Abstract
Background
The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the ...most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality.
Methods
A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes.
Results
Of 11.916.974 discharges from all acute-care hospitals during the study period (2005–2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (
p
< 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (
p
< 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (
p
< 0.0001).
Conclusions
The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant.
Anticipating and avoiding preventable intrahospital cardiac arrest and clinical deterioration are important priorities for international healthcare systems and institutions. One of the ...internationally followed strategies to improve this matter is the introduction of the Rapid Response Systems (RRS). Although there is vast evidence from the international community, the evidence reported in a Spanish context is scarce.
A nationwide cross-sectional research consisting of a voluntary 31-question online survey was performed. The Spanish Society of Intensive, Critical and Coronary Care Medicine (SEMICYUC) supported the research.
We received 62 fully completed surveys distributed within 13 of the 17 regions and two autonomous cities of Spain. Thirty-two of the participants had an established Rapid Response Team (RRT). Common frequency on measuring vital signs was at least once per shift but other frequencies were contemplated (48.4%), usually based on professional criteria (69.4%), as only 12 (19.4%) centers used Early Warning Scores (EWS) or automated alarms on abnormal parameters. In the sample, doctors, nurses (55%), and other healthcare professionals (39%) could activate the RRT via telephone, but only 11.3% of the sample enacted this at early signs of deterioration. The responders on the RRT are the Intensive Care Unit (ICU), doctors, and nurses, who are available 24/7 most of the time. Concerning the education and training of general ward staff and RRT members, this varies from basic to advanced and specific-specialized level, simulating a growing educational methodology among participants. A great number of participants have emergency resuscitation equipment (drugs, airway adjuncts, and defibrillators) in their general wards. In terms of quality improvement, only half of the sample registered RRT activity indicators. In terms of the use of communication and teamwork techniques, the most used is clinical debriefing in 29 centers.
In terms of the concept of RRS, we found in our context that we are in the early stages of the establishment process, as it is not yet a generalized concept in most of our hospitals. The centers that have it are in still in the process of maturing the system and adapting themselves to our context.
Abstract Background We aimed to analyze compliance with 2010 European guidelines' quality criteria for external chest compressions (ECC) during 2 minutes of uninterrupted cardiopulmonary ...resuscitation. Methods Seventy-two healthy nurses and physicians trained in advanced cardiopulmonary resuscitation performed 2 uninterrupted minutes of ECC on a training manikin (Resusci Anne Advanced SkillTrainer; Laerdal Medical AS, Stavanger, Norway) that enabled us to measure the depth and rate of ECC. When professionals agreed to participate in the study, we recorded their age, body mass index (BMI), smoking habit, and their own subjective estimation of their physical fitness. To measure fatigue, we analyzed participants' heart rates, percentage of maximum tolerated heart rate (MHR), and subjective perception of their fatigue on a visual analog scale. Results Nearly half (48.6%) the rescuers failed to achieve a minimum average ECC depth of 50 mm. Only 48.1% of ECCs fulfilled the 2010 guidelines' quality criteria; quality deteriorated mainly after the first minute. Poor ECC quality and deteriorating quality after the first minute were associated with BMI < 23 kg/m2. Rescuers with BMI ≥ 23 kg/m2 fulfilled the quality criteria throughout the 2 minutes, whereas those with BMI < 23 kg/m2 fulfilled them for 80% of ECCs during the first minute, but for only 30% at the end of the 2 minutes. Conclusions Compliance with the 2010 guidelines' quality criteria is often poor, mainly due to lack of proper depth. The greater depth recommended in the 2010 guidelines with respect to previous guidelines requires greater force, so BMI < 23 kg/m2 could hinder compliance. Limiting each rescuer's uninterrupted time doing ECC to 1 minute could help ensure compliance.
Summary Objectives To analyse how rescuers tolerate the effort derived of giving uninterrupted chest compressions during 2 min. Materials and methods Twenty-three healthy volunteers, nurses and ...doctors of the Intensive Care Unit (ICU), members of the hospital cardiac arrest team, were enrolled in the study. Using a training manikin, participants were asked to perform chest compressions during 2 min at a rate of 100 min−1 . The oxygen saturation and cardiac rate of the subjects were monitored using pulse oximetry before and after one and 2 min performing chest compressions. The percentage of the maximal heart rate of the rescuer over the theoretical maximum allowed in a conventional stress test was calculated, taking into account age and body mass index (BMI) of the subjects. Fatigue was measured using a visual analogical scale (VAS). Results The means (±S.D.) of chest compressions in the first and second minutes were 103 ± 12, and 104 ± 11, respectively. The mean percent of the maximum heart rate observed was 61 ± 8%. None of the subjects had difficulties to complete the test. All subjects recovered their basal values in less than 2 min, and the mean value recorded in the VAS was 3 ± 2. Conclusions The practice of uninterrupted chest compressions during 2 min by the same rescuer is well tolerated by health professionals trained in cardiopulmonary resuscitation (CPR).
There are no specific generally accepted therapies for the coronavirus disease 2019 (COVID-19). The full spectrum of COVID-19 ranges from asymptomatic disease to mild respiratory tract illness to ...severe pneumonia, acute respiratory distress syndrome (ARDS), multisystem organ failure, and death. The efficacy of corticosteroids in viral ARDS remains unknown. We postulated that adjunctive treatment of established ARDS caused by COVID-19 with intravenous dexamethasone might change the pulmonary and systemic inflammatory response and thereby reduce morbidity, leading to a decrease in duration of mechanical ventilation and in mortality.
