Trezentos setenta e oito pacientes foram avaliados consecutivamente. A terapia precoce guiada por metas proposta por Rivers et al. Todos os pacientes atendidos na primeira fase deste estudo foram tratados conforme as diretrizes da CSS. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
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Revista Brasileira de Terapia Intensiva. Rev Bras Ter Intensiva. Submitted on March 30, Accepted on May 12, Stage I: Patients with severe sepsis or septic shock were included consecutively over 15 months and treated according to the Surviving Sepsis Campaign guidelines. Stage II: In the 10 subsequent months, patients with severe sepsis or septic shock were enrolled based on an active search for signs suggesting infection SSI in hospitalized patients.
The demographic variables were similar in both stages. There was no difference in compliance to the bundles. In parallel there was significant reduction of mortality rates at 28 days Sepsis is a set of sometimes dramatic and catastrophic reactions of human beings in response to invasion by pathogenic microorganisms.
It is a clinical syndrome that presents with different degrees of severity. If not diagnosed and adequately treated it may worsen over time. Usually, the clinical condition begins with nonspecific and subtle changes of the vital signs such as tachycardia and tachypnea. Generally speaking, sepsis often goes unnoticed until advanced stages even in hospital settings 4 because its manifestations are not marked by an ictus as in acute myocardium infraction AMI or stroke S. Diagnosis of the septic syndrome is clinical, based on changes that comprise the systemic inflammatory response syndrome SIRS.
It is an acute condition caused by systemic release of inflammatory mediators and generalized activation of the endothelium, generating break of the endothelial homeostasis with impairment and dysfunction of organs distant from the primary focus. It reflects the level of organic stress associated to different clinical conditions such as: trauma, burns, acute severe pancreatitis, surgery, transfusion therapy and infection. When SIRS is secondary to infection, the diagnosis is sepsis.
Sepsis is considered severe when there is at least one associated organ dysfunction and, if hypotension persists regardless of vigorous administration of water, it is septic shock.
It was proven that adopting the therapeutic strategy proposed by the Serving Sepsis Campaign SSC that includes early tissue reperfusion and control of the infection focus, 2,5,6 bring about decreased mortality. Failure to identify sepsis delays onset of adequate treatment, causes progress of multiple organ dysfunction and severely jeopardizes prognosis of patients. In this context we proposed a simple institutional procedure to facilitate identification of severe sepsis or septic shock in our hospital.
This study intended to verify if institutional emphasis to identify risk of sepsis may help early recognition of severe sepsis or septic shock and influence its prognosis. Written consent was not given, as it is an institutional program to attend patients. Patients detected in any sector of the hospital with a diagnosis of severe sepsis or septic shock was included.
Terminal disease or shock by other etiologies were considered exclusion criteria. The study encompasses two distinct periods stage I and stage II that differ according to the screening strategy of patients with risk of sepsis. In stage I 15 months were consecutively included patients with severe sepsis or septic shock, managed according to the SSC recommendations.
Diagnosis and treatment strategy was divided into three parts, shown in chart 1. At stage II, 10 months patients with sepsis or septic shock were identified as from an active search strategy for signs suggesting infection SSI in all patients admitted to the hospital. A new form was devised for a record of SSI Appendix 1 , grouping vital signs and eventual clinical signs of organ dysfunction of all patients in each ward.
Register of at least two SSI in this form were promptly informed to the responsible nurse by the sector that completed the screening form Appendix 2. A single nursing technician in each ward was in charge of the task. After initial assessment by the responsible nurse and by the sector, the nursing staff of the Hospital Infection Control Committee HICC was advised to evaluate and follow-up the case.
The on duty physician internal medicine resident was immediately called when suspicion of sepsis was confirmed Appendix 2. When diagnosis was defined, therapeutic bundles were started from 6 and 24 hours Appendix 3 and 4 according to SSC guidelines Figure 1. Nurses and resident physicians of intensive care and internal medicine of HMS were trained and supervised by intensivists to ascertain that patients were adequately treated in any ward.
In our hospital, as well as many others in Brazil, often a bed is not available in the ICU. Categorical variables were expressed in absolute and relative values and compared by the Chi-Square test.
Three hundred seventy eight patients were consecutively assessed. During stage I, 76 patients were identified with severe sepsis or septic shock, of which 8 were excluded for lack of a therapeutic perspective related to the baseline disease.
