Original articleClinical management for patients admitted to a critical care unit with severe sepsis or septic shock☆
Introduction
Sepsis is the clinical syndrome that results from a dysregulated inflammatory response to an infection. It exists if two or more of the following abnormalities are present, along with either a culture-proven or a visually identified infection:
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temperature >38.3 or <36 °C
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heart rate >90 beats/minutes
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respiratory rate >20 breaths/minutes or PaCO2 <32 mmHg
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WBC >12000 cells/mm3, <4000 cells/mm3 or >10% immature (band) forms.
Severe sepsis refers to sepsis plus at least one of the following signs of hypoperfusion or organ dysfunction:
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areas of mottled skin
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capillary refilling requiring three seconds or longer
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urine output <0.5 ml/kg over at least one hour, or renal replacement therapy
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lactate >2 mmol/L
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abrupt change in mental status
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abnormal electro-encephalographic (EEG) findings
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platelet count <100,000 per ml
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disseminated intravascular coagulation
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acute lung injury or acute respiratory distress syndrome (ARDS)
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cardiac dysfunction (i.e., left ventricular systolic dysfunction), as defined by echo-cardiography or direct measurement of the cardiac index.
Septic shock exists if there is severe sepsis, plus one or both of the following:
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systematic mean blood pressure <60 mmHg (or <80 mmHg if the patient has baseline hypertension) despite adequate fluid resuscitation
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maintaining systematic mean blood pressure at >60 mmHg (or >80 mmHg if the patient has baseline hypertension) requires dopamine >5 mcg/kg per minutes, norepinephrine >0.25 mcg/kg per minutes, or epinephrine >0.25 mcg/kg per minutes, despite adequate fluid resuscitation (Neviere, 2013b).
Many septic shock or severe sepsis patients require immediate critical care support. According to the Surviving Sepsis Campaign guidelines 2012 (Dellinger et al., 2013a), protocolised resuscitation of a patient with sepsis should be initiated once hypoperfusion is recognised, with the goal of keeping central venous pressure (CVP) 8–12 mmHg, mean arterial pressure (MAP) > 65 mmHg, urine output >0.5 ml/kg/hour and central venous or mixed venous oxygen saturation (Casserly et al., 2012). For haemodynamic support, norepinephrine or dopamine centrally administered are the initial vasopressors of choice to maintain MAP > 65 mmHg (Beale et al., 2004, Dellinger et al., 2004, Dellinger et al., 2008). All these targets require support in the critical-care unit. However, despite such support, the presence of septic shock or severe sepsis is still associated with high mortality, in both developed and developing countries (Beovic et al., 2008, Cheng et al., 2007, Elias et al., 2012, Jaramillo-Bustamante et al., 2012, Khan et al., 2012, Moore et al., 2011, Pociello Alminana et al., 2007, Suka et al., 2006, Vincent and Atalan, 2008, Wang et al., 2006).
To treat patients with severe sepsis and septic shock, norepinephrine is now the first choice of many clinicians. A recent systematic review of randomised clinical trials showed the superiority of norepinephrine over dopamine for in-hospital or 28-day mortality with pooled RR: 0.91 (C.I. 0.83–0.99; p-value = 0.028) (Vasu et al., 2012), and many other studies also have similar findings (De Backer et al., 2012, Ferguson-Myrthil, 2012, Lamontagne et al., 2011, Sandifer and Jones, 2012). However, norepinephrine, like any other drug, may have considerable side effects, such as vasoconstriction in many vascular beds, decreased renal and visceral blood flow and impaired visceral organ function (Bellomo, 2003). The consequences of these side effects include gangrene of the extremities, where amputation may be required. Hence, norepinephrine should be phased out as soon as possible once the condition has stabilised. This study aims to explore (1) the clinical management of patients with septic shock or severe sepsis in a critical care unit, with a special focus on the total volume and amount of crystalloids and norepinephrine administered and (2) factors affecting the outcomes of this group of patients. Approval has been obtained from the ethics committees of both the hospital and the University.
Section snippets
Methods
A chart review of ICU admission records was carried out in 2013, at a 26-bed unit spread over two wards on the same floor, a general ICU catering for both medical and surgical cases, including trauma, orthopaedic and neurosurgical patients. The annual turnover of patients is 1800–2000, making it one of the biggest ICUs in Hong Kong.
The data collection period ran from 1 January 2011 to 31 December 2013, with patients admitted to the hospital's ICU identified from the unit's admission book.
Patient characteristics
The median age of patients was 61.6 (range 18–94) and the male-to-female ratio was 66:34 (approximately 2:1).
Admission, mortality and duration of stay in ICU
The mean stay in the ICU was 13.4 days (range = 1–371). 14 patients (14%) died there, and the 28-day mortality rate was 22%. The mean duration of mechanical ventilation was 6.1 days (range = 0–137).
Details of operations
Before or during their stay in the ICU, 47 patients underwent an operation. Of these, 43 (91.5%) had an operation immediately before admission, with the remaining four (8.5%) having a percutaneous
Discussion
This study describes the clinical management outcomes of patients in Hong Kong with severe sepsis or septic shock requiring admission to the ICU, giving local and international healthcare professionals a clearer view of the situation in the territory.
The median age of patients in our study was 61.6, with a distribution skewed towards the left, meaning a large proportion of patients aged over 60. This is consistent with other studies related to patients with severe sepsis or septic shock
Conclusion
In summary, we hope this study may provide local and international healthcare workers with more information about the clinical management of ICU patients in Hong Kong suffering from severe sepsis or septic shock, and about their subsequent clinical outcomes. What this study adds to the present body of knowledge about such patients includes: (1) the mean duration of norepinephrine infusion in ICU for septic shock patients is almost three days; (2) the more crystalloid is required to correct the
Funding
The authors have no sources of funding to declare.
Conflict of interest
The authors have no conflict of interest to declare.
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This study was performed in Intensive Care Unit of Tuen Mun Hospital, 23 Tsing Chung Koon Road, Tuen Mun, Hong Kong: SAR.
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