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Life-support tools for improving performance of the Surviving Sepsis Campaign Hour-1 bundle
Herramientas de soporte vital para mejorar la ejecución del paquete de medidas de 1 hora de la Surviving Sepsis Campaign
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Jibaja, J.L. Sufan, D.A. Godoy" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Jibaja" ] 1 => array:2 [ "nombre" => "J.L." "apellidos" => "Sufan" ] 2 => array:2 [ "nombre" => "D.A." "apellidos" => "Godoy" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173572718301735" "doi" => "10.1016/j.medine.2018.09.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718301735?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569118301505?idApp=WMIE" "url" => "/02105691/0000004200000009/v1_201811220619/S0210569118301505/v1_201811220619/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0210569118300123" "issn" => "02105691" "doi" => "10.1016/j.medin.2017.12.012" "estado" => "S300" "fechaPublicacion" => "2018-12-01" "aid" => "1165" "copyright" => "Elsevier España, S.L.U. y SEMICYUC" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Intensiva. 2018;42:541-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2831 "formatos" => array:3 [ "EPUB" => 169 "HTML" => 1842 "PDF" => 820 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">SERIES EN MEDICINA INTENSIVA: ACTUALIZACIÓN EN METODOLOGÍA EN MEDICINA INTENSIVA</span>" "titulo" => "Errores metodológicos frecuentes en la investigación clínica" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "541" "paginaFinal" => "546" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Frequent methodological errors in clinical research" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 875 "Ancho" => 1593 "Tamanyo" => 62508 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Evolución del número de revistas depredadoras existentes entre 2011 y 2017.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L.C. Silva Aycaguer" "autores" => array:1 [ 0 => array:2 [ "nombre" => "L.C." "apellidos" => "Silva Aycaguer" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173572718301905" "doi" => "10.1016/j.medine.2018.10.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572718301905?idApp=WMIE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569118300123?idApp=WMIE" "url" => "/02105691/0000004200000009/v1_201811220619/S0210569118300123/v1_201811220619/es/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Point of view</span>" "titulo" => "Life-support tools for improving performance of the Surviving Sepsis Campaign Hour-1 bundle" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "547" "paginaFinal" => "550" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E.P. Plata-Menchaca, R. Ferrer" "autores" => array:2 [ 0 => array:3 [ "nombre" => "E.P." "apellidos" => "Plata-Menchaca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "R." "apellidos" => "Ferrer" "email" => array:1 [ 0 => "r.ferrer@vhebron.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Institut d’Investigació Biomèdica de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Intensive Care, Vall d’Hebron University Hospital, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Research Institute, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herramientas de soporte vital para mejorar la ejecución del paquete de medidas de 1 hora de la <span class="elsevierStyleItalic">Surviving Sepsis Campaign</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2917 "Ancho" => 2314 "Tamanyo" => 694247 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The Rational Life Support in Sepsis (RALSS) algorithm. This algorithm is based on the Surviving Sepsis Campaign (SSC) hour-1 bundle of care, as well as adapted to the institutional protocol and available resources. At time zero, clinician on charge should suggest verbally and share with other staff members the diagnosis (<span class="elsevierStyleItalic">say</span> sepsis), <span class="elsevierStyleItalic">look for</span> the source (and <span class="elsevierStyleItalic">consider</span> imaging studies), <span class="elsevierStyleItalic">attach</span> the monitor to the patient and <span class="elsevierStyleItalic">obtain</span> at least 2 blood and other cultures according to clinical suspicion (preferably before administration of broad-spectrum antibiotics) <span class="elsevierStyleBold">(box 1)</span>. Afterwards, administration of appropriate IV antibiotic(s) and the best strategy for control of sepsis source should be ensured (if a drainable focus of infection is present) <span class="elsevierStyleBold">(box 2)</span>. <span class="elsevierStyleItalic">Sepsis without hypotension</span><span class="elsevierStyleBold">(box 3)</span><span class="elsevierStyleItalic">or Sepsis and hypotension</span><span class="elsevierStyleBold">(box 4)</span> pathway should be followed according to patient status. If hypotension is present, <span class="elsevierStyleItalic">start</span> resuscitation with IV fluids (30<span class="elsevierStyleHsp" style=""></span>ml/kg) and re-measure lactate if initial value was >2<span class="elsevierStyleHsp" style=""></span>mmol/L or if clinical deterioration