Sepsis Champions: October 2024

Welcome to the latest key papers and publications focussing mainly on all things sepsis in the nursing profession.

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Multimodal Quality Initiatives in Sepsis Care: Assessing Impact on Core Measures and Outcomes
Abstract: Providing timely and effective care for patients with sepsis is challenging due to delays in recognition and intervention. The Surviving Sepsis Campaign has developed bundles that have been shown to reduce sepsis mortality. However, hospitals have not consistently adhered to these bundles, resulting in suboptimal outcomes. To address this, a multimodal quality improvement sepsis program was implemented from 2017 to 2022 in a large urban tertiary hospital. The aim of this program was to enhance the Severe Sepsis and Septic Shock Management Bundle compliance and reduce sepsis mortality. At baseline, the Severe Sepsis and Septic Shock Management Bundle compliance rates were low, at 25%, with a sepsis observed/expected mortality ratio of 1.14. Our interventions included the formation of a multidisciplinary committee, the appointment of sepsis champions, the implementation of sepsis alerts and order sets, the formation of a Code Sepsis team, real-time audits, and peer-to-peer education. By 2022, compliance rose to 62%, and the observed/expected mortality ratio decreased to 0.73. Our approach led to improved outcomes and hospital rankings. These findings underscore the efficacy of a comprehensive sepsis care initiative, emphasizing the importance of interdisciplinary collaboration. A multimodal hospital-wide sepsis performance program is feasible and can contribute to improved outcomes. However, further research is necessary to determine the specific impact of individual strategies on sepsis outcomes.
Source: Garcia M. Journal for Healthcare Quality, 2024 Jul-Aug; 46(4): 245-250
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Sepsis without borders
Abstract: Sepsis is a global public health problem, accounting for 48.9 million cases and 11 million sepsis-related deaths worldwide in 2020, with the highest burden felt in low-income countries (LICs) (World Health Organization (WHO), 2024a). The main challenge is that as a syndrome and not a disease, the range of signs and symptoms seen can make it difficult to diagnose in its early stages. In consequence, health professionals always need to rule out sepsis rather than rule it in, using the question ‘Could it be sepsis?’ (Sepsis Trust, 2024). This comment piece highlights the ongoing nature of the burden of sepsis, as countries continue to grapple with this global problem.
Source: Carter C. British Journal of Nursing, 2024 Jul; 33(14): 654-655

The frequency of sepsis-associated delirium in intensive care unit and its effect on nurse workload
Abstract: Aim: To determine the frequency of sepsis-associated delirium (SAD) in the intensive care unit and its effect on nurse workload.
Design: A cross-sectional and correlational design was used.
Methods: The study was conducted with 158 patients in the adult intensive care unit of a hospital between October 28 and July 28, 2022. Data analysis included frequency, chi-squared/fisher's exact test, independent samples t-test, correlation analysis, simple and multiple linear regression analyses. The study adhered to the STROBE guidelines.
Results: Sepsis was detected in 12.7% of the patients, delirium in 39.9%, and SAD in 10.1%. SAD was more common in males (19%) and 56.3% of the patients were admitted to the unit from the emergency department. Patients developing SAD had significantly higher age and mean sequential organ failure evaluation, acute physiology and chronic health evaluation II, and C-reactive protein and lactate scores, but their Glasgow Coma Scale scores were significantly low. There was a moderate positive relationship between the patients' Sequential Organ Failure Assessment score and the presence of SAD. The most common source of infection in patients diagnosed with SAD was bloodstream infection (44.4%). SAD significantly increased nurse workload and average care time (1.8 h) and it explained 22.8% of the total variance in nurse workload. Additionally, the use of antibiotics, vasopressors and invasive mechanical ventilation significantly increased nurse workload.
Conclusion: In the study, in patients who developed SAD increased nurse workload and average care time significantly. Preventive nursing approaches and effective management of SAD can reduce the rate of development of SAD and nurse workload.
Implications for the profession and patient care: It is important to work with routine screening, prevention and patient–nurse ratio appropriate to the workload for SAD.
Source: Alici S. Journal of Clinical Nursing, 2024 May; Online ahead of print

Emergency clinicians' use of adult and paediatric sepsis pathways: An implementation redesign using the behaviour change wheel
Abstract: Aims: To identify facilitators and barriers and tailor implementation strategies to optimize emergency clinician's use of adult and paediatric sepsis pathways.
Design: A qualitative descriptive study using focus group methodology.
Methods: Twenty-two emergency nurses and ten emergency medical officers from four Australian EDs participated in eight virtual focus groups. Participants were asked about their experiences using the New South Wales Clinical Excellence Commission adult and paediatric sepsis pathways using a semi-structured interview template. Facilitators and barriers to use of the sepsis pathways were categorized using the Theoretical Domains Framework. Tailored interventions were selected to address facilitators and barriers, and a re-implementation plan was devised guided by the Behaviour Change Wheel.
