Variability in management of early severe sepsis

Reade, MC; Huang, Defeng; Bell, Dean D.; Coats, Timothy; Cross, Anthony; Moran, John L.; Peake, Sandra; Singer, Mervyn; Yealy, Donald M.; Angus, Derek C.

doi:10.1136/emj.2008.070912

Cited by 62 publications

(45 citation statements)

References 23 publications

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“…À noter que 23 % des services n'avaient pas de protocole « sepsis » ou n'avaient pas prévu d'en faire un, et que 16 % des médecins étaient en désaccord avec l'EGDT [19]. Dans l'étude par questionnaire menée en 2007 auprès de médecins d'adultes de Grande-Bretagne, des États-Unis, d'Australie et de Nouvelle-Zélande, les barrières à l'implémentation du bouquet des six premières heures les plus fréquemment mentionnées étaient le manque de temps (aux urgences) et l'absence de preuve d'efficacité de l'EGDT (en réanimation) ; 20 % des médecins des urgences disaient n'avoir pas connaissance de l'EGDT [20]. Dans notre enquête menée en 2008 auprès des 37 unités et services de réanimation pédiatrique français (trois de centres hospitaliers généraux et 34 de centres hospitaliers universitaires) figurant dans l'annuaire du GFRUP, 83 % des réanimateurs pédiatres et 91 % des pédiatres de Smur utilisaient un protocole écrit de traitement du sepsis ; les barrières à l'implémentation des recommandations de la campagne SAS les plus souvent mentionnées étaient, pour les réanimateurs pédiatres, le monitorage de la ScvO 2 (76 % des répondeurs), puis la collaboration entre les équipes des urgences et de réanimation ( [13], chiffre comparable au 10,7 % de la dernière étude française [24] et au 11,2 % de l'étude espagnole [25], mais plus faible que les 31,3 % de l'étude internationale [7].…”

Section: Quelles Sont Les Barrières à L'implémentation Des Recommandaunclassified

Actualités dans la prise en charge du choc septique en réanimation — Campagne « Survivre au Sepsis »: qu’en est-il en 2011 ?

Leclerc¹,

Botte²,

Lampin³

et al. 2010

Réanimation

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Section: Quelles Sont Les Barrières à L'implémentation Des Recommandaunclassified

Actualités dans la prise en charge du choc septique en réanimation — Campagne « Survivre au Sepsis »: qu’en est-il en 2011 ?

Leclerc¹,

Botte²,

Lampin³

et al. 2010

Réanimation

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“…This has led some authors to question whether all the elements of the original protocol are still necessary [19][20][21].…”

Section: Introductionmentioning

confidence: 99%

Early goal-directed therapy vs usual care in the treatment of severe sepsis and septic shock: a systematic review and meta-analysis

et al. 2015

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Sepsis is a common and high-burden healthcare problem with a mortality exceeding 20 % in severe sepsis and nearly 50 % when septic shock is present. Early goal-directed therapy (EGDT) is recommended by sepsis guidelines as the standard of care following a landmark study by Rivers et al. alongside other observational studies. Three recent randomized controlled trials have questioned the Rivers' results. The objective of our systematic review was to assess the effectiveness of EGDT in reducing the mortality of severe sepsis or septic shock. Relevant primary studies were identified by searching the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Clinical Trials to identify randomized controlled trials assessing the effectiveness of EGDT for sepsis. Data from all trials were combined and analyzed using a random effects model. Five studies, enrolling a total of 4033 patients, were included in the meta-analysis. In-hospital mortality did not differ between the two treatment groups (RR 0.93, 95 % CI 0.77-1.11, P = 0.42), although moderate heterogeneity between studies was noted (I (2) = 48 %). A non-significant trend toward reduction in 60-day mortality in the EGDT group was noted (RR 0.93, 95 % CI 0.82-1.05, P = 0.22, I (2) = 24 %). Heterogeneity between trials precludes a definitive conclusion on the utility of EGDT in severe sepsis. Until further evidence is available, it is reasonable to consider EGDT in the care of patients with severe sepsis and septic shock.

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“…An international survey-based study in 2007 found that 71.5% of respondents would perform a CVC in a patient with severe sepsis; 33 however, in practice this frequency is likely much lower, with Walkey et al 4 reporting a rate of 19.2% in their 2009 data. This is consistent with the 2005 through 2007 cohort of Mikkelsen et al, 34 in which EGDT initiation rates were 58% and completion rates (for those in which EGDT was initiated) were 43%.…”

Section: Discussionmentioning

confidence: 99%

Emergency Physician Perspectives on Central Venous Catheterization in the Emergency Department: A Survey‐based Study

Ballard

Reed

Rauchwerger

et al. 2014

Academic Emergency Medicine

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Objectives: The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. Methods:The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goaldirected therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in realtime ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, timerelated, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. Results:The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater selfreported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing USguided internal jugular catheters. Conclusions:In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in From The Permanente

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Variability in management of early severe sepsis

Abstract: Reported management of early sepsis varies between specialities and countries, and the responses do not follow SSC guidelines. Concerns relate to knowledge, attitudes and resources.

Cited by 62 publications

References 23 publications

Actualités dans la prise en charge du choc septique en réanimation — Campagne « Survivre au Sepsis »: qu’en est-il en 2011 ?

Actualités dans la prise en charge du choc septique en réanimation — Campagne « Survivre au Sepsis »: qu’en est-il en 2011 ?

Early goal-directed therapy vs usual care in the treatment of severe sepsis and septic shock: a systematic review and meta-analysis

Emergency Physician Perspectives on Central Venous Catheterization in the Emergency Department: A Survey‐based Study

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