Reduction of the severe sepsis or septic shock associated mortality by reinforcement of the recommendations bundle: a multicenter study.

INTRODUCTION: We determined whether the implementation of a bundle of 10 recommendations leads to the reduction of mortality in ICU patients with severe sepsis or septic shock. METHODS: All patients with severe sepsis or septic shock during two consecutive phases: a 6-month quality control period (observational) and secondly a 6-month intervention period based on the implementation of a bundle of 10 recommendations adapted from the Surviving Sepsis Campaign guidelines (initial bacteriological samples and initiating antibiotics, measurement of arterial lactate, volume expansion > or =20 ml/kg, targeted mean arterial pressure > or =65 mmHg and the assessments of central venous pressure and Scv(O2); glucose control, low doses of corticosteroids, a tidal volume < or =8 ml/kg in mechanically ventilated patients with ALI; adequate use of recombinant human activated protein C) were evaluated in 15 ICUs. The primary endpoint was the 28-day mortality rate and the secondary endpoint was the compliance with the recommendations of the care bundle. MEASUREMENT AND RESULTS: Four hundred and forty-five patients (230 and 215 in the observational and intervention periods, respectively) were included. In the two periods, the patients had similar characteristics. The 28-day mortality rate significantly decreased from 40% in the observational period to 27% in the intervention period (P=0.02). According to each recommendation, compliance with the care bundle was achieved in 9 to 100% of patients. CONCLUSION: The implementation of a care bundle adapted from the Surviving Sepsis Campaign guidelines decreases the 28-day mortality rate in patients with severe sepsis and/or septic shock.

Simple coagulation tests improve survival prediction in patients with septic shock.

BACKGROUND: Classic mortality prediction models in intensive care units (ICUs) are based on clinical scores, which do not contain any coagulation test (SAPS-II or SOFA scores). OBJECTIVES: To determine whether coagulation tests can improve mortality prediction in patients with septic shock. PATIENTS AND METHODS: One hundred fifty-eight consecutive patients with septic shock entering our institution's ICU were investigated on the first day of admission, and deaths were registered during the first month. RESULTS: Among all the coagulation tests performed, only the fibrinogen (Fg) plasma level, together with the SAPS-II score and the age, were included in our simplified mortality score [area under the receiver operating curve (AUC) 0.927, standard deviation (SD) 0.030], which was more efficient than SAPS-II and SOFA scores themselves in predicting first-week mortality, its optimized cut-off having a very high negative predictive value (NPV) [0.989; 95% confidence interval (CI) 0.967-1.000)]. A simplified score predicting first-month mortality, containing the prothrombin ratio and the antithrombin activity values in addition to the age, the hemoglobin concentration, and the SAPS-II and SOFA scores (AUC 0.889, SD 0.026), was found to be superior to the SAPS-II and SOFA scores, the optimized cut-off value having a high NPV (0.952; 95% CI 0.888-1.000). CONCLUSIONS: In patients admitted to an ICU with septic shock, some initial coagulation test values can help identify those who will survive in the first week and then in the first month.