Results: Thirty-two facilitators and 58 barriers were identified corresponding to 11 Theoretical Domains Framework domains. Tailored strategies were selected to optimize emergency clinicians' use of the sepsis pathways including refinement of existing education and training programmes, modifications to the electronic medical record system, introduction of an audit and feedback system, staffing strategies and additional resources.
Conclusion: The implementation of sepsis pathways in the Emergency Department setting is complex, impacted by a multitude of factors requiring tailored strategies to address facilitators and barriers and optimize uptake.
Implications for Patient Care: This study presents a theory-informed systematic approach to successfully implement and embed adult and paediatric sepsis pathways into clinical practice in the Emergency Department.
Impact: Optimizing uptake of sepsis pathways has the potential to improve sepsis recognition and management, subsequently improving the outcome of patients with sepsis.
Reporting Method: The Consolidated Criteria for REporting Qualitative research guided the preparation of this report.
Patient or Public Contribution: Nil.
Source: Munroe B. Journal of Advanced Nursing, 2024 September; Online ahead of print

Predicting sepsis at emergency department triage: Implementing clinical and laboratory markers within the first nursing assessment to enhance diagnostic accuracy
Abstract: Background: Early identification of sepsis in the emergency department (ED) triage is both valuable and challenging. Numerous studies have endeavored to pinpoint clinical and biochemical criteria to assist clinicians in the prompt diagnosis of sepsis, but few studies have assessed the efficacy of these criteria in the ED triage setting. The aim of the study was to explore the accuracy of clinical and laboratory markers evaluated at the triage level in identifying patients with sepsis.
Methods: A prospective study was conducted in a large academic urban hospital, implementing a triage protocol aimed at early identification of septic patients based on clinical and laboratory markers. A multidisciplinary panel of experts reviewed cases to ensure accurate identification of septic patients. Variables analyzed included: Charlson comorbidity index, mean arterial pressure (MAP), partial pressure of carbon dioxide (PetCO2), white cell count, eosinophil count, C-reactive protein to albumin ratio, procalcitonin, and lactate.
Results: A total of 235 patients were included. Multivariable analysis identified procalcitonin ≥1 ng/mL (OR 5.2; p < 0.001); CRP-to-albumin ratio ≥32 (OR 6.6; p < 0.001); PetCO2 ≤ 28 mmHg (OR 2.7; p = 0.031), and MAP <85 mmHg (OR 7.5; p < 0.001) as independent predictors for sepsis. MAP ≥85 mmHg, CRP/albumin ratio <32, and procalcitonin <1 ng/mL demonstrated negative predictive values for sepsis of 90%, 89%, and 88%, respectively.
Conclusions: Our study underscores the significance of procalcitonin and mean arterial pressure, while introducing CRP/albumin ratio and PetCO2 as important variables to consider in the very initial assessment of patients with suspected sepsis in the ED.
Clinical relevance: Early identification of sepsis since the emergency department (ED) triage is challenging Implementing the ED triage protocol with simple clinical and laboratory markers allows to recognize patients with sepsis with a very good discriminatory power (AUC 0.88).
Source: Sisto U G. Journal of Nursing Scholarship, 2024 June; Online ahead of print

Association between measures of resuscitation in the critical care resuscitation unit and in-hospital mortality among patients with sepsis
Abstract: Objectives: We hypothesized that lactate clearance and reduction of the Sequential Organ Failure Assessment (SOFA) score during patients’ critical care resuscitation unit (CCRU) stay would be associated with lower in-hospital mortality.
Methods: This was a retrospective study of adult patients who had sepsis diagnoses and were admitted to the CCRU in 2018. Multivariable logistic regression analysis was performed to assess the association of clinical factors, lactate clearance, and SOFA reduction with hospital mortality.
Results: A total of 401 patients with lactate clearance data and 455 patients with SOFA score data were included in the study. The mean (SD) lactate and SOFA score on admission were 2.2 (1.8) mmol/L and 4.4 (4.3), respectively. Average lactate clearance was 0.1 (2.6) mmol/L, and average SOFA score reduction was 0.65 (5.9). Patients with a one point reduction in SOFA score during their CCRU stay had a 31% reduction of mortality (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.62–0.77, p < 0.001). SOFA score reduction was associated with lower hospital mortality for both surgical patients (OR 0.69, 95% CI 0.58–0.81, p < 0.001) and non-surgical patients (OR 0.71 95% CI 0.06–0.83, p < 0.001).
Conclusion: SOFA score reduction, but not lactate clearance during the CCRU stay, was associated with lower odds of in-hospital mortality. These findings suggest that resuscitative efforts leading to an early improvement in SOFA score may benefit patients with sepsis.
