Prasad Priya A, Shea Erica R, Shiboski Stephen, Sullivan Mary C, Gonzales Ralph, Shimabukuro David
From the *Division of General Internal Medicine, School of Medicine, University of California, San Francisco, California; †Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California; ‡Department of Quality, Sepsis Program, University of California, San Francisco, California; and §Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California.
Anesth Analg. 2017 Aug;125(2):507-513. doi: 10.1213/ANE.0000000000002085.
Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data.
We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT).
Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32-0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03-1.24).
The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.
脓毒症是对感染的一种全身反应，可导致组织损伤、器官衰竭和死亡。人们已努力制定基于证据的干预集束方案，以便在疾病过程早期识别和管理脓毒症，从而降低脓毒症相关的发病率和死亡率。我们使用针对观察性数据的稳健方法评估了微创脓毒症干预集束方案与住院死亡率之间的关系。
我们在加利福尼亚大学旧金山分校医学中心进行了一项回顾性队列研究，研究对象为2012年1月1日至2014年12月31日期间出院的成年患者，这些患者被诊断为严重脓毒症/脓毒性休克（SS/SS）。脓毒症干预集束方案的要素包括测量血乳酸；在开始使用抗生素之前采集血培养样本；在急诊科脓毒症表现后3小时内或住院病房表现后1小时内开始使用广谱抗生素；如果患者低血压或血乳酸水平>4 mmol/L，则给予静脉推注液体；如果患者在给予液体推注后仍低血压，则开始使用静脉血管加压药。对于二元结局变量，使用泊松回归来估计调整后的发病率比（IRR），以比较以二元预测变量衡量的集束方案依从性所定义的组中的死亡率，并估计调整后的治疗所需人数（NNT）。
在对急诊科的SS/SS表现、入院时存在的SS/SS（POA）、年龄、入院时疾病严重程度和死亡风险、医疗补助/医疗保险支付者状态、免疫功能低下宿主状态以及充血性心力衰竭POA进行调整后，完全符合集束方案与降低31%的死亡风险相关（调整后的IRR为0.69，95%置信区间[CI]为0.53 - 0.91）。挽救一条生命的调整后NNT为15（CI为8 - 69）。其他与死亡率独立相关的因素包括入院时的SS/SS（调整后的IRR为0.55；CI为0.32 - 0.92）和年龄增加（每增加10岁调整后的IRR为1.13；CI为1.03 - 1.24）。
在对混杂因素进行稳健控制和风险调整后，加利福尼亚大学旧金山分校的脓毒症集束方案与各医院科室住院死亡率降低相关。调整后的NNT为观察诊断为SS/SS的患者结局的可测量改善提供了一个合理且可实现的目标。
