Journal of intensive care medicine
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J Intensive Care Med · Sep 2011
Resuscitation bundle compliance in severe sepsis and septic shock: improves survival, is better late than never.
While clinicians' management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign's (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥ 65 mm Hg, central venous pressure (CVP) ≥ 8 mm Hg, and central venous oxygen saturation (ScvO₂) ≥ 70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% (P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01. ⋯ Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.
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J Intensive Care Med · Sep 2011
Review Practice GuidelineEnd-of-life care in ICU: a practical guide.
Proper critical care training and management rests on 3 pillars-evidence-based patient care, proficient procedural skills, and compassionate end-of-life (EOL) management. The purpose of this manuscript is to provide a practical guide to EOL management for all bedside practitioners. ⋯ Like any other procedure in medicine, it requires preparation, implementation and conclusion, as well as supervision and repetition to become proficient. Therefore, at the conclusion of this paper, an attempt is made to correct this lack of training by providing such outline and a guide.
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J Intensive Care Med · Sep 2011
ReviewDiagnosis and management of life-threatening pulmonary embolism.
Pulmonary embolus (PE) is estimated to cause 200 000 to 300 000 deaths annually. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. The diagnosis of PE in the critically ill is often challenging because the presentation is nonspecific. ⋯ Evidence suggests that sub-massive PE is a heterogeneous group with respect to risk. It is possible that those at highest risk may benefit from thrombolysis, but existing studies do not identify subgroups within the sub-massive category. The role of inferior vena cava (IVC) filters, catheter-based interventions, and surgical embolectomy in life-threatening PE has yet to be completely defined.
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J Intensive Care Med · Sep 2011
Massive aspiration past the tracheal tube cuff caused by closed tracheal suction system.
Aspiration past the tracheal tube cuff has been recognized to be a risk factor for the development of ventilator-associated pneumonia (VAP). This study investigated the effect of closed tracheal suctioning on aspiration of fluid past the tracheal tube cuff in an in vitro benchtop model. ⋯ Massive aspiration of fluid occurs along the tracheal tube cuff during suction with the closed tracheal suction system.