION: These results suggest reducing SS and SSh patient mortality is a complex process that involves multiple performance measures and interventions.

Relato de caso: cuidado ao paciente em sepse grave sob a óptica da enfermagem / Case report: severe sepsis patient care according to the nursing point of view

A sepse é uma resposta inflamatória do organismo secundária a processo infeccioso, com foco presumido ou conhecido, levando ao comprometimento de múltiplos órgãos e ao óbito. É uma das mais frequentes causas de admissão em Unidade de Terapia Intensiva. O tratamento da sepse baseada na Campanha Sobrevivendo à Sepse (Surviving Sepsis Campaign - SSC) parece adequado e prático. O objetivo deste estudo foi o de rever o tratamento da sepse e relatar um caso de paciente com sepse grave que evoluiu favoravelmente. O relato de caso é de paciente com 72 anos de idade, do sexo feminino, com antecedentes de obesidade, diabetes melito tipo 2, hipertensão, cardiopatia não-especificada, e tratamento de infecção de trato urinário por Escherichia coli. A paciente foi admitida com quadro de confusão mental e queixa de dor abdominal há duas horas. Ao exame físico, apresentou hipotensão, taquicardia e estado febril (39ºC). Em decorrencia do quadro sugestivo de sepse foram iniciados o protocolo institutcional e a administração precoce de antibiótico. Em vigência dos resultados dos exames e tendo em vista a piora das disfunções orgâonicas...