A Critical Review of the Government Mandated Cardiovascular Resuscitation Interventions for Sepsis (SEP-1)

国家质量论坛（NQF）批准和CMS制定了一项性能指标，适用于脓毒症患者，称为严重脓毒症和脓毒性休克早期管理捆绑包（SEP-1）。该性能指标的主要目的是降低医院死亡率和与脓毒症、严重脓毒症和脓毒性休克相关的护理成本。性能指标包括与脓毒症患者血流动力学管理相关的五种干预（治疗和措施）：在严重脓毒症成人中，必须在就诊后3小时内进行初始乳酸水平测量，如果初始乳酸水平升高，必须在就诊后6小时内进行重复乳酸水平测量。在感染性休克的成人中，必须在出现后3小时内使用30 ml/kg晶体液进行复苏。在感染性休克出现后6小时内，如果补液后低血压持续存在，成人必须接受血管加压药治疗。此外，如果输液后低血压持续存在或初始乳酸水平> 4 mmol/L，则必须进行容量状态和组织灌注评估。根据CMS性能指标，容量状态和组织灌注的评估需要进行重点体格检查（必须进行生命体征、心肺检查、毛细血管再充盈评价、外周脉搏评估和皮肤检查）或以下任何两项：测量CVP、测量ScvO 2、床旁心血管超声或被动抬腿或液体激发。目前，CMS要求提供者报告其机构在这一业绩衡量中使用干预措施的情况。然而，随后，CMS将要求提供者完成所有干预措施。这一性能指标是复杂的，需要大量的医院资源来实现合规性。我们将进行一项系统性综述和荟萃分析，重点关注支持使用这些血流动力学干预措施降低脓毒症死亡率的证据，以及住院时间、器官衰竭和护理费用。

The National Quality Forum (NQF) endorsed and CMS has instituted a performance measure to be applied to patients presenting with sepsis termed the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). The primary purpose of this performance measure is to decrease hospital mortality and costs of care related to sepsis, severe sepsis and septic shock. The performance measure includes five interventions (both treatments and measures) related to the hemodynamic management of patients with sepsis: In adults with severe sepsis, initial lactate level measurement must be performed within 3 hours of presentation, and repeat lactate level measurement must be performed within 6 hours of presentation, if initial lactate level is elevated. In adults with septic shock, resuscitation with 30ml/kg crystalloid fluids must be performed within 3 hours of presentation. Within 6 hours of presentation of septic shock, adults must receive vasopressors if hypotension persists after fluid administration. Also, if hypotension persists after fluid administration or if the initial lactate level is > 4 mmol/L, then a volume status and tissue perfusion assessment must be performed. According to the CMS performance measure, assessment of volume status and tissue perfusion requires either a focused physical exam (vital signs, cardiopulmonary exam, capillary refill evaluation, peripheral pulse assessment and skin examination all must be performed), or any two of the following: measure CVP, measure ScvO2, bedside cardiovascular ultrasound, or passive leg raise or fluid challenge. At present CMS requires that providers report on their institutions use of the interventions in this performance measure. Subsequently, however, CMS will require that providers complete all interventions. This performance measure is complex and requires substantial hospital resources to achieve compliance. We will perform a systematic review and meta-analysis that will focus on the evidence supporting the use of each of these hemodynamic interventions in decreasing mortality from sepsis, as well as the length of hospital stay, organ failure and cost of care.