exists although the initial lactate was ≤2<span class="elsevierStyleHsp" style=""></span>mmol/L <span class="elsevierStyleBold">(box 5)</span>. If hypotension persists and lactate is >2<span class="elsevierStyleHsp" style=""></span>mmol/L start vasopressors <span class="elsevierStyleBold">only</span> in those patients who have received an initial resuscitation with IV fluids and are not considered to be hypovolemic <span class="elsevierStyleBold">(box 6 and box 7)</span>. In septic shock patients assess for fluid responsiveness and ask for an intensivist consultation <span class="elsevierStyleBold">(box 7)</span>. Continuous assessment of clinical and laboratory variables and control of focus of infection reassessment may be carried out to enhance initial resuscitation interventions <span class="elsevierStyleBold">(box 8)</span>. Complementary assessments may be requested, and institutional protocol activated. During all interventions continuous reassessment and ruling out of other sources of shock should be conducted <span class="elsevierStyleBold">(box 9</span>). <span class="elsevierStyleItalic">ID</span> denotes Infectious Diseases, <span class="elsevierStyleItalic">MAP</span> mean arterial pressure, <span class="elsevierStyleItalic">SAP</span> systolic arterial pressure, <span class="elsevierStyleItalic">DAP</span> diastolic arterial pressure, <span class="elsevierStyleItalic">ScVO<span class="elsevierStyleInf">2</span></span> central venous oxygen saturation, <span class="elsevierStyleItalic">PCO<span class="elsevierStyleInf">2</span></span> Partial pressure of carbon dioxide, <span class="elsevierStyleItalic">ICU</span> intensive care unit. <span class="elsevierStyleSup">a</span> Do not significantly delay antimicrobial therapy while awaiting for cultures or blood samples. Out-of-hospital approach should attempt to store baseline blood samples for rapid analysis at hospital admission. <span class="elsevierStyleSup">b</span> Broad-spectrum antibiotics considering the likely etiology of infection, specific drug properties and increased extra-renal drug elimination during sepsis/septic shock, history of multidrug-resistant microorganisms, presence of acute kidney injury (±renal replacement therapies) or liver failure and presence of obesity.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Despite current initiatives aimed to improve sepsis awareness and early treatment, patient outcomes still depend upon the performance of accurate interventions which in turn rely on practical aspects surrounding the time of presentation of patients. Effective accomplishment of core interventions in sepsis demands a correct evaluation and requires a system that coordinates emergency services, general wards, surgical teams, intensive care department and pharmacy to provide optimal treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recognizing the need to improve early identification of sepsis, new definitions were published in 2016.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Nonetheless, catastrophic consequences still exist as a consequence of the lack of sepsis awareness and systemic errors even within experienced health care institutions where presiding training programs promoting early sepsis diagnosis and management protocols are being encouraged at the same time.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Less severe sepsis cases are those cases that frequently remain unrecognized, as they develop subtle clinical signs and appear less sick; comprising a subgroup of patients at risk of being inadequately treated, with associated mortality rates exceeding 25% in some studies.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Noteworthy, training programs directed to improve awareness of sepsis are not sufficient to obtain palpable results.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> In recent years, high-quality evidence has demonstrated protocolized care for early resuscitation in sepsis to be the recommended approach not only aimed to reduce deaths, but also to prevent systemic errors and their overall individual, social and health care system consequences.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Thus, many educational programs on protocolized care for early sepsis care and shock resuscitation have been derived from this recommendation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">As a step forward, the Surviving Sepsis Campaign (SSC) have produced and updated different bundles for the acute management of sepsis in order to provide a reliable tool containing evidence-based recommendations for the best care of patients. A bundle is a selected set of interventions or processes of care distilled from evidence-based practice guidelines that when implemented as a group provide a more robust picture of the quality of care provided. Individual hospitals can and should codify bundle elements into customized clinical protocols that function best in their institutions. However, to provide standard-of-care therapies to patients, no element of the bundle should be ignored. Despite several studies have shown that bundle care is associated to better outcomes, some elements of the initial bundles have not confirmed