STOP Sepsis Bundle Significantly Reduces Sepsis Mortality

[Dr.Vad]

A fast sepsis treatment protocol when completed in the emergency department of a large academic medical center reduced in-hospital sepsis mortality to 12.5% compared with a 34.2% mortality rate among sepsis patients in whom the protocol was not completed, according to results presented here at the 34th Critical Care Congress of the Society of Critical Care Medicine (SCCM).

H. Bryant Nguyen, MD, MS, an assistant professor in the department of emergency medicine at Loma Linda University in California, told Medscape that he designed the protocol, the 6-hour Strategies to Timely Obviate the Progression of Sepsis (STOP Sepsis), called a 6-Hour STOP Sepsis Bundle, by adapting the 6-hour severe sepsis bundle developed by the Institute for Healthcare Improvement, as part of the worldwide Surviving Sepsis Campaign (SSC), to the Loma Linda emergency department environment.

"The published SSC/IHI 6-hour bundle gives explicit directions about what should be done to achieve each goal; I concentrate on the target," Dr. Nguyen said. "I wasn't concerned about how to get there; I just wanted everyone to agree to the goal, for example, blood pressure, CVP and ScvO2 goals. Rather than writing down directions, we use education to teach how to reach the goal."

Dr. Nguyen has been at Loma Linda for about 18 months and when he arrived the emergency department was "reaching none of these goals, zero." During the first quarter with the STOP Sepsis Bundle protocol (October-December 2003), 8% of patients had achieved all early goal-directed therapy (EGDT) goals by 6 hours, 22% had lactate clearance monitoring at 6 hours, and 49% had appropriate steroid therapy. Within 6 months, the emergency department was completing all EGDT 6-hour goals in 26% of patients, 52% of patients had lactate clearance monitoring, and 67% were receiving appropriate steroid therapy.

The 6-hour EGDT completion rate has varied over the months from April to December 2004 — hitting a low of 9% in July — but is now at 22%, Dr. Nguyen said.

Data were reported from 208 sepsis patients treated since initiation of the 6-hour STOP Sepsis Bundle protocol. All components of the bundle were completed in 24 patients and in those patients the mortality rate was 12.5% (P = .008), and the hospital length of stay averaged 8.1 days compared with 11.9 days for the 184 patients in whom the bundle was not completed (P = .06).

Criteria to initiate the STOP Sepsis Bundle include systemic inflammatory response syndrome plus source of infection plus a systolic blood pressure less than 90 mm Hg after a 20 mL/kg fluid bolus, or lactate of 4 mmol/L or higher, or evidence of organ dysfunction.

For patients meeting those criteria, bundle strategies are initiated:

hemodynamic monitoring (CVP/ScvO2 ) within 2 hours;
broad spectrum antibiotics administered within 4 hours;
EGDT achieved at 6 hours, including CVP of 8 mm Hg or higher, MAP of 65 mm Hg or higher, ScvO2 of 70% or higher;
monitor for decreasing lactate; and
administer steroid if the patient is on a vasopressor.

A simple form using a yes/no format is used to track these bundle targets, Dr. Nguyen said.

Jean-Louis Vincent, MD, PhD, chair of the department of intensive care at the Erasme University Hospital in Brussels, Belgium, and a member of the writing group of the Surviving Sepsis Campaign sepsis bundles, complimented Dr. Nguyen on his implementation of the 6-hour STOP sepsis bundle. "I think you have improved on our guidelines. This is better," said Dr. Vincent, who chaired the oral abstract session where Dr. Nguyen presented his results. Dr. Vincent is also a member of the steering committee of the Surving Sepsis Campaign and chairman of the International Sepsis Forum.

Jeffery S. Vender, MD, chairman of the department of anesthesiology and professor of medicine at Northwestern University Medical School in Chicago, Illinois, told Medscape that Dr. Nguyen's results were impressive because they demonstrate that "you can organize an institution to deliver this type of treatment with a very high degree of consistency." Dr. Vender is cochair of the program committee for the SCCM Congress.

Dr. Vender added that many institutions — his included — are working to initiate similar STOP Sepsis bundle programs but noted that few are as far along as Dr. Nguyen's.

Dr. Nguyen noted that he trained under Emanuel P. Rivers, MD, from Henry Ford Hospital in Detroit, Michigan, who is generally recognized as the clinical leader in the EGDT for sepsis field, and that Dr. Rivers helped with the Loma Linda study.

SCCM 34th Critical Care Congress: Abstract 44. Presented Jan. 17,2005.

[Dr. Makhotin]

Очень интересно и достойно внимания. Полезный опыт для наших специалистов, чтобы хотя бы частично следовать указанной методике в своих клиниках.
Но не стоит забывать, что окончательные выводы будут сделаны гораздо позже.
Так было с Зигрисом (дротрекогин альфа): достоверно снижает смертность при тяжелом сепсисе плюс МОН в многочисленных исследованиях, но не стал панацеей, просто вошел в алгоритмы терапии.