Sepsis Third Edition Guillermo Ortiz-Ruiz Carmelo Dueñas-Castell Editors 123 Sepsis Guillermo Ortiz-Ruiz  •  Carmelo Duas-Castell Editors Sepsis Third Edition Editors Guillermo Ortiz-Ruiz Department of Internal Medicine Pulmonary Medicine and Critical Care Hospital Santa Clara Universidad del Bosque Bogotá Colombia Carmelo Duas-Castell Department of Critical Care Clínica Gestión Salud Universidad de Cartagena Cartagena Colombia ISBN 978-1-4939-7332-3    ISBN 978-1-4939-7334-7 (eBook) https://doi.org/10.1007/978-1-4939-7334-7 Library of Congress Control Number: 2017954326 © Springer Science+Business Media LLC 2004, 2006, 2018 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer Science+Business Media LLC The registered company address is: 233 Spring Street, New York, NY 10013, USA To my parents to whom I owe everything; to my family for their self-denial, support, and sacrifice; and to my patients for their teachings — (Carmelo Dueñas) To my patients, my students, and my family — (Guillermo Ortiz) Preface Sepsis is a global public health problem; it generates more than 3,000,000 hospitalizations per year Despite the advances in modern medicine, more than 5.3 million people die from sepsis annually It remains the leading cause of death in critically ill patients in noncoronary intensive care units, with an estimated overall mortality of about 30% In order to face a problem of such magnitude, it is essential to have an objective, a clear and universal definition Although the first description dates back to more than 3,500 years, it was only in 1992 that an effort was made to reach a consensus on a definition From a definition by a consensus of experts in 1992, a switch was made to another one based on a compilation of clinical studies that included a large number of patients We present a historical summary of the changes that the definition of sepsis and septic shock has undergone and the fundamentals of these changes The latest publication in 2016, despite being a gigantic achievement, has been the subject of ample questions that show that the definition of sepsis is still under construction The present text aims to review the basic aspects of sepsis from its definition, the immunity in sepsis, and the implementation of biomarkers and their actual usefulness We also reviewed the cost and overall impact of sepsis as well as the total economic cost of antibiotic resistance Estimates vary but have ranged as high as $20 billion in excess direct healthcare costs, with additional costs to society for lost productivity as high as $35 billion a year (2008 dollars) We present the extent of diagnostic imaging in the workup of sepsis, organ dysfunction, and mechanisms of resistance The information we obtain and extract from the antibiogram has a great clinical and epidemiological impact, because, on one hand, it serves as a guide to choose the antimicrobial treatment in an infectious process and, on the other hand, it avoids the use of other antibiotics in an unnecessary way, thus leading to a reduction in the ecological impact vii viii Preface In one chapter, we develop the antibiogram and its objective, importance, and interpretation in the health environment Finally we review the n­ on-­antibiotic management of sepsis and septic shock, the new strategies for training high-­performance teams, and the role of simulation in sepsis We hope that this text will be useful to the kind readers and generates such a concern that will allow us all to diminish the great uncertainty existing about a pathology as old as not yet known Bogotá, Colombia Cartagena, Colombia Guillermo Ortiz-Ruiz Carmelo Dueñas-Castell Contents Sepsis: A Definition Under Construction    1 Carmelo Dueñas-Castell, Guillermo Ortiz-Ruiz, and Diana Borré-Naranjo Economic Impact of Infections and Antibiotics   11 Nelson Alvis-Guzman, Fernando De la Hoz-Restrepo, and Hernando Pinzon-Redondo Immunity in Sepsis   25 Nelson Javier Fonseca-Ruiz Biomarkers in Sepsis   39 Mario Lora-Andosilla, Kevin Cantillo-García, Diana Borré-Naranjo, Melkis