their efficacy or are no longer available, like activated protein C or quantitative resuscitation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> A new SSC bundle update was recently published,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> in which authors combine both the 3- and 6-hour bundles and simplify them into the 1-hour bundle as a means of providing education and achieving improvements on sepsis management (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Substantial agreement exists among international experts regarding establishment of earlier interventions to overcome barriers precluding definitive actions to be taken by clinicians when facing a suspected case of sepsis. Indeed, novel concepts have been recently introduced, such as the door-to-needle time for antibiotic administration, depicting global concerns about setting up a time window after the onset of symptoms.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Nevertheless, in some situations, attaining an effective application of institutional protocols during the <span class="elsevierStyleItalic">golden hour</span> of sepsis may represent a real challenge to be achieved. First, significant delays from first medical contact to administration of appropriate therapy have been observed in the pre- and in-hospital setting. Of note, community-acquired sepsis cases transported by emergency medical systems have been associated with high adjusted in-hospital mortality rates associated with delays from first medical contact to antibiotic administration.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Second, there are several aspects of sepsis management in which observational evidence has showed that current practices regarding some of its core interventions are highly variable. For instance, a large multinational study showed that a great proportion of hemodynamic management assessments were based on misunderstanding of clinical indications for fluid challenges and goals of fluid therapy.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Third, a variable but non-negligible proportion of first medical contacts are provided by non-critical care professionals. Furthermore, existent variations in internal policies among different institutions determining immediate medication availability,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> general beliefs regarding sepsis prognosis, institutional policies, etc., which thwart any initiative aimed to encourage quality improvements. In addition, as pointed out by the IDSA, stipulating an aggressive, fixed-time period may lead to unintended consequences, namely an increased likelihood that broad-spectrum antibiotics will be given more frequently to patients with <span class="elsevierStyleItalic">infection-like</span> syndromes in the rush to meet the fixed timeframe stipulated for infected patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In some previous algorithm-based training programs for the management of other clinical situations, in which time has a major role (“time is life”), the performance of life support proceedings have led to significant improvements in acute emergency care.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> As patient outcomes are time-dependent and the first medical contact is a crucial element contributing to patient outcomes, all health care professionals facing a suspicious case of sepsis should be able to perform initial <span class="elsevierStyleItalic">skilled</span> life support interventions even while awaiting for a clearer diagnosis and treatment. In fact, less severe sepsis cases pose a great opportunity to apply the hour-1 bundle when chances to survive are higher.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Aiming at improving the <span class="elsevierStyleItalic">very early</span> treatment window in sepsis we propose the “<span class="elsevierStyleItalic">rational life support in sepsis</span>” algorithm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) that may be useful to better clear-cut the current recommended skills to be acquired by first medical contacts regardless of their area of expertise. Indeed, we intended to provide a reliable tool at bedside which, rather than substituting institutional protocols for early management for sepsis care, is intended to facilitate training of health care professionals on early sepsis management and to create a global consciousness among medical and non-medical professionals.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Sepsis is a time-dependent medical emergency requiring effective interventions focused on reducing the time interval between a suspected diagnosis and effective treatment. Advocating for general healthcare staff training on the acquisition of skilled life support interventions focused on the initial management recommendations of the hour-1 bundle and strengthen by the use of pragmatic tools should probably be assessed, in order to reduce delays from first medical contact to appropriate therapy; and to avoid systemic errors when facing a suspected case of sepsis. Such a strategy may significantly contribute to current initiatives on the development of educational programs for sepsis prevention and to promote the SSC targets, as it is focused on the endorsement of aspects unequivocally being associated with best practice standards.