Source: Emamian N. Journal of the American College of Emergency Physicians, 2024 August; 5(5): e13281

Outcomes and prognosis of sepsis and septic shock in critically ill hematology patients
Abstract: Introduction and aim: Hematology patients are at high risk for sepsis/septic shock as a result of both their primary disease and treatment. In this patient population, it is very important to examine the entire course of sepsis/septic shock and to define the affecting factors in order to determine the measures for reducing sepsis-related mortality.
Patients and methods: The patients admitted to hematology intensive care unit (ICU) in a university hospital were retrospectively examined between January 01, 2018 and December 31, 2022. Those followed up with the diagnosis of sepsis/septic shock were included in the study. The demographic characteristics of the patients, comorbidities, reasons for ICU admission, organ failure scores on ICU admission, underlying hematological diseases and the status of diseases, the presence of neutropenia, decubitus wounds, nutritional support, the source of the infection and infectious agents, sepsis/septic shock-related complications and laboratory data were evaluated in detail. The effects of these data on mortality were examined.
Results: A total of 260 sepsis episodes of 149 patients were analyzed. The underlying hematological diseases, 32.8% were acute leukemia, 24.2% multiple meyloma, 20.8% lymphoproliferative disease, 12.1% chronic leukemia and HSCT was performed in 65 patients. The median SOFA score at ICU admission was 9 (7–12) and the APACHE-II median was 25 (20–32). The most common sources of infection were pulmonary infection with a rate of 73.8% and blood stream infection (BSI) with a rate of 42.3%. The ICU mortality rate was 50,3%. The SOFA score at ICU admission, admission from inpatient clinics or other ICUs, presence of neutropenia and decubitus wound, laboratory findings such as procalcitonin (PCT), lactate, creatinine and pH, sepsis/septic shock-related complications, source of infections, culture negativity, and presence of fungal infection were all defined as significant factors affecting mortality in univariate analysis. The admission from inpatient clinics or other ICUs, SOFA score and presence of decubitus wound at ICU admission, not feeding orally or enterally, BSI as a sepsis/septic shock source, and requirement for renal replacement therapy (RRT) were defined as independent variables for ICU mortality in logistic regression analysis (Table 1).
Conclusion: This study showed that the course and prognosis of sepsis/septic shock were determined by presence of organ failure (SOFA score) and decubitus wounds (indirect indicator of performance status), not feeding orally and enterally, and requirement of RRT rather than the variables related to the underlying hematological disease.
Source: Bozkurt H K. Journal of Critical Care, 2024 June; 81: 154653
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Effect of an interdisciplinary sepsis team on the management of patients with sepsis and septic shock in the emergency department: A literature review
Abstract: Introduction and aim: Sepsis is a life-threatening condition which is due to a systematic inflammatory and immune response to an infection. The optimization of the management of patients with sepsis, requires immediate identification, appropriate antibiotic therapy, hemodynamic support, and control of the source of infection. Delayed early identification, and initiation of treatment can lead to septic shock, multiorgan failure, and death. Through the literature, it seems that the existence of an interdisciplinary sepsis team is a factor that contributes significantly to the improvement of sepsis recognition, as well as compliance with the guidelines and consequently to the improvement of patients' outcomes. To investigate the literature regarding the impact of an interdisciplinary sepsis team on the degree of compliance with the Surviving Sepsis Campaign (SSC) guidelines (1-Hour Bundle: whether they are implemented and times) in ERs.
Patients and methods: Α systematic review of the literature in the PubMed and CINAHL databases using specific keywords, inclusion and exclusion criteria. The search was established during the period 2022–2023. NOS tool was used for the quality assessment of the research methodology of the studies included in the current review.
Results: The search resulted in a total of 9 studies published during the period 2017–2022. 4 of them were retrospective, 1 cohort, 1 quasi-experimental, 2 retrospective and prospective studies and 1 prospective study. The results show a statistically significant improvement in compliance with sepsis guidelines within 1 h in taking blood cultures before giving antibiotics (40% to 85%), administration of broad-spectrum antibiotics (25% to 76.9%), administration of crystalloid intravenous fluids (30 ml/kg BW), (31% to 81%), administration of vasopressors drugs if hypotension persists after administration of intravenous fluids (43% to 58%), in measurement of 1st lactate (13% to 47%), and 2nd lactic acid (76% to 90%) within 3 h.
Conclusion: Interdisciplinary sepsis management teams can use existing knowledge, skills and tools to improve sepsis compliance by improving the processing time of measures, such as improving the time to measure lactate, administer fluids, take blood cultures and administer antibiotics.
