Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock.
Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock.
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DOI：
10.1097/ccm.0000000000002949
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发表时间：
2018-04
影响因子：
8.8
通讯作者：
Simon G
中科院分区：
文献类型：
--
作者：
Pruinelli L;Westra BL;Yadav P;Hoff A;Steinbach M;Kumar V;Delaney CW;Simon G
详细说明适用于严重脓毒症或脓毒性休克的特定3小时捆绑式脓毒症生存运动（SSC）指南建议的延迟何时变得有害并影响死亡率。回顾性队列研究。2011年1月1日至2015年7月31日，一个由中西部州的6家医院和45家诊所组成的卫生系统。所有因严重脓毒症或脓毒性休克住院的成人患者。4个3小时SSC指南建议：1）在使用抗生素前进行血培养，2）获得乳酸水平，3）给予广谱抗生素，4）给予30 mL/kg晶体液治疗低血压（定义为平均动脉压（MAP）< 65）或乳酸（> 4）。为了确定在进行每项干预时延迟t分钟的效果，基线特征的倾向评分匹配补偿了健康状况的差异。平均治疗效果（ATT）计算为较短延迟与较长延迟后治疗的患者之间结局的平均差异。为了估计与ATT指标相关的不确定性并构建95%置信区间，进行了1，000次重复的自助估计。在5，072例严重脓毒症或脓毒性休克患者中，1，412例（27.8%）发生院内死亡。大多数患者在3小时内开始了4次3小时捆绑建议。对于每种建议，延迟增加死亡风险的统计学显著时间（分钟）为：乳酸盐，20.0分钟;血培养，50.0分钟;晶体，100.0分钟;抗生素治疗，125.0分钟。指南建议表明，较短的延迟表明更好的结果。没有证据表明3小时是安全的;即使是很短的延迟也会对结果产生不利影响。研究结果表明，一种新的方法，将时间t分析结果的影响，并为临床实践和研究提供了新的证据。
To specify when delays of specific 3-hour bundle Surviving Sepsis Campaign (SSC) guideline recommendations applied to severe sepsis or septic shock become harmful and impact mortality. Retrospective cohort study. One health system composed of six hospitals and 45 clinics in a Midwest state from January 01, 2011 and July 31, 2015. All adult patients hospitalized with billing diagnosis of severe sepsis or septic shock. Four 3-hour SSC guideline recommendations: 1) obtain blood culture before antibiotics, 2) obtain lactate level, 3) administer broad-spectrum antibiotics, and 4) administer 30 mL/kg of crystalloid fluid for hypotension (defined as mean arterial pressure (MAP) < 65) or lactate (> 4). To determine the effect of t minutes of delay in carrying out each intervention, propensity score matching of baseline characteristics compensated for differences in health status. The Average Treatment effect in the Treated (ATT) computed as the average difference in outcomes between those treated after shorter versus longer delay. To estimate the uncertainty associated with the ATT metric and to construct 95% confidence intervals, bootstrap estimation with 1,000 replications was performed. From 5,072 patients with severe sepsis or septic shock, 1,412 (27.8%) had in-hospital mortality. The majority of patients had the four 3-hour bundle recommendations initiated within three hours. The statistically significant time in minutes after which a delay increased the risk of death for each recommendation was: lactate, 20.0 minutes; blood culture, 50.0 minutes; crystalloids, 100.0 minutes; and antibiotic therapy, 125.0 minutes. The guideline recommendations showed that shorter delays indicates better outcomes. There was no evidence that 3 hours is safe; even very short delays adversely impact outcomes. Findings demonstrated a new approach to incorporate time t when analyzing the impact on outcomes and provide new evidence for clinical practice and research.