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-05-30" "fechaAceptado" => "2018-07-10" "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2917 "Ancho" => 2314 "Tamanyo" => 694247 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The Rational Life Support in Sepsis (RALSS) algorithm. This algorithm is based on the Surviving Sepsis Campaign (SSC) hour-1 bundle of care, as well as adapted to the institutional protocol and available resources. At time zero, clinician on charge should suggest verbally and share with other staff members the diagnosis (<span class="elsevierStyleItalic">say</span> sepsis), <span class="elsevierStyleItalic">look for</span> the source (and <span class="elsevierStyleItalic">consider</span> imaging studies), <span class="elsevierStyleItalic">attach</span> the monitor to the patient and <span class="elsevierStyleItalic">obtain</span> at least 2 blood and other cultures according to clinical suspicion (preferably before administration of broad-spectrum antibiotics) <span class="elsevierStyleBold">(box 1)</span>. Afterwards, administration of appropriate IV antibiotic(s) and the best strategy for control of sepsis source should be ensured (if a drainable focus of infection is present) <span class="elsevierStyleBold">(box 2)</span>. <span class="elsevierStyleItalic">Sepsis without hypotension</span><span class="elsevierStyleBold">(box 3)</span><span class="elsevierStyleItalic">or Sepsis and hypotension</span><span class="elsevierStyleBold">(box 4)</span> pathway should be followed according to patient status. If hypotension is present, <span class="elsevierStyleItalic">start</span> resuscitation with IV fluids (30<span class="elsevierStyleHsp" style=""></span>ml/kg) and re-measure lactate if initial value was >2<span class="elsevierStyleHsp" style=""></span>mmol/L or if clinical deterioration exists although the initial lactate was ≤2<span class="elsevierStyleHsp" style=""></span>mmol/L <span class="elsevierStyleBold">(box 5)</span>. If hypotension persists and lactate is >2<span class="elsevierStyleHsp" style=""></span>mmol/L start vasopressors <span class="elsevierStyleBold">only</span> in those patients who have received an initial resuscitation with IV fluids and are not considered to be hypovolemic <span class="elsevierStyleBold">(box 6 and box 7)</span>. In septic shock patients assess for fluid responsiveness and ask for an intensivist consultation <span class="elsevierStyleBold">(box 7)</span>. Continuous assessment of clinical and laboratory variables and control of focus of infection reassessment may be carried out to enhance initial resuscitation interventions <span class="elsevierStyleBold">(box 8)</span>. Complementary assessments may be requested, and institutional protocol activated. During all interventions continuous reassessment and ruling out of other sources of shock should be conducted <span class="elsevierStyleBold">(box 9</span>). <span class="elsevierStyleItalic">ID</span> denotes Infectious Diseases, <span class="elsevierStyleItalic">MAP</span> mean arterial pressure, <span class="elsevierStyleItalic">SAP</span> systolic arterial pressure, <span class="elsevierStyleItalic">DAP</span> diastolic arterial pressure, <span class="elsevierStyleItalic">ScVO<span class="elsevierStyleInf">2</span></span> central venous oxygen saturation, <span class="elsevierStyleItalic">PCO<span class="elsevierStyleInf">2</span></span> Partial pressure of carbon dioxide, <span class="elsevierStyleItalic">ICU</span> intensive care unit. <span class="elsevierStyleSup">a</span> Do not significantly delay antimicrobial therapy while awaiting for cultures or blood samples. Out-of-hospital approach should attempt to store baseline blood samples for rapid analysis at hospital admission. <span class="elsevierStyleSup">b</span> Broad-spectrum antibiotics considering the likely etiology of infection, specific drug properties and increased extra-renal drug elimination during sepsis/septic shock, history of multidrug-resistant microorganisms, presence of acute kidney injury (±renal replacement therapies) or liver failure and presence of obesity.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">2012 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">2016 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">2018 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">6-hour Resuscitation bundle:</span><br>1. Measure serum lactate.<br>2. Obtain blood cultures prior to antibiotic administration.<br>3. Administer broad-spectrum antibiotics within 3<span class="elsevierStyleHsp" style=""></span>hours from time of presentation.<br>4. In the event of hypotension and/or lactate<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mmol/L:<br>a. Deliver an initial minimum of 20<span class="elsevierStyleHsp" style=""></span>ml/kg of crystalloid (or colloid equivalent).<br>b. Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) ≥65<span class="elsevierStyleHsp" style=""></span>mm Hg.