Source: Georgiou C. Journal of Critical Care, 2024 June; 81: 154666
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Effect of antibiotics efficacy in patients with sepsis and septic shock presenting in the emergency department: A literature review
Abstract: Introduction and aim: Sepsis is a life-threatening condition which is due to a systematic inflammatory and immune response to an infection. Patients comes in Emergency Department (ERs) with infections that could lead in sepsis and septic shock. Approximately 50 million patients develop severe sepsis and septic shock worldwide. More than half are admitted to an intensive care unit (ICU). Early diagnosis and treatment of these patients is critical and is associated not only with improved morbidity and mortality, but also with reduced length of hospital stay (LOS). As a consequence of the immediate recognition of sepsis, the timely administration of antibiotics is a necessary condition for its effective treatment. To investigate the literature regarding the effectiveness of timely administration of antibiotics in patients with sepsis in the ERs.
Patients and methods: Α systematic review of the literature in the PubMed and CINAHL databases. All possible combinations have been using the word “and”. Study Inclusion criteria were: a) studies examining the timely administration of antibiotics in septic patients, b) studies correlating the time of antibiotic administration and in-hospital mortality, c) published in scientific journals in English, the last 5 years.
Results: The search resulted in a total of 7 studies. 4 from Asia, 2 from USA and 1 from United Kingdom, that were published between 2017 and 2022. It is argued that the untimely administration of antibiotics increases mortality. In-hospital mortality rates were reduced in patients receiving antibiotics within 1 h (30% to 18%), (p < 0,001) compared to those who did not receive the timely treatment (20% to 55%) (p = 0.046), (p = 0.009). Among patients who received antibiotics within the appropriate time showed 35% (p = 0.042), (p < 0,001) increased risk of mortality for every 1 h delay in antibiotics.
Conclusion: Early administration of antibiotics improves outcomes in patients with sepsis and septic shock. Delays in the initiation of antibiotics in the emergency department are associated with a clinically significant increase in the risk of mortality from sepsis. The need to improve the timely treatment of patients with sepsis who come to the ERs is emphasized.
Source: Georgiou C. Journal of Critical Care, 2024 June; 81: 154667
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Recognition, diagnosis, and early management of suspected sepsis: summary of updated NICE guidance
Abstract: What you need to know: Calculate NEWS2 scores to determine an adult’s risk of severe illness or death from sepsis in acute hospital, mental health, and ambulance settings. Use the person’s risk level to help determine the time window in which to give antibiotics.
Sepsis is defined as life threatening organ dysfunction caused by a dysregulated host response to infection.1 In 2016, the National Institute for Health and Care Excellence (NICE) first published guidance on recognising, diagnosing, and managing suspected sepsis. [...]in January 2024, NICE guidance was updated to include NEWS2 for stratifying risk of severe illness or death from sepsis.4 The updated guideline aims to ensure that early recognition of patient deterioration and treatment for sepsis becomes standardised nationally, and includes recommendations on the timing of antibiotic prescribing based on a person’s risk level, while investigating the underlying infection source. Evaluating risk level using NEWS2 A new recommendation was made that NEWS2 scores should be recorded for all patients aged 16 and over (excluding people who are or have recently been pregnant) in acute hospital, mental health, and ambulance settings to help stratify risk of severe illness or death from sepsis. Deferring administration of a broad spectrum antibiotic treatment for up to three hours after calculating the person’s first NEWS2 score on initial assessment in the emergency department or deterioration in the ward, and using this time to gather information for a more specific diagnosis. Discussing the person’s condition with a senior clinical decision maker.
Source: Gildea A. BMJ, 2024 June; 385: q1173

Fluid Resuscitation and Sepsis Management in Patients with Chronic Kidney Disease Or Endstage Renal Disease: Scoping Review
Abstract: Managing sepsis and fluid resuscitation in patients with chronic kidney disease or end-stage renal disease is challenging for health care providers. Nurses are essential for early identification and treatment of these patients. Nurse education on assessing perfusion and implementing 3-hour bundled care can improve mortality rates in patients with sepsis. In this scoping review, initial screening identified 1176 articles published from 2015 through 2023 in the National Library of Medicine database; 29 articles were included in the literature summary and evidence synthesis. A systematic review meta-analysis was not possible because of data heterogeneity. The review revealed that most patients with chronic kidney disease or end-stage renal disease received more conservative resuscitation than did the general population, most likely because of concerns about volume overload. However, patients with chronic kidney disease or end-stage renal disease could tolerate the standard initial fluid resuscitation bolus of 30 mL/kg for sepsis. Outcomes in patients with chronic kidney disease or end-stage renal disease were similar to outcomes in patients without those conditions, whether they received standard or conservative fluid resuscitation. Patients who received the standard (higher) fluid resuscitation volume did not have increased rates of complications such as longer duration of mechanical ventilation, increased mortality, or prolonged length of stay. Using fluid responsiveness to guide resuscitation was associated with improved outcomes. The standard initial fluid resuscitation bolus of 30 mL/kg may be safe for patients with chronic kidney disease or end-stage renal disease and sepsis. Fluid responsiveness could be a valuable resuscitation criterion, promoting better decision-making by multidisciplinary teams. Further research is required.
