The Use of Different Sepsis Risk Stratification Tools on the Wards and in Emergency Departments Uncovers Different Mortality Risks: Results of the Three Welsh National Multicenter Point-Prevalence Studies.

OBJECTIVES: To compare the performance of Sequential Organ Failure Assessment, systemic inflammatory response syndrome, Red Flag Sepsis, and National Institute of Clinical Excellence sepsis risk stratification tools in the identification of patients at greatest risk of mortality from sepsis in nonintensive care environments. DESIGN: Secondary analysis of three annual 24-hour point-prevalence study periods. SETTING: The general wards and emergency departments of 14 acute hospitals across Wales. Studies were conducted on the third Wednesday of October in 2017, 2018, and 2019. PATIENTS: We screened all patients presenting to the emergency department and on the general wards. MEASUREMENTS AND MAIN RESULTS: We recruited 1,271 patients, of which 724 (56.9%) had systemic inflammatory response syndrome greater than or equal to 2, 679 (53.4%) had Sequential Organ Failure Assessment greater than or equal to 2, and 977 (76.9%) had Red Flag Sepsis. When stratified according to National Institute of Clinical Excellence guidelines, 450 patients (35.4%) were in the "High risk" category in comparison with 665 (52.3%) in "Moderate to High risk" and 156 (12.3%) in "Low risk" category. In a planned sensitivity analysis, we found that none of the tools accurately predicted mortality at 90 days, and Sequential Organ Failure Assessment and National Institute of Clinical Excellence tools showed only moderate discriminatory power for mortality at 7 and 14 days. Furthermore, we could not find any significant correlation with any of the tools at any of the mortality time points. CONCLUSIONS: Our data suggest that the sepsis risk stratification tools currently utilized in emergency departments and on the general wards do not predict mortality adequately. This is illustrated by the disparity in mortality risk of the populations captured by each instrument, as well as the weak concordance between them. We propose that future studies on the development of sepsis identification tools should focus on identifying predicator values of both the short- and long-term outcomes of sepsis.

Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards.

The 'Sepsis Six' bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016-2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full 'Sepsis Six' care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the 'Sepsis Six' bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1-26.9) with no difference between each year of study. 90-day survival for years 2017-2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

Resultados del cierre de la comunicación interventricular supracristal por vía transpulmonar / Result of transpulmonary closure of supracristal interventricular comunication

Entre noviembre de 1988 y marzo de 1993, 17 pacientes portadores de comunicación interventricular (CIV) supracristal (Conal) cuyas edades oscilaron entre 45 días y 6 años, fueron sometidos a cirugía correctora con circulación extracorpórea utilizando la vía de abordaje transpulmonar. La sobrevida quirúrgica y durante el seguimiento, cuyo tiempo promedio fue de 18,5 meses (rango 2-54 meses), es del 100 por ciento encontrándose los pacientes asintomáticos, libres de medicación, con ritmo sinusal y sin evidencias de cortocircuito residual. Solo un paciente presentó insuficiencia aórtica (IA) mínima, la que había sido detectada en el preoperatorio y que no requirió plástica valvular. El cierre temprano de la CIV supracristal previene la instalación de insuficiencia aórtica por elongación y prolapso de las cúspides valvulares aórticas. El abordaje transpulmonar es la vía de elección en el cierre quirúrgico de la CIV supracristal. (AU)

Resultados del cierre de la comunicación interventricular supracristal por vía transpulmonar / Result of transpulmonary closure of supracristal interventricular comunication

Entre noviembre de 1988 y marzo de 1993, 17 pacientes portadores de comunicación interventricular (CIV) supracristal (Conal) cuyas edades oscilaron entre 45 días y 6 años, fueron sometidos a cirugía correctora con circulación extracorpórea utilizando la vía de abordaje transpulmonar. La sobrevida quirúrgica y durante el seguimiento, cuyo tiempo promedio fue de 18,5 meses (rango 2-54 meses), es del 100 por ciento encontrándose los pacientes asintomáticos, libres de medicación, con ritmo sinusal y sin evidencias de cortocircuito residual. Solo un paciente presentó insuficiencia aórtica (IA) mínima, la que había sido detectada en el preoperatorio y que no requirió plástica valvular. El cierre temprano de la CIV supracristal previene la instalación de insuficiencia aórtica por elongación y prolapso de las cúspides valvulares aórticas. El abordaje transpulmonar es la vía de elección en el cierre quirúrgico de la CIV supracristal.

Atriopulmonary anastomosis.

Atriopulmonary anastomosis (APA) has been performed in 29 patients, 3 to 22 years of age, since 1971. The diagnoses were tricuspid atresia in 21, single ventricle with low pulmonary vascular resistance in seven, and one case of dextro-transposition of the great arteries with ventricular septal defect and pulmonary stenosis. Four different techniques were used: Technique I (anterior end-to-end APA with a homograft or Dacron tube); Technique II (anterior end-to-end APA with the patient's own pulmonary artery); Technique III (nonvalved anterior anastomosis between the right atrium and the right ventricle); and Technique IV (largest, posterior, nonvalved direct APA between the right atrium and the main pulmonary artery and its right branch). Since the right atrium does not function as a pump, caval valves were never used. The total hospital mortality was 17.2%. Proper patient selection and the development of Technique IV reduced the mortality to 9%. Low end-diastolic ventricular pressure and a nonrestrictive APA are mandatory to obtain a good clinical result without pleural effusion. Twenty-one survivors are in Functional Class I, 17 of them without medication. Twelve of the 24 survivors were recatheterized. The best clinical and hemodynamic results were achieved in patients with low right atrial pressure and low end-diastolic ventricular pressure. The follow-up demonstrated a consistent superiority of the posterior nonvalved APA (Technique IV) in comparison with other techniques described. Therefore, this technique is proposed as the procedure of choice for the performance of an APA, irrespective of the precise diagnosis (tricuspid atresia or single ventricle) and irrespective of the type of great arterial relationship.

[Interventricular communications with aortic insufficiency surgical considerations]. / Les communications interventriculaires avec insuffisance aortique. Considérations chirurgicales

The authors report a series of 11 patients with ventricular septal defect associated with aortic incompetence who underwent surgery between 1963 and March 1976. Separate consideration is given to the operations performed before and after 1972. 5 patients were operated on during the first period, with only mediocre results. At this time, the technique of valvuloplasty did not appear to be the right one. During the second period, 6 patients were operated on. In five of them the technique of Plauth, Frater, Spencer and Trusler was used. All these patients have a satisfactory result. The last of the series had an abnormally low commissure, and the adjacent valves were protuberant, and thickened, so that a valvular replacement was carried out. The operation of choice for a ventricular septal defect associated with aortic incompetence is valvuloplasty with closure of the defect. The following criteria are necessary indications for this type of surgery: --the aortic incompetence must be secondary to the prolapse of a valve; --the aortic valve must have three cusps. An early operation makes the valvuloplasty easier, and avoids the problems of damage to the left ventricle from a persistant and progressive aortic incompetence.