SAN FRANCISCO – Meeting the goals of the Surviving Sepsis Campaign’s resuscitation care bundle significantly decreased the risk for in-hospital mortality, even when the goals were met beyond the recommended 6-hour window after diagnosis of severe sepsis, a study of 395 patients found.
In-hospital mortality rates were 88% lower in the 85 patients who met the resuscitation bundle goals 6-18 hours after diagnosis and 55% lower in the 95 patients who met the goals within the desired 6 hours after diagnosis compared with 216 patients who did not reach the goals within 18 hours of diagnosis, Dr. Zerihun A. Bunaye reported at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
Dr. Zerihun A. Bunaye
For resuscitation care in severe sepsis, it’s better late than never, he said. "Definitely this is showing that there’s a benefit if we continue to aggressively resuscitate the patients beyond 6 hours and try to achieve the goals," said Dr. Bunaye of Mercy Hospital, St. Louis. The lead investigator in the study was Dr. Farid Sadaka, also of the hospital.
Better survival in the group that complied with resuscitation bundle goals in 6-18 hours compared with the 6-hour compliance group surprised the investigators and may be due to several confounding factors that were not analyzed in the study, he said.
The Surviving Sepsis Campaign recommends two sets of "bundles" of care (sets of elements of care selected from evidence-based practice guidelines that have an effect on outcomes when implemented as a group that’s beyond the effect of individual implementation), some to be completed within 3 hours and other goals to be met within 6 hours.
The resuscitation bundle of care aims to prescribe appropriate antibiotics within 3 hours and within 6 hours to get the patient’s mean arterial pressure above 65 mm Hg, get central venous pressure above 8 mm Hg, achieve central venous oxygen saturation greater than 70%, and measure lactic acid, Dr. Bunaye said.
The investigators prospectively collected data as part of a performance improvement project with feedback mechanisms for alerting physicians when bundle goals were not being met so they could continue efforts to meet the goals beyond the recommended deadlines.
The study included patients with septic shock treated between July 2011 and January 2013 in a 54-bed ICU at the large university-affiliated hospital. It compared compliance with the resuscitation bundles within 18 hours of diagnosis and survival rates during approximately 31 days in the hospital.
Compared with the 54% of cases that did not comply with the resuscitation bundles within 18 hours, the hazard ratio for mortality was 0.45 in the 24% of cases that complied within 6 hours and 0.12 in the 22% that complied within 18 hours, Dr. Bunaye reported. Patients in the three groups did not differ significantly at baseline by age, weight, or Sequential Organ Failure Assessment score.
Previous studies have suggested that only 30%-40% of hospitals adhere to the Surviving Sepsis Campaign guidelines. The current study suggests that continuing efforts to meet the goals beyond 6 hours are beneficial, he said.
The findings are limited by the small sample size and the focus on a single institution. The study also did not account for potential confounding variables.
Severe sepsis in the United States is more common than AIDS, colon cancer, and breast cancer combined and is the leading cause of death in noncoronary ICUs, the literature suggests. The United States sees more than 500,000 cases of severe sepsis and septic shock each year, leading to death in 20% of patients with severe sepsis and 45% of those with septic shock, Dr. Bunaye said.
The investigators reported that they have no relevant financial disclosures.
Data suggest better late than never
Dr. Steven Q. Simpson, FCCP, comments: It is very encouraging to see that benefit accrues to patients who meet SSC (and National Quality Forum) bundle goals for physiological parameters, even if they are not met until later in the course of severe sepsis treatment. It seems a bit paradoxical that those who meet physiological goals between 6 and 16 hours after presentation have a higher mortality reduction than those who meet goals within 6 hours. Unfortunately, the study was not set up to determine how or why that may have happened, and whether the phenomenon is real.
The key point, though, is that these are valid goals to work toward in patients with severe sepsis and septic shock, and that we should follow through even when we miss the 6-hour time frame.
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