Source: Haley M. American Journal of Critical Care, 2024 January; 33(1): 45-53

Clinical evaluation of different sepsis filters
Abstract: Introduction and aim: Sepsis is a life-threatening organ dysfunction in response to a host's infection. In addition to treatments with proven efficacy in sepsis, there are also treatment methods under investigation. The use of cytokine filters is recognized as a promising adjunctive therapy in the treatment of sepsis. The aim of this study is to evaluate the results of sepsis cytokine filters applied in sepsis patients.
Patients and methods: In this retrospective single center study, 17 patients who were followed up in the Internal Diseases Intensive Care Clinic of Kayseri City Hospital due to sepsis and were applied sepsis cytokine filter were included in the study. Three sepsis filters were applied to the patients according to their clinical status. CPFA sepsis filter was applied in 5 patients(Group 1), Oxiris in 7 patients(Group 2), and Jafron HA330 in 5 patients(Group 3).ResultsThe mean age of the patients was 67.1 ± 17.9 years. Seven of the patients were femal (41%) and 10 were male(59%). The hospitalization period of the patients was 30.1 ± 32.3 days and the day of hospitalization in the intensive care unit was 11.1 ± 8.8 days. The mean APACHE value of the patients was 32.8 ± 7.1 and the hospitalization glaskow coma score was 10.3 ± 3.3. There was a significant difference between the glaskow coma score at the intensive care unit admission and the glaskow coma score at the time of discharge from the intensive care unit (p = 0.010). CRP decrease rates and procalcitonin decrease rates before and after sepsis filter were significant, but WBC decrease rate was not significant (p < 0.001, p = 0.001, and p = 0.570, respectively). Procalcitonin decrease percentages of the patients were 0.87 ± 0.15, and CRP decrease percentages were 0.64 ± 0.31. The percentages of decrease in Procalcitonin were found to be significant in the CPFA sepsis filter applied group compared to the groups in which Oxiris and Jafron HA330 were applied (p = 0.020), there was no difference between the three groups in terms of CRP decrease percentages (p = 0.755). There was no difference in mortality between the groups.
Conclusion: Sepsis cytokine filters have been shown in many studies to contribute positively to reducing procalcitonin and CRP values. It has been reported that cytokine filters used in selected sepsis patients have positive effects on mortality. The significant decrease in the percentage of procalcitonin in CPFA may be due to the smaller pore size. Studies to be conducted in larger patient groups will be appropriate in terms of evaluating the effect on mortality.
Source: Sirakaya H A. Journal of Critical Care, 2024 June; 81: 154719
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Can Artificial Intelligence and Machine Learning Techniques improve the ability to detect Sepsis and Septic Shock. A retrospective study of 218,562 adult patients in a university hospital
Abstract: Introduction and aim: The use of Artificial Intelligence (AI) and Machine Learning (ML) techniques has improved a sepsis (SE) and septic shock (SS) early detection compared with traditional rules according to recent retrospective, prospective and meta-analysis (1). Develop predictive models using algorithms based on AI-ML techniques and compare with fixed rules for SE/SS detection, assessing whether these new models improve predictive capability.
Methods: We carried out an observational, retrospective non interventional study developed in our University General Hospital. The period assessed was from January 2014 to October 2018. The diagnosis and validation of each SE or SS case were made prospectively by the clinical experts of the Multidisciplinary Sepsis Unit (MSU). We used a Sepsis 2 definition. We developed AI-ML techniques from historical data from the Electronic Health Record (EHR). The structured variables were obtained from different data sources and from non-structured text from the Triage and Emergency Department (ED). The Mann-Whitney-Wilcoxon test was used to identify statistically significant clinical and analytical variables, as well as wrapper techniques, with a significance level of 0.01 and to obtain relevant unstructured data using a Natural Language Processing (NLP) techniques.
Results: A total of 815,170 records of the EHR have been assessed. We included 218.562 adult patients from all hospital departments. We divided into 2 groups: 1) with SE/SS were 9301 (4.6%); and 2) 209,261 (95.4%) who did NOT have sepsis (NSE). A total of 3927 variables have been extracted from the different data sources. By relevance and after being validated by the UMS team, 244 (6.2%) both structured and unstructured variables were associated with the detection of SE/SS. Within the structured variables, we identified many that are not blackened by the classic scorings of SE/SS, such as hemoglobin or eosinopenia. We developed about 30 different predictive models for SE/SS detection, using fixed rules individually, using only AI-ML based algorithms or the combination of fixed rules with AI-ML techniques. The best model using only fixed rules was the one using the Sepsis.2 criterion, while the best model using AI-ML techniques was called BISEPRO and was a combination of SEPSIS.2 with AI-ML techniques.
Conclusion: In this retrospective study including adult patients in all areas of a hospital the use of AI-ML based techniques was significantly superior for the detection of SE/SS.