At stage II, patients had two or more signs suggesting infection. That is to say, in the second stage of the study for each 2. It was further observed that length of stay in the ICU and hospital was not significantly different between stages Table 1. Table 2 shows comparisons among survivors and not survivors in the 2 stages of this study. When comparing the total of survivors to the total of not survivors it was found that age, APACHE II, number of patients in septic shock, number of patients of male gender and time of detection of severe sepsis were significantly higher among not survivors.
Length of hospital stay was significantly shorter among not survivors. Time of detection of survivors was similar in both stages Table 2. Findings of this study disclosed that the organized search for signs suggesting infection leads to an earlier diagnosis of sepsis and implies decreased mortality related with this disease.
A series of evidences presented in the last decades clearly point that quick and systematic assistance in clinical situations like AMI, stroke and trauma results in an impressive decrease of associated deaths. However, severe sepsis and septic shock related mortality has undergone changes in the last 25 years.
Patients under treatment, even when appropriate, after multiple organ dysfunction have a worse prognosis. There is evidence that therapeutic intervention with hemodynamic resuscitation and antibiotic therapy are associated to lower mortality rates. Goal directed early therapy proposed by Rivers et al. The basis of this strategy is to treat overall tissue hypoxia as fast as possible to revert the unbalance between offer and consumption of oxygen to avoid development of MOD.
All patients cared in the first stage of this study were treated according to SSC guidelines. They set forth that management of the patient be grouped in two "bundles" of procedures which should be accomplished until the sixth and 24 th hours.
Respectively, "6 hours bundle" and 24 hours bundle". Probably, the high mortality rate of patients was associated to delayed identification of the septic condition. The long time period needed to detect sepsis at stage I, if compared to stage II, was remarkable. It is possible that organizational shortcomings associated to the low specificity of the systemic signs of infection are the main causes of delay in reaching diagnosis of sepsis, as noted in the first stage.
Probably, early detection permitted identification of patients prior to worsening of lactic acidosis and organ dysfunction such as renal failure, and volume-nonresponsive hypotension. Subsequent early intervention brings about more effective reperfusion and interruption of the sepsis "cascade" effect blocking evolution of this dysfunction.
Furthermore, am immeasurable aspect must be considered, the motivational factor that resulted in greater collective involvement surrounding the septic patients and better quality of assistance Hawthorne effect.
It was possible to reproduce findings from other studies showing a decrease in mortality after adoption of the SSC guidelines. Unquestionably, subjectivity and subtlety of signs of inflammation delay diagnosis of sepsis in some patients, with no evident focus of infection at the syndrome's early stages.
In this context, we added to the screening of sepsis protocols besides the most recent leukometry analysis, manifestations that show organ dysfunction and that might be clinically detected. Probably, increase of sensitivity generated by these screening models has facilitated early identification of physiological changes associated to infectious activity. This correction was based on retrieval of the importance of care with the patient, the role of each professional involved and importance of vital signs as marker for alert.
To investigate the cause of these changes and assess the need for an aggressive treatment is crucial. To adopt a multidisciplinary institutional strategy focused on early identification of patients at risk of sepsis, thwarts evolution of the syndrome towards more severe stages and brings about a decreased risk of death associated to severe sepsis and septic shock.
Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Surviving sepsis campaign in Brazil. Sepse manual. Rio de Janeiro: Atheneu; Knobel E, Beer I. Prat Hosp [Internet]. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: Implementation of an evidence-based "standard operating procedure" and outcome in septic shock.
Before-after study of a standardized hospital order set for the management of septic shock. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Rapidity of source control implementation following onset of hypotension is a major determinant of survival in human septic shock: Source control in the management of severe sepsis and septic shock: an evidence-based review.
Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. The impact of compliance with 6-hour and hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care. Mortality rate reduction associated with a severe sepsis management protocol implementation.
Crit Care ; 11 Suppl 3 The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock. Clinics Sao Paulo. Latin American Sepsis Institute. Campanha sobrevivendo a sepse [Internet]. Hollenberg SM. Top ten list in myocardial infarction. Population-based research assessing the effectiveness of trauma systems.
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016
Foram obtidos dados no manuseio da sepse conforme a campanha "Sobrevivendo a Sepse", uso da drotrecogina alfa, mortalidade aos 28 dias e sangramentos intensos. Neste grupo 32 O estudo de Rivers e col. Semin Thromb Hemost, ; Regulation and functions of the protein C anticoagulant pathway. Haematologica, ; Esmon CT - The protein C pathway.
Fluid therapy for septic shock resuscitation: which fluid should be used?
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