The impact of early monitored management on survival in hospitalized adult Ugandan patients with severe sepsis: a prospective intervention study*.
The impact of early monitored management on survival in hospitalized adult Ugandan patients with severe sepsis: a prospective intervention study*.
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DOI：
10.1097/ccm.0b013e31824e65d7
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发表时间：
2012-07
影响因子：
8.8
通讯作者：
Promoting Resource-Limited Interventions for Sepsis Management in Uganda Study Group
中科院分区：
文献类型：
--
作者：
Jacob ST;Banura P;Baeten JM;Moore CC;Meya D;Nakiyingi L;Burke R;Horton CL;Iga B;Wald A;Reynolds SJ;Mayanja-Kizza H;Scheld WM;Promoting Resource-Limited Interventions for Sepsis Management in Uganda Study Group
在撒哈拉以南非洲，败血症是一个重要的死亡原因，但由于缺乏物资和熟练的卫生工作者，包括液体复苏、早期抗生素施用和患者监测在内的最佳败血症管理受到限制。评估由研究医务人员提供的早期监测脓毒症管理是否可以提高乌干达两家公立医院收治的严重脓毒症患者的生存率。一项前瞻性的干预队列研究（n=426），严重脓毒症患者接受早期监测脓毒症管理，与一组观察队列（n=245）相似病情的严重脓毒症患者在乌干达两家医院的病房入院后接受标准管理进行比较。由专门的研究医务人员提供的早期败血症管理包括住院前6小时的液体复苏、早期抗生素和定期监测。采用Kaplan-Meier生存期和未调整及调整Cox比例风险分析比较早期监测脓毒症管理对干预组（2008年5月至2009年5月入组）和观察组（2006年7月至2006年11月入组）患者30天死亡率的影响。两个队列中的大多数（86%）患者都感染了艾滋病毒。干预组患者住院前6小时提供的中位液量高于观察组患者（3000 mL vs 500 mL, p<0.001），干预组患者在1小时内接受抗菌治疗的比例更高（67% vs 30.4%, p<0.001）。干预组30天死亡率显著低于观察组（33.0% vs 45.7%, log-rank p=0.005）。在对潜在混杂因素进行校正后，干预组的30天死亡率比观察组低26%（校正后HR=0.74, 95% CI= 0.55-0.98）。在13%出现呼吸窘迫迹象的干预患者中，死亡率与基线疾病严重程度有关，而与给液量无关。在乌干达，对严重脓毒症患者进行早期监测管理可提高生存率，即使在繁忙的公立转诊医院也是可行和安全的。
In sub-Saharan Africa, sepsis is an important cause of mortality but optimal sepsis management including fluid resuscitation, early antibiotic administration and patient monitoring is limited by a lack of supplies and skilled health workers. To evaluate whether early, monitored sepsis management provided by a study medical officer can improve survival among patients with severe sepsis admitted to two public hospitals in Uganda. A prospective before and after study of an intervention cohort (n=426) with severe sepsis receiving early, monitored sepsis management compared to an observation cohort (n=245) of similarly ill patients with severe sepsis receiving standard management after admission to the medical wards of two Ugandan hospitals. Early sepsis management provided by a dedicated study medical officer comprised of fluid resuscitation, early antibiotics and regular monitoring in the first 6 hours of hospitalization. Kaplan-Meier survival and unadjusted and adjusted Cox proportional hazards analysis were used to compare the effect of early, monitored sepsis management on 30-day mortality between the intervention cohort (enrolled May 2008 to May 2009) and observation cohort (enrolled July 2006 to November 2006). The majority (86%) of patients in both cohorts were HIV-infected. Median fluid volume provided in the first 6 hours of hospitalization was higher in intervention than observation cohort patients (3000 vs. 500 mL, p<0.001) and a greater proportion of intervention cohort patients received antibacterial therapy in less than one hour (67% vs 30.4%, p<0.001). Mortality at 30 days was significantly lower in the intervention cohort compared to the observation cohort (33.0% vs 45.7%, log-rank p=0.005). After adjustment for potential confounders, the hazard of 30-day mortality was 26% less in the intervention cohort compared to the observation cohort (adjusted HR=0.74, 95% CI=0.55–0.98). Mortality among the 13% of intervention patients who developed signs of respiratory distress was associated with baseline illness severity rather than fluid volume administered. Early, monitored management of severely septic patients in Uganda improves survival and is feasible and safe even in a busy public referral hospital.