Post operative pediatric appendicitis nurse-driven discharge: Patient outcomes and nursing perspectives.

BACKGROUND: Nurse-driven discharge pathways following pediatric appendectomies have proven effective in children's hospitals; studies in general hospital settings are lacking. Additionally, despite the central role of nursing in such pathways, nursing perspectives aren't investigated in the literature. METHODS: Data from all pediatric acute uncomplicated appendicitis patients who underwent laparoscopic appendectomy in the 12 months following institution of a nurse-driven discharge pathway (intervention, n = 67) were compared to those treated in the preceding year (control, n = 64). Surveys on the pathway were distributed to pediatric ward nurses. RESULTS: Postoperative length of stay (POLOS) decreased by 37% in the intervention group, about 6 h, (0.44 days ± 0.22 vs 0.7 days ± 0.27, p-value 0.0001), without a significant increase in related readmissions. Same day discharges increased from 10.9% to 46.3%, (P-value 0.0001). Nurse surveys revealed a high approval of the pathway (7-10/10) and yielded valuable feedback. CONCLUSION: A nurse-driven discharge pathway decreased POLOS without increasing readmission following pediatric laparoscopic appendectomy in a general hospital setting. Valuable insight into nursing perspectives on this pathway was acquired.

Prognostic utility of plasma lactate measured between 24 and 48 h after initiation of early goal-directed therapy in the management of sepsis, severe sepsis, and septic shock.

BACKGROUND: Based on the proven efficacy of lactate in predicting mortality and morbidity in sepsis when measured early in the resuscitative protocol, our group hypothesized that this utility extends later in the course of care. This study sought to investigate the prognostic potential of plasma lactate clearance measured 24-48 h after the initiation of treatment for nonsurgical patients with sepsis, severe sepsis, and septic shock. METHODS: Plasma lactate values, measured 24-48 h after the initiation of treatment, were collected in nonsurgical septic, severe septic, and septic shock patients. The primary outcome was 30-day mortality, while secondary outcomes included requirements for vasopressors and boluses of intravenous fluids. Analysis of these three outcomes was performed while controlling for clinical severity as measured by Sequential Organ Failure Assessment (SOFA), renal dysfunction, and hepatic dysfunction. Lactate clearance was defined as the percent change in plasma lactate levels measured after 24-48 h of treatment from the plasma lactate level at initial presentation. RESULTS: Two hundred twenty-nine nonsurgical patients were divided into two groups, clearers (above median lactate clearance [31.6 %]) and nonclearers (below median lactate clearance [31.6 %]). The adjusted odds ratio of mortality in clearers compared to nonclearers was 0.39 (CI 0.20-0.76) (p = 0.006). For vasopressor requirement, the adjusted odds ratio was 0.41 (CI 0.21-0.79) in clearers compared to nonclearers (p = 0.008). For intravenous fluid bolus requirement, the adjusted odds ratio was 0.81 (CI 0.48-1.39) in clearers compared to nonclearers (p = 0.45). CONCLUSIONS: Lower plasma lactate clearance 24-48 h after the initiation of treatment is associated with higher 30-day mortality and requirements for vasopressors in nonsurgical septic patients and may be a useful noninvasive measurement for guiding late-sepsis treatment. Further investigation looking at mechanisms and therapeutic targets to improve lactate clearance in late sepsis may improve patient mortality and outcomes.

Lactate kinetics in sepsis and septic shock: a review of the literature and rationale for further research.

Over the last two decades, there have been vast improvements in sepsis-related outcomes, largely resulting from the widespread adoption of aggressive fluid resuscitation and infection control. With increased understanding of the pathophysiology of sepsis, novel diagnostics and resuscitative interventions are being discovered. In recent years, few diagnostic tests like lactate have engendered more attention and research in the sepsis arena. Studies highlighting lactate's prognostic potential for mortality and other outcomes are ubiquitous and largely focus on the early stage of sepsis management, defined as the initial 6 h and widely referred to as the "golden hours." Additional investigations, although more representative of surgical and trauma patients, suggest that lactate measurements beyond 24 h from the initiation of resuscitation continue to have predictive and prognostic utility. This review summarizes the current research and evidence regarding lactate's utility as a prognosticator of clinical outcomes in both early and late sepsis management, defines the mechanism of lactate production and clearance, and identifies areas warranting further research.