<br>5. In the event of persistent hypotension despite fluid resuscitation and/or lactate<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>mmol/L:<br>a. Achieve central venous pressure (CVP) of ≥8<span class="elsevierStyleHsp" style=""></span>mm Hg.<br>b. Achieve central venous oxygen saturation (ScvO2) of ≥70%.<br><br><span class="elsevierStyleBold">24-hour Management bundle:</span><br>1. Administer low-dose steroids for septic shock in accordance with a standardized ICU policy.<br>2. Administer drotrecogin alfa (activated) in accordance with a<br>standardized ICU policy.<br>3. Maintain glucose control ≥ lower limit of normal, but <150<span class="elsevierStyleHsp" style=""></span>mg/dl.<br>4. Maintain inspiratory plateau pressures <30<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O for mechanically ventilated patients. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">3-hour bundle:</span><br>1. Measure serum lactate.<br>2. Obtain blood cultures prior to antibiotic administration.<br>3. Administer broad-spectrum antibiotics within 3<span class="elsevierStyleHsp" style=""></span>hours from time of presentation.<br>4. Administer 30<span class="elsevierStyleHsp" style=""></span>ml/kg crystalloid for hypotension or lactate ≥4<span class="elsevierStyleHsp" style=""></span>mmol/L<br><br><span class="elsevierStyleBold">6-hour bundle:</span><br>1. Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) ≥65<span class="elsevierStyleHsp" style=""></span>mm Hg.<br>2. In the event of persistent hypotension despite fluid resuscitation and/or lactate >4<span class="elsevierStyleHsp" style=""></span>mmol/L:<br>a. Measure central venous pressure (CVP).<br>b. Measure central venous oxygen saturation (ScvO2) of ≥70%.<br>3. Remeasure lactate if initial lactate was elevated. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">hour-1 bundle:</span><br>1. Measure lactate level. Re-measure if initial lactate is >2<span class="elsevierStyleHsp" style=""></span>mmol/L (Weak recommendation, low quality of evidence).<br>2. Obtain blood cultures prior to administration of antibiotics (Best practice statement).<br>3. Administer broad-spectrum antibiotics (Strong recommendation, moderate quality of evidence).<br>4. Rapidly administer 30<span class="elsevierStyleHsp" style=""></span>ml/kg crystalloid for hypotension or lactate ≥4<span class="elsevierStyleHsp" style=""></span>mmol/L (Strong recommendation, low quality of evidence).<br>5. Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥65<span class="elsevierStyleHsp" style=""></span>mm Hg (Strong recommendation, moderate quality of evidence). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1900809.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Surviving Sepsis Campaign Bundles from 2012 to 2018.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New definition of sepsis and septic shock: what does it give us?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Rodríguez" 1 => "I. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 20 | 15 | 35 |
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| 2024 Enero | 306 | 44 | 350 |
| 2023 Diciembre | 448 | 52 | 500 |
| 2023 Noviembre | 320 | 50 | 370 |
| 2023 Octubre | 227 | 51 | 278 |
| 2023 Septiembre | 216 | 60 | 276 |
| 2023 Agosto | 184 | 41 | 225 |
| 2023 Julio | 169 | 39 | 208 |
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| 2023 Mayo | 186 | 34 | 220 |
| 2023 Abril | 315 | 70 | 385 |
| 2023 Marzo | 419 | 50 | 469 |
| 2023 Febrero | 372 | 68 | 440 |
| 2023 Enero | 349 | 56 | 405 |
| 2022 Diciembre | 193 | 58 | 251 |
| 2022 Noviembre | 213 | 70 | 283 |
| 2022 Octubre | 226 | 50 | 276 |
| 2022 Septiembre | 255 | 97 | 352 |
| 2022 Agosto | 188 | 58 | 246 |
| 2022 Julio | 170 | 58 | 228 |
| 2022 Junio | 187 | 48 | 235 |
| 2022 Mayo | 190 | 68 | 258 |
| 2022 Abril | 186 | 66 | 252 |
| 2022 Marzo | 232 | 87 | 319 |
| 2022 Febrero | 270 | 62 | 332 |
| 2022 Enero | 318 | 75 | 393 |
| 2021 Diciembre | 185 | 70 | 255 |
| 2021 Noviembre | 221 | 72 | 293 |
| 2021 Octubre | 296 | 112 | 408 |
| 2021 Septiembre | 183 | 74 | 257 |
| 2021 Agosto | 234 | 78 | 312 |
| 2021 Julio | 201 | 58 | 259 |
| 2021 Junio | 196 | 67 | 263 |
| 2021 Mayo | 289 | 111 | 400 |
| 2021 Abril | 789 | 217 | 1006 |
| 2021 Marzo | 555 | 80 | 635 |
| 2021 Febrero | 306 | 92 | 398 |
| 2021 Enero | 252 | 58 | 310 |
| 2020 Diciembre | 189 | 43 | 232 |
| 2020 Noviembre | 260 | 29 | 289 |
| 2020 Octubre | 431 | 50 | 481 |
| 2020 Septiembre | 615 | 57 | 672 |
| 2020 Agosto | 326 | 52 | 378 |
| 2020 Julio | 319 | 50 | 369 |
| 2020 Junio | 198 | 41 | 239 |
| 2020 Mayo | 280 | 56 | 336 |
| 2020 Abril | 386 | 51 | 437 |
| 2020 Marzo | 417 | 53 | 470 |
| 2020 Febrero | 714 | 95 | 809 |
| 2020 Enero | 362 | 59 | 421 |
| 2019 Diciembre | 231 | 37 | 268 |
| 2019 Noviembre | 153 | 43 | 196 |
| 2019 Octubre | 211 | 55 | 266 |
| 2019 Septiembre | 109 | 43 | 152 |
| 2019 Agosto | 115 | 32 | 147 |
| 2019 Julio | 50 | 28 | 78 |
| 2019 Junio | 49 | 38 | 87 |
| 2019 Mayo | 52 | 49 | 101 |
| 2019 Abril | 51 | 42 | 93 |
| 2019 Marzo | 31 | 46 | 77 |
| 2019 Febrero | 57 | 14 | 71 |
| 2019 Enero | 16 | 22 | 38 |
| 2018 Diciembre | 16 | 13 | 29 |
| 2018 Noviembre | 30 | 25 | 55 |
| 2018 Octubre | 2 | 4 | 6 |
| 2018 Septiembre | 0 | 1 | 1 |
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