さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

Time to Treatment and Mortality during Mandated Emergency Care for Sepsis

今週のJournal Clubプレゼンターは、専門看護師です。

2017年6月 NEJMに発表された、ニューヨーク州におけるSepsis バンドル(3hour bundle : lactate、血培、抗菌薬投与)の有用性の報告。

 

Abstract

 

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.).

 

Fig and Tab

 

f:id:akinohanayuki:20170715023609p:plain

f:id:akinohanayuki:20170715023619p:plain

f:id:akinohanayuki:20170715023632p:plain

f:id:akinohanayuki:20170715023642p:plain

Fig3

 

f:id:akinohanayuki:20170715023655p:plain

 

limitations

 

First, this was not a randomized trial, so the results may be biased by confounding. Of greatest concern may be the lack of data about the appropriateness of broad-spectrum antibiotics. The appropriateness of the initial choice of an antibiotic agent has been associated with risk-adjusted mortality but may be measurable only in the minority of patients with positive cultures and may differ according to local pathogen and antimicrobial resistance profiles. The hospitals included in this study were limited to a single state that may have epidemiologic features of sepsis that are distinct from those in other geographic regions. The start time for measuring delays may not be accurate in all cases. To address this, we evaluated models that used the earliest time of arrival in the emergency department and found no change in associations.

 

感想

 

著者は、"We found no association between the time to completion of the initial bolus of intravenous fluids and outcome"と述べています。

 

私は、ボーラスを早く思考することが、sepsis治療の鍵だと考えてため、この結果は予想外でした。

 

Fig3から、抗菌薬投与への時間の重要性が示されている。

 

しかし、時間を意識するあまり、最初は全てカルバペネムは避けたい。

 

感染臓器ー想定する微生物ー重症度 この3点から、どのような抗菌薬選択が良いのか、各施設のアンチバイオとsepsis要因を踏まえながら、あらかじめ議論することが望ましいだろう。

 

当院は、感染臓器別に重症と中等に分けた、エンピリック一覧表を作成している。

 

Fig2において、グラム陽性の有意差がなかった。

私は、グラム陽性こそ差が着くと思っていたため、こちらも感覚と異なっていた。