Source: Gonzalez V L H. Journal of Critical Care, 2024 June; 81: 154684
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Hemodynamic profile of cirrhotic patients with sepsis and septic shock: A propensity score matched case-control study
Abstract: Purpose: Our understanding of hemodynamics in cirrhotic patients with sepsis remains limited. Our study aims to investigate differences in hemodynamic profiles using echocardiography between septic patients with and without cirrhosis.
Materials and methods: This is a single-center, retrospective study of septic patients with echocardiogram within 3 days of ICU admission. We compared baseline characteristics, echocardiographic markers of LV systolic function arterial load between patients with and without cirrhosis. A propensity score-matched case-control model was developed to describe the differences in those echocardiography derived parameters between the groups.
Results: 3151 patients with sepsis were included of which 422 (13%) had cirrhosis. In the propensity score matched group with 828 patients, cirrhotic patients had significantly higher left ventricular ejection fraction (64 vs.56%, p < 0.001) and stroke volume (72 vs.48 ml, p < 0.001) along with lower arterial elastance (Ea) (1.35 1vs.20.3, p < 0.001) and systemic vascular resistance (SVR) (851 vs.1209 dynes/s/m−5, p = 0.001). The left ventricular elastance (Ees) (2.83 vs 2.45, p = 0.002) was higher and ventricular-arterial coupling (Ea/Ees) (0.48 vs. 0.86, p < 0.001) lower in cirrhotic compared to non-cirrhotic.
Conclusions: Septic patients with cirrhosis had higher LVEF with lower Ea and SVR with higher Ees and significantly lower Ea/Ees suggesting vasodilation as the principal driver of the hyperdynamic profile in cirrhosis.
Source: You J Y. Journal of Critical Care, 2024 June; 81: 154532
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Time Is Survival: Continuing Education on Sepsis for Neurosurgical Critical Care Nurses
Abstract: Background: Early identification of sepsis among neurosurgical critical care patients is a significant challenge because of the many possible confounding variables that lead to altered mental status in this specific patient population. Nurses' knowledge, attitudes, confidence, and practices related to the early identification and management of sepsis are crucial to patients' survival.
Method: This evidence-based intervention project implemented continuing education for neurosurgical critical care nurses on the early signs and symptoms of sepsis and the management of sepsis according to the Surviving Sepsis Campaign (SSC) Guidelines.
Results: Continuing education on sepsis increased neurosurgical critical care nurses' knowledge of the SSC 1-hour sepsis bundle, reported confidence in the management of sepsis, and likelihood of assessing for sepsis.
Conclusion: Continuing education for neurosurgical critical care nurses on the signs and symptoms of sepsis and the SSC Guidelines is necessary and may improve patient outcomes.
Source: Rios E M. Journal of Continuing Education in Nursing, 2024 May; 55(5): 224–230

Previously healthy adults among septic patients: Population-level epidemiology and outcomes
Abstract: Purpose: Previously healthy adults with community-onset sepsis were recently reported to have, counterintuitively, higher short-term mortality than those with comorbid conditions. However, the population-level generalizability of this finding and its applicability to all hospitalized septic patients are unclear.
Methods: We used a statewide dataset to identify hospitalizations aged ≥18 years with a diagnosis of sepsis in Texas during 2018–2019. Comorbidities were defined as those included in the Charlson Comorbidity Index and other prevalent conditions associated with mortality. Hierarchical models were used to estimate the association of comorbid state with short-term mortality (defined as in-hospital mortality or discharge to hospice), overall and in community-onset and hospital-onset sepsis.
Results: Among 120,371 sepsis hospitalizations, 6611 (5.5%) were previously healthy and 105,455 (87.6%) had community-onset sepsis. Short-term mortality among the previously healthy and those with comorbidities was 11.7% vs 28.2% overall, 11.0% vs 25.2% in community-onset sepsis, and 22.0% vs 48.7% in hospital-onset sepsis, respectively. On adjusted analysis, being previously healthy remained associated with lower short-term mortality overall (adjusted odds ratio 0.62 [95% CI 0.57–0.69]), with findings consistent with the primary analysis in community-onset sepsis, hospital-onset sepsis.
Conclusions: Previously healthy septic patients had lower short-term mortality compared to those with comorbid conditions.
Source: Oud L. Journal of Critical Care, 2024 February; 79: 154427
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Early prediction of sepsis in intensive care patients using the machine learning algorithm NAVOY® Sepsis, a prospective randomized clinical validation study
Abstract: Purpose: To prospectively validate, in an ICU setting, the prognostic accuracy of the sepsis prediction algorithm NAVOY® Sepsis which uses 4 h of input for routinely collected vital parameters, blood gas values, and lab values.
