脓毒症强制紧急治疗的治疗时间与死亡率
Time to Treatment and Mortality during Mandated Emergency Care for Sepsis.
作者信息
Seymour Christopher W, Gesten Foster, Prescott Hallie C, Friedrich Marcus E, Iwashyna Theodore J, Phillips Gary S, Lemeshow Stanley, Osborn Tiffany, Terry Kathleen M, Levy Mitchell M
机构信息
From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.).
出版信息
N Engl J Med. 2017 Jun 8;376(23):2235-2244. doi: 10.1056/NEJMoa1703058. Epub 2017 May 21.
BACKGROUND
In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients.
METHODS
We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid.
RESULTS
Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21).
CONCLUSIONS
More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality. (Funded by the National Institutes of Health and others.).
背景
2013年，纽约开始要求医院遵循脓毒症早期识别和治疗的方案。然而，对于脓毒症更快速的治疗是否能改善患者预后存在争议。
方法
我们研究了2014年4月1日至2016年6月30日期间上报给纽约州卫生部的脓毒症和脓毒性休克患者的数据。患者在抵达急诊科后6小时内启动脓毒症方案，并且脓毒症患者3小时护理集束（即血培养、广谱抗生素和乳酸测量）中的所有项目在12小时内完成。使用多水平模型评估完成3小时护理集束的时间与风险调整后死亡率之间的关联。我们还检查了抗生素给药时间和静脉输液初始推注完成时间。
结果
在149家医院的49331例患者中，40696例（82.5%）在3小时内完成了3小时护理集束。完成3小时护理集束的中位时间为1.30小时（四分位间距，0.65至2.35），抗生素给药的中位时间为0.95小时（四分位间距，0.35至1.95），静脉输液推注完成的中位时间为2.56小时（四分位间距，1.33至4.20）。在12小时内完成3小时护理集束的患者中，完成护理集束的时间越长，风险调整后的住院死亡率越高（比值比，每小时1.04；95%置信区间[CI]，1.02至1.05；P<0.001），抗生素给药时间越长也是如此（比值比，每小时1.04；95%CI，1.03至1.06；P<0.001），但静脉输液推注完成时间较长则不然（比值比，每小时1.01；95%CI，0.99至1.02；P=0.21）。
结论
更快速地完成3小时脓毒症护理集束和快速给予抗生素，但不是快速完成静脉输液初始推注，与风险调整后的较低住院死亡率相关。（由美国国立卫生研究院等资助。）
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