Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study

Abstract

Objectives: To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign's resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance.

Design: Prospective cohort study.

Setting: 150 intensive care units in 16 Asian countries.

Participants: 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients' baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded.

Main outcome measure: Compliance with the Surviving Sepsis Campaign's resuscitation (six hours) and management (24 hours) bundles.

Results: Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle.

Conclusions: While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.

Fig 1 Compliance with resuscitation and management bundles by country. Only countries that enrolled more than 100 patients are shown. Others include Bahrain, Bangladesh, Brunei, Indonesia, Japan, Nepal, Pakistan, Saudi Arabia, Taiwan, and Vietnam. Drotrecogin alfa was unavailable in nine countries, including China, Hong Kong, and South Korea

Fig 2 Proportion of emergency departments and intensive care units with facilities and equipment to perform various functions. Emergency departments not surveyed for drotrecogin alfa and glucose measurements. Fibreoptic catheters with in vivo spectrophotometry or blood gas analysers with co-oximetry are required to measure ScvO₂ and SvO₂. CVP=central venous pressure; ScvO₂=central venous oxygen saturation; SvO₂=mixed venous oxygen saturation

Fig 3 Proportion of emergency departments and intensive care units with protocols to achieve individual bundle targets. Emergency departments not surveyed for steroids, drotrecogin alfa, glucose measurements, and tidal volumes. CVP=central venous pressure; PBW=predicted body weight; ScvO₂=central venous oxygen saturation; SvO₂=mixed venous oxygen saturation

Fig 4 Achievement of specific bundle targets in intensive care units with and without corresponding protocols. CVP=central venous pressure; PBW=predicted body weight; ScvO₂=central venous oxygen saturation; SvO₂=mixed venous oxygen saturation