Materials and methods: Patients 18 years or older admitted to the ICU at Skåne University Hospital Malmö from December 2020 to September 2021 were recruited in the study. A total of 304 patients were randomized into one of two groups: Algorithm group with active sepsis alerts, or Standard of care. NAVOY® Sepsis made silent predictions in the Standard of care group, in order to evaluate its performance without disturbing the outcome. The study was blinded, i.e., study personnel did not know to which group patients were randomized. The healthcare provider followed standard practices in assessing possible development of sepsis and intervening accordingly. The patients were followed-up in the study until ICU discharge.
Results: NAVOY® Sepsis could predict the development of sepsis, according to the Sepsis-3 criteria, three hours before sepsis onset with high performance: accuracy 0.79; sensitivity 0.80; and specificity 0.78.
Conclusions: The accuracy, sensitivity, and specificity were all high, validating the prognostic accuracy of NAVOY® Sepsis in an ICU setting, including Covid-19 patients.
Source: Persson I. Journal of Critical Care, 2024 April; 80: 154400

Embracing a New Evidence-Based Thought Paradigm of Sepsis
Abstract: In 1991, sepsis was first defined by the Society of Critical Care Medicine as the systemic inflammatory response syndrome, in the presence of infection. Systemic inflammatory response syndrome is an adaptive host response to infection, as well as to other insults like trauma and stress. Research pertaining to sepsis was guided by this adaptive definition for 25 years. After established guidelines for sepsis management were challenged in 2014, sepsis was redefined in 2016 as a dysregulated host response to infection. However, there still remains no consensus on which immunologic or metabolic mechanisms have become dysregulated. We sought to examine sepsis literature published after the 2016 consensus definition and compare it to the original systemic inflammatory response syndrome paradigm proposed in 1991. The purpose of this intensive analysis was to recommend a new sepsis archetype, with consideration to dysregulated immunologic and metabolic mechanisms that have recently been identified in sepsis. Nurses and other clinicians must shift their thought paradigm toward an evidence-based dysregulated model, in order to improve on sepsis recognition and management.
Source: Richardson L. Clinical Nurse Specialist, 2024 Jul – Aug; 38(4): 171–174

Burden of sepsis in critically ill children with cancer: A retrospective study
Abstract: Introduction and aim: The mortality of pediatric intensive care unit is 27.8% globally and its even higher, i.e. 46.2% in children with sepsis. Children with cancer suffer higher incidence as well as severity of sepsis. Five-year survival of children with cancer has tremendously improved to 83% and two thirds of them require at least one intensive care admission throughout their disease course. Sepsis is the commonest cause of admission and death in intensive care (ICU).We aim to review mortality in critically ill children with cancer with respect to sepsis and its causative microorganisms.
Patients and methods: We retrospectively studied all pediatric admissions to ICU during the period from 1st January 2022 to 31st December 2022 in a tertiary cancer hospital in Mumbai, India. The primary outcome was ICU mortality in this cohort and secondary outcomes included proportion of children admitted with sepsis, suspected source of sepsis, culture results with special focus on ESKAPE organisms (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Pseudomonas aeruginosa, Enterobacter species).
Results: Over a period of 12 months, 386 children (0–18 years) had 513 admissions in our ICU, with 138 girls (35.8%) and 248 males (64.2%). The ICU mortality was 22.5%. Two hundred and twenty four (58%) patients were admitted with sepsis, out of which 82 patients had culture positive results in one or more samples such as blood, bronchoalveolar lavage, cerebrospinal fluid, etc. The ESKAPE organisms constituted most of the culture isolates with Escherichia coli being the most common, followed by Klebsiella and Pseudomonas. Nearly half of the children (42/82) with positive culture results died as opposed to one fourth mortality in children with culture negative results (32/141). The gram-negative bacilli exhibited a high incidence of carbapenem resistance. Overall incidence of gram-positive infections was low. Viral and fungal infections were diagnosed more clinically or radiologically, or using molecular testing, serum biomarkers as opposed to culture testing.
Conclusions: Sepsis with ESKAPE organism is a major concern in critically ill children with cancer. The high mortality and rising antimicrobial resistance demand focus on tailoring research to improve outcomes in this patient population.
Source: Sharma S. Journal of Critical Care, June 2024; 81: 154599
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Analysis of the factors that contributed to the passage of Rory's regulations using the 3I + E framework: Implications for future sepsis policy
Abstract: Introduction and aim: Sepsis is the dysregulated host response to an infection, accounting for an estimated 48.9 million cases and 11 million sepsis-related deaths worldwide. In 2013, New York State passed Rory's Regulations, requiring all hospitals to develop protocols for early identification and treatment of sepsis. The purpose of this analysis is to (a) identify and describe the ideas, interests, and institutions that led to the New York State Sepsis Regulations; and (b) the implications for future sepsis policy.
Methods: This study was a retrospective document analysis using qualitative description. To guide this policy analysis, the framework was utilized. This framework includes consideration of institutions, interests, ideas, and external factors and is the most appropriate methodology to identify the factors that contribute to the development of a policy. To identify relevant sources of information, we conducted (a) a literature search of academic databases; (b) a review of publicly available policy documents and government websites; and (c) a review of news media.
