quali risultati vorresti e quali hai journal club ‘sopravvivere alla sepsi: i primi 5 anni’ 2...
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QUALI RISULTATI VORRESTI E QUALI HAI
Journal Club ‘Sopravvivere alla Sepsi: i primi 5 anni’
2 dicembre 2010
SURGICAL - “SEPTIC” ICU (01/2005-12/2008)
307 patients severe sepsis/septic shock
195 patients
66 Severe sepsis
129 Septic shock
112 excluded:- cirrhosis waiting list OLT- OLT- Pediatrics
ICU (2005-2009) severe sepsis/septic shock
I. I. Management of Severe SepsisManagement of Severe Sepsis• Initial ResuscitationInitial Resuscitation• DiagnosisDiagnosis• Antibiotic therapyAntibiotic therapy• Source ControlSource Control• FluidsFluids• VasopressorVasopressor• Inotropic TherapyInotropic Therapy• SteroidsSteroids• rhAPCrhAPC• Blood Product Blood Product
adiministartionadiministartion50 Strong Recommendations (1 A-C)
19 Weak Recommendations (2 B-D)
II. II. Supportive Therapy of SepsisSupportive Therapy of Sepsis• Mechanical VentilationMechanical Ventilation• SedationSedation• Glucose controlGlucose control• Renal replacementRenal replacement• Bicarbonate TherapyBicarbonate Therapy• Deep Vein Thrombosis Deep Vein Thrombosis
ProphylaxisProphylaxis• Stress Ulcer ProphylaxisStress Ulcer Prophylaxis• SDDSDD• Limitation of SupportLimitation of SupportIII. III. Pediatric Consideration in Pediatric Consideration in
severe sepsissevere sepsis
GUIDELINES
PartnershipSSC and Institute for Healthcare Improvement
PartnershipSSC and Institute for Healthcare Improvement
SEPSIS BUNDLES
ICU (2005-2007) severe sepsis/septic shock
BUNDLES COMPLIANCE
Jan 05
Jun 05
July 05
Dec 05
July 06
Dec 06
Jan 06
Jun 06
Jan 07
Jun 07
% p
ati
ents 6-Hours6-Hours
24-Hours24-Hours
All bundlesAll bundles
EDUCATION
PROCESS CHANGES
ICU (2005-2008) severe sepsis/septic shock
BUNDLES COMPLIANCE
6H bundle
24 H bundle
n =195
Perc
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GIViTI
Septic Shock
year SAPS II Mort.H
2005 55±18 62,1
2009 55±18 59,0
SAPS II
50±16 58±2764±2
456±1
661±1
656±21 66±22 53±14 60±16 57±17
EDUCATION
SEPSIS TEAM
SAPS II
hospital
30 days
TI (2005-2008) severe sepsis/septic shock
BUNDLES COMPLIANCE
ICU (2005-2008) severe sepsis/septic shock
MORTALITY
Septic shock n = 129
TI (2005-2008) severe sepsis/septic shock
BUNDLES COMPLIANCE
ICU (2005-2008) severe sepsis/septic shock
MORTALITY (f) BUNDLES
Multivariate Logistic Regression
30-d MortalityConfounders: age, sex, SAPS II, SOFA, Shock,
Semester
Independent: 9 sepsis interventions* + IgGAM
n =129
ICU (2005-2008) severe sepsis/septic shock
mortality (f) sepsis interventions
Hosmer-Lemeshow = 0,565
* sepsis Interventions1. Blood Cultures2. Antibiotic < 3h3. Source control4. Fluids5. SvO2> 70%
6. Glycamia 7. Steroids8. rhAPC9. PIP<30cmH20
OR 95% CI p
Source Control 0,245 0,069-0,871 0,030
Antibiotic 0,119 0,024-0,592 0,009
Fluids 5,007 1,260-19,90 0,022
6 H Bundles 0,274 0,065-1,152 0,077
Steroids 4,238 1,13-15,82 0,032
rhAPC 0,226 0,064-0,803 0,021
IgGAM 0,094 0,019-0,774 0,014
77 Spanish ICUs
2804 patients severe sepsis/septic shock
Before and after 2 months educational program
WHICH INTERVENTION ?