De Miguel-Yanes José M, Andueza-Lillo Juan A, González-Ramallo Víctor J, Pastor Luis, Muñoz Javier
Emergency Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain.
Am J Emerg Med. 2006 Sep;24(5):553-9. doi: 10.1016/j.ajem.2006.01.012.
The main objective was to evaluate if consensus "bundle" measures to optimize the treatment of sepsis have been integrated in our routine practice. We also tried to identify variables significantly associated to mortality.
An observational, unblinded study of those patients who, according to their physicians, met criteria for sepsis under its different stages of severity was conducted. Six items as proposed by surviving sepsis campaign were evaluated: (1) measurement of blood lactate; (2) obtaining blood samples for culture before use of antibiotics; (3) early use of antibiotics (>3 h); (4) fluid replacement with at least 20 mL/kg of crystalloids in the first hour, unless contraindicated, if hypotension or blood lactate >4 mmol/L; (5) use of vasoactive drugs, other than dopaminergic doses of dopamine, if hypotension or shock; (6) measurement of central venous pressure and central venous O2 saturation in shock. Data concerning several aspects of diagnosis, treatment, and consultation to ICU were collected.
Compliance with published guidelines is poor after evaluating the 6 items proposed: 12.5% of shocked patients had determinations of blood lactate; 15% of septic patients had no blood cultures drawn; 32% had received their first dose of antibiotics in the first 3 hours after admission; 46.6% of the cases of severe sepsis or shock received a fluid aggressive therapy; 43.3% of the patients with an indication for vasoactive drugs received them; no patient had central venous pressure monitoring at the ED. In addition, intensive care specialists were seldom consulted (17%). Having used dopaminergic doses of dopamine and having a respiratory focus as a source of infection were independently associated to mortality, respective OR: 21 ([1.7-254.9]; 95% CI) and 9.6 ([1.7-52]; 95% CI).
The "bundle" measures proposed in the surviving sepsis campaign seem not to have had enough impact in our ED. This is the start point of a "plan-do-study-act" process directed to improve the outcome of patients with sepsis at our institution.
主要目的是评估优化脓毒症治疗的共识“集束化”措施是否已纳入我们的常规实践。我们还试图确定与死亡率显著相关的变量。
对那些经医生判断符合不同严重程度阶段脓毒症标准的患者进行了一项非盲观察性研究。评估了拯救脓毒症运动提出的六个项目：（1）测定血乳酸；（2）在使用抗生素前采集血样进行培养；（3）早期使用抗生素（>3小时）；（4）除非有禁忌证，若出现低血压或血乳酸>4 mmol/L，在第一小时内用至少20 mL/kg晶体液进行液体复苏；（5）若出现低血压或休克，使用除多巴胺能剂量多巴胺以外的血管活性药物；（6）休克时测定中心静脉压和中心静脉血氧饱和度。收集了有关诊断、治疗和入住重症监护病房会诊等几个方面的数据。
在评估所提出的6个项目后，对已发表指南的依从性较差：12.5%的休克患者测定了血乳酸；15%的脓毒症患者未进行血培养；32%的患者在入院后3小时内接受了首剂抗生素治疗；46.6%的严重脓毒症或休克病例接受了积极的液体治疗；43.3%有血管活性药物使用指征的患者接受了此类药物治疗；急诊科没有患者进行中心静脉压监测。此外，很少咨询重症监护专家（17%）。使用多巴胺能剂量的多巴胺以及以呼吸道为感染源与死亡率独立相关，各自的比值比分别为：21（[1.7 - 254.9]；95%置信区间）和9.6（[1.7 - 52]；95%置信区间）。
拯救脓毒症运动中提出的“集束化”措施在我们的急诊科似乎没有产生足够的影响。这是我们机构旨在改善脓毒症患者治疗结果的“计划 - 实施 - 研究 - 改进”过程的起点。