Buelvas-Villalba, Guillermo Ortiz-Ruiz, and Carmelo Dueñas-Castell Diagnostic Imaging in Sepsis of Pulmonary Origin   51 Jorge Alberto Carrillo-Bayona and Liliana Arias-Alvarez Multiorgan System Failure in Sepsis   67 Marco A Gonzalez and Cristhiaan D Ochoa 7 Resistance Mechanisms: A Problem and an Approach to the Solution   73 Gerson Arias-León 8 Interpretive Reading of the Antibiogram: A Tool for Clinical Practice   95 Wilfrido Coronell-Rodríguez, Cindy Arteta-Acosta, and Carmelo Dueñas-Castell 9 Sepsis Management: Non-antibiotic Treatment of Sepsis and Septic Shock  117 Manuel Garay-Fernández ix x Contents 10 New Strategies for Training High-Performance Teams  135 Carolina Martínez-Esparza, Andrea Martínez de la Vega Celorio, and Rodrigo Rubio-Martínez 11 Simulation and Sepsis: What Is the Best Evidence?  151 Guillermo Ortiz-Ruiz, José M Maestre, Demian Szyld, Ignacio Del Moral, Jenny W Rudolph, and Germán Díaz Index  167 Contributors Liliana Arias-Alvarez  Hospital Universitario San Ignacio, Bogotá, Colombia Nelson  Alvis-Guzman, MD, MPH, PhD  Health Economics Research Group, Universidad de Cartagena, Avenida del consulado Campus Piedra de Bolivar, Cartagena, Bolivar, Colombia Universidad de la Costa, Barranquilla, Colombia Mario Lora-Andosilla  Internal Medicine, Critical Medicine and Intensive Care, Universidad de Cartagena, Cartagena, Colombia Cindy  Arteta-Acosta  MPH Epidemiology, Universidad del Norte, Barranquilla, Colombia Medicine Universidad de Cartagena, Cartagena, Colombia Jorge Alberto Carrillo-Bayona  Department of Diagnostic Imaging, Universidad Nacional de Colombia, Bogotá, Colombia Diana  Borré-Naranjo  Internal Medicine, Critical Medicine and Intensive Care, Universidad de Cartagena, Cartagena, Colombia Wilfrido Coronell-Rodríguez  Pediatrician, Universidad del Valle, Cali, Colombia Infectious disease Universidad Autonoma de Mexico, Mexico City, Mexico Professor of Universidad de Cartagena, Tropical Medicine Universidad de Cartagena, Cartagena, Colombia Germán Díaz  Hospital Santa Clara, Universidad el Bosque, Bogotá, Colombia Carmelo Dueñas-Castell  Postgraduate Program in Critical Medicine and Intensive Care, Universidad de Cartagena, Intensive Care Unit, Gestion Salud, Cartagena, Bolivar, Colombia Universidad del Bosque, Bogotá, Colombia Critical Care Medicine, Universidad de la Sabana, Cundinamarca, Colombia Carolina Martínez-Esparza  ABC Medical Center, Mexico City, Mexico xi 11  Simulation and Sepsis: What Is the Best Evidence? 157 Chih-Huang Li et al evaluated teaching based on simulation during a medical training to improve clinical knowledge of therapies used in severe sepsis and septic shock by a 21-item checklist, an 18-question test before the intervention, 18 questions at the end of the intervention, and 2 weeks after the intervention A 57% rate of pretest correct answers was found; the first and second posttests rated 85% and 80% This study does not show well-established limitations and concludes that simulation can improve clinical experience in the management of severe sepsis and septic shock [45] The last study compared a short course of acquisition of knowledge (1.5 days) vs 1.5 days of simulation and no intervention in medical students, to improve skills in situations of crisis scenarios, using the Situation Awareness Global Assessment Technique (SAGAT) method that consists of questionnaires that measure perception, awareness, or anticipation A checklist for clinical performance was also made The Likert 6-point scale was used besides a previous test (14 days before training) and days after the intervention No limitations were described It was noted that none of the interventions were satisfactory to improve the clinical management of resuscitation in sepsis [46] The articles that were included were evaluated separately, and two of them were excluded by the quality evaluation method (Table 11.2) The use of scores that identified adequate and poor performance levels [47], as well as the usefulness of the mannequin in the development of competencies, related with the early