Early sepsis bundle compliance for non-hypotensive patients with intermediate versus severe hyperlactemia

Daniel E. Leisman, Jason A. Zemmel D'Amore, Jeanie L. Gribben, Mary Frances Ward, Kevin D. Masick, Andrea R. Bianculli, Kathryn H. Bradburn, John K. D'Angelo, Martin E. Doerfler

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7 Scopus citations

Abstract

Objective To compare the association of 3-h sepsis bundle compliance with hospital mortality in non-hypotensive sepsis patients with intermediate versus severe hyperlactemia. Methods This was a cohort study of all non-hypotensive, hyperlactemic sepsis patients captured in a prospective quality-improvement database, treated October 2014 to September 2015 at five tertiary-care centers. We defined sepsis as 1) infection, 2) ≥ 2 SIRS criteria, and 3) ≥ 1 organ dysfunction criterion. “Time-zero” was the first time a patient met all sepsis criteria. Inclusion criteria: systolic blood pressure > 90 mmHg, mean arterial pressure > 65 mmHg, and serum lactate ≥ 2.2 mmol/L. Primary exposures: 1) intermediate(2.2–3.9 mmol/L) versus severe(≥ 4.0 mmol/L) hyperlactemia and 2) full 3-h bundle compliance. Bundle elements: 1. Blood cultures before antibiotics.2. Parenteral antibiotics administered ≤ 180 min from ≥ 2 SIRS and lactate ordered, or ≤ 60 min from “time-zero”, whichever occurred first.3. Lactate result available ≤ 90 min post-order.4. 30 mL/kg crystalloid bolus initiated ≤ 30 min from “time-zero”.The primary outcome was 60-day in-hospital mortality. Results 2417 patients met inclusion criteria. 704(29%) had lactate ≥ 4.0 mmol/L versus 1775 patients with lactate 2.2–3.9 mmol/L. Compliance was 75% for antibiotics and 53% for fluids. Full-compliance was comparable between lactate groups (n = 200(29%) and 488(28%), respectively). We observed 424(17.5%) mortalities: intermediate/non-compliant – 182(14.9%), intermediate/compliant – 41(8.4%), severe/non-compliant – 147(29.2%), severe/compliant – 54(27.0%) [difference-of-differences = 4.3%, CI = 2.6–5.9%]. In multivariable regression, mortality predictors included severe hyperlactemia (OR = 1.99, CI = 1.51–2.63) and bundle compliance (OR = 0.62, CI = 0.42–0.90), and their interaction was significant: p(interaction) = 0.022. Conclusion We observed a significant interaction between 3-h bundle compliance and initial hyperlactemia. Bundle compliance may be associated with greater mortality benefit for non-hypotensive sepsis patients with less severe hyperlactemia.

Original languageEnglish
Pages (from-to)811-818
Number of pages8
JournalAmerican Journal of Emergency Medicine
Volume35
Issue number6
DOIs
StatePublished - Jun 2017

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