Results: The implementation of Rory's regulations legally mandated the use of protocols that require timely fluid resuscitation, antibiotic administration, and frequent assessment of hemodynamic response to therapy. At the time, there was evidence to support the efficacy of early detection and treatment of sepsis; however, less was known about the impact of government-mandated regulations (1,2). Although the interplay of institutions, interests, and ideas contributed to the decision to enact Rory's regulations, the passing of Rory Staunton facilitated the passage and limited the negative effects of institutions, interests, and ideas that may otherwise have prevented the passage of Rory's regulations. This analysis highlights potential barriers including (a) failure to justify the need for a policy response, and (b) lack of coordination with existing policies or programs, which could influence decisions against proceeding with sepsis regulations. Given the impact of COVID-19, which can lead to sepsis, and the 2017 WHO resolution that identified sepsis as a global priority, understanding what other countries have done to address sepsis, and the lessons learned is important to identify future policy directions.
Conclusion: We identified and described the institutions, interests, ideas, and external events that aided the passage of Rory's regulations, using the 3I+ E framework. This analysis provides a useful framework for other jurisdictions considering similar policies to identify potential facilitators and barriers and, importantly, to identify next steps to bring sepsis policy to the forefront.
Source: Sheikh F. Journal of Critical Care, 2024 June; 81: 154657

What NICE’s updated sepsis guidance means for you: A nurse specialist explains how more targeted antibiotic use based on level of risk supports antimicrobial stewardship
Abstract: National has been guidance updated on to sepsis ensure treatment antibiotics are being used in a more targeted way for people at higher risk of severe illness or death. The National Institute for Health and Care Excellence (NICE) revised part of its guidance so clinicians can have more time to examine patients who are less severely ill while prioritising antibiotic treatment for those who need it most. Here is what you need to know.
Source: Trivedi S S. Cancer Nursing Practice, 2024 May; 23(3): 10–11

Sepsis epidemiology and prognosis in cancer patients: Preliminary results of a multicenter prospective observational study
Abstract: Introduction and aim: Determination of risk factors for sepsis, focus of sepsis, causative microorganisms and mortality in cancer patients.
Patients and methods: Prospective, observational planned. Patients diagnosed with cancer and hospitalized for any reason, followed for at least 72 h, were included. Demographic data, cancer diagnoses, presence of invasive equipment, chemotherapy and antimicrobial treatment histories of the patients were recorded. Sepsis scores, causative microorganisms, resistance profile and mortality were recorded.
Results: The mean age of 383 patients included in the study was 58 and 62% were male. 84% of the patients were followed up in internal clinics and the most common reason for follow-up was the chemotherapy plan. Non-Hodgkin lymphoma (29%) was the most prevalent kind of hematologic malignancy. During the patients' episode's follow-up, 36 cases of sepsis in 35 patients (9.1%) developed. Patients with sepsis had statistically significantly higher rates of hypertension(p = 0.01), coronary artery disease (p = 0.002), heart failure (p = 0.02), graft versus host disease (GVHD) (p = 0.012), hospitalization in the intensive care unit within the previous three months (p = 0.019), urethral catheter (p < 0.001), central catheter (p = 0.02), galactomannan positivity rate (p = 0.001), 28-day mortality (p < 0.001), and hospitalization in the intensive care unit (p = 0.019). GVHD in multivariate analysis (OR = 30.985 (4.459–215.304), p = 0.001), urethral catheter OR = 4.322 (1.533–12.184), p = 0.006) and CVC (OR = 2.870 (1.155–7.131), p = 0.023) were found to be risk factors for sepsis. Septic shock developed in 19 (52.8%) of the episodes and required ICU in 27 episodes. Treatment was initiated within the first hour in 31 episodes requiring crystalloids. In 33 episodes (91.7%), cultures were taken in the first hour and antibiotic treatment was started. The most common sepsis focus was lung. The causative agent was Gram-negative in 17 out of 23 bacteria isolated from the episodes. Multidrug resistance rate was 65%. The most commonly used antibiotics in empirical treatment were carbapenem (80.6%) and glycopeptides (44.4%). The mean duration of treatment was 10 days and the 28-day mortality rate was 66.7%. In multivariate analysis, it was concluded that the presence of sepsis increased mortality 9.6 times (OR = 9.682 (4.512–20.774), p < 0.001).
Conclusion: This is the first multicenter epidemiology study of sepsis in cancer patients in Turkey. The rate of development of sepsis was 9%, and the presence of GVHD and invasive device was the most important risk factor for sepsis. It was found that the development of sepsis increased the mortality 10 times. Rational use of catheters (if necessary, in accordance with asepsis, short-term) saves lives in cancer patients.
Source: Ture Z. Journal of Critical Care, 2024 June; 81: 154660