PATIENT SAFETY


Figure 1: The Resuscitation Bundle focuses on the first six hours following presentation of a patient with sepsis.


1 2 3 4


Measure serum lactate.


Obtain blood cultures prior to antibiotic administration. Administer broad-spectrum antibiotics within 1 hour.


Treat hypotension and/or elevated lactate with fluids: Deliver an initial minimum of 20 mL/kg crystalloid or equivalent. Administer vasopressors for hypotension not responding to initial fluids to maintain mean arterial pressure (MABP) of >65 mmHg.


5


In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate >4 mmol/L maintain adequate central venous pressure and central venous oxygen saturation: Achieve a central venous pressure (CVP) of >8 mmHg (>12 mmHg if ventilated).


Achieve a central venous oxygen saturation (ScvO2) of >70% or a mixed venous oxygen saturation of >65%.


professional bodies around the world, including the European Society of Intensive Care Medicine as the care standard. Yet, after a dedicated and funded international improvement programme over two years, and the voluntary submission of data sets from over 15,000 care episodes, compliance with the most widely-known of these bundles increased from 10.9% to just 21.5%.10


strategy for early targeted therapy.13-15 It is


unlikely that any of these will confirm that Rivers’ protocol is the ultimate answer, but it is likely that EGDT is here to stay. Despite Rivers demonstrating a 16%


absolute risk reduction for mortality, the use of EGDT to restore the circulation in septic shock will achieve little without adequate pathogen recognition investigations, antimicrobial administration and source control strategies. These basic aspects of care are often neglected. In a landmark paper, Kumar showed that each hour’s delay in antibiotic administration in septic shock was associated with a 7.6% increased risk of death.16


Median time to delivery in this Data submitted by the remaining


UK centres to the Surviving Sepsis Campaign after the study period ceased showed that compliance had fallen to just 14%. Fewer than one in seven patients currently receive care according to international standards. Critical Care Units (incorporating


Intensive Care and High Dependency Care in most UK hospitals) comprise one of the most expensive areas to care for a patient. A large part of this expense – over 50% – arises from the high nurse-to- patient ratio needed to provide the required level of care. Most units in the UK estimate that a typical bed day costs around £1,500. The cost for patients with severe sepsis is likely to be higher due to their greater dependency. It has been estimated in European studies that a typical episode of severe sepsis costs a


healthcare organisation approximately €25,000.11


Assuming that we see 100,000


cases of severe sepsis per annum, this equates to a direct cost to the NHS of over £2.3 bn.


Standards of care The Resuscitation Bundle (Fig. 1) focuses on the first six hours following presentation of a patient with sepsis and encompasses basic aspects of care (including the sampling of blood cultures and administration of broad spectrum antibiotics within one hour) and a more aggressive targeted resuscitation bundle termed ‘Early Goal-Directed Therapy’ (EGDT) for those patients with septic shock. EGDT demands the insertion of a central venous catheter, and for many


46 THE CLINICAL SERVICES JOURNAL


retrospective study, however, was six hours, and only 12% of patients received their antibiotics within the recommended one hour. More recently, it has been shown that patients receiving appropriate antibiotics within the first hour had an odds ratio for death of 0.3 compared with those receiving antibiotics later, but again only 15.7% of patients received their antibiotics according to international recommendations.17 Intravenous fluid resuscitation is a


patients requires the administration of vasoactive infusions. The inclusion of EGDT, according to a


protocol devised by Emanuel Rivers in 2001, was based upon the marked outcome benefits seen in his well conducted but single-centre randomised controlled trial.12


Unsurprisingly, EGDT


as the ‘sexier’ end of the Resuscitation Bundle has generated far more discussion than the importance of reliable delivery of rapid, basic aspects of care, particularly in the emergency and acute medicine communities. Three major multi-centre studies are currently evaluating the external validity of Rivers’ protocol, with one of these also exploring an alternative


central tenet of sepsis management, aiming to restore the circulation through replacing relative (through vasodilatation) and absolute (through capillary leakage) reductions in circulating volume. EGDT mandates the delivery of fluid challenges of significant volume – 20-60 mL per kg body weight – in septic shock, but even in patients with septic shock this is unreliably achieved. In patients without shock, and particularly in those yet to develop shock, the delivery of intravenous fluids is less directed, meaning that patients may have to wait until their physiology deteriorates to the prescribed level before receiving optimal care.


If we are failing patients with sepsis, why? As previously stated, sepsis is a relatively recently defined clinical entity and education and the incorporation of robust information on sepsis into undergraduate curricula are of immediate importance. There are, however, more significant factors at play. A patient with sepsis does not arrive in hospital ‘waving a flag’ that they have sepsis, and, in the patient


Figure 2: The Sepsis Six has been shown to be associated with a 50% reduction in mortality.


1 2 3 4 5 6


Give high-flow oxygen. Take blood cultures.


Administer IV antibiotics. Start IV fluid resuscitation.


Check haemoglobin and lactate. Monitor accurate urine output.


Via non-rebreathe bag. Hartmann’s or equivalent. May require catheter. MARCH 2012


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