This is a multicenter, randomized, controlled, parallel, open-label, superiority trial testing dexamethasone in 200 mechanically ventilated adult patients with established moderate-to-severe ARDS caused by confirmed SARS-CoV-2 infection. Established ARDS is defined as maintaining a PaO
/FiO
≤ 200 mmHg on PEEP ≥ 10 cmH
O and FiO
≥ 0.5 after 12 ± 3 h of routine intensive care. Eligible patients will be randomly assigned to receive either dexamethasone plus standard intensive care or standard intensive care alone. Patients in the dexamethasone group will receive an intravenous dose of 20 mg once daily from day 1 to day 5, followed by 10 mg once daily from day 6 to day 10. The primary outcome is 60-day mortality. The secondary outcome is the number of ventilator-free days, defined as days alive and free from mechanical ventilation at day 28 after randomization. All analyses will be done according to the intention-to-treat principle.
This study will assess the role of dexamethasone in patients with established moderate-to-severe ARDS caused by SARS-CoV-2.
ClinicalTrials.gov NCT04325061 . Registered on 25 March 2020 as DEXA-COVID19.
Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the ...rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic.
Prospective, observational, and cohort study.
Forty-three Spanish ICU.
A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020).
None.
At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death.
A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.
To analyse how rescuers tolerate the effort derived of giving uninterrupted chest compressions during 2min.
Twenty-three healthy volunteers, nurses and doctors of the Intensive Care Unit (ICU), ...members of the hospital cardiac arrest team, were enrolled in the study. Using a training manikin, participants were asked to perform chest compressions during 2min at a rate of 100min(-1). The oxygen saturation and cardiac rate of the subjects were monitored using pulse oximetry before and after one and 2min performing chest compressions. The percentage of the maximal heart rate of the rescuer over the theoretical maximum allowed in a conventional stress test was calculated, taking into account age and body mass index (BMI) of the subjects. Fatigue was measured using a visual analogical scale (VAS).
The means (+/-S.D.) of chest compressions in the first and second minutes were 103+/-12, and 104+/-11, respectively. The mean percent of the maximum heart rate observed was 61+/-8%. None of the subjects had difficulties to complete the test. All subjects recovered their basal values in less than 2min, and the mean value recorded in the VAS was 3+/-2.
The practice of uninterrupted chest compressions during 2min by the same rescuer is well tolerated by health professionals trained in cardiopulmonary resuscitation (CPR).
This paper aims to analyze agreement in the assessment of external chest compressions (ECC) by 3 human raters and dedicated feedback software.While 54 volunteer health workers (medical transport ...technicians), trained and experienced in cardiopulmonary resuscitation (CPR), performed a complete sequence of basic CPR maneuvers on a manikin incorporating feedback software (Laerdal PC v 4.2.1 Skill Reporting Software) (L), 3 expert CPR instructors (A, B, and C) visually assessed ECC, evaluating hand placement, compression depth, chest decompression, and rate. We analyzed the concordance among the raters (A, B, and C) and between the raters and L with Cohen's kappa coefficient (K), intraclass correlation coefficients (ICC), Bland-Altman plots, and survival-agreement plots.The agreement (expressed as Cohen's K and ICC) was ≥0.54 in only 3 instances and was ≤0.45 in more than half. Bland-Altman plots showed significant dispersion of the data. The survival-agreement plot showed a high degree of discordance between pairs of raters (A-L, B-L, and C-L) when the level of tolerance was set low.In visual assessment of ECC, there is a significant lack of agreement among accredited raters and significant dispersion and inconsistency in data, bringing into question the reliability and validity of this method of measurement.
Purpose
To describe data on epidemiology, microbiology, clinical characteristics and outcome of adult patients admitted in the intensive care unit (ICU) with secondary peritonitis, with special ...emphasis on antimicrobial therapy and source control.
Methods
Post hoc analysis of a multicenter observational study (Abdominal Sepsis Study, AbSeS) including 2621 adult ICU patients with intra‐abdominal infection in 306 ICUs from 42 countries. Time-till-source control intervention was calculated as from time of diagnosis and classified into ‘emergency’ (< 2 h), ‘urgent’ (2–6 h), and ‘delayed’ (> 6 h). Relationships were assessed by logistic regression analysis and reported as odds ratios (OR) and 95% confidence interval (CI).
Results
The cohort included 1077 cases of microbiologically confirmed secondary peritonitis. Mortality was 29.7%. The rate of appropriate empiric therapy showed no difference between survivors and non-survivors (66.4% vs. 61.3%,
p
= 0.1). A stepwise increase in mortality was observed with increasing Sequential Organ Failure Assessment (SOFA) scores (19.6% for a value ≤ 4–55.4% for a value > 12,
p
< 0.001). The highest odds of death were associated with septic shock (OR 3.08 1.42–7.00), late-onset hospital-acquired peritonitis (OR 1.71 1.16–2.52) and failed source control evidenced by persistent inflammation at day 7 (OR 5.71 3.99–8.18). Compared with ‘emergency’ source control intervention (< 2 h of diagnosis), ‘urgent’ source control was the only modifiable covariate associated with lower odds of mortality (OR 0.50 0.34–0.73).
Conclusion
‘Urgent’ and successful source control was associated with improved odds of survival. Appropriateness of empirical antimicrobial treatment did not significantly affect survival suggesting that source control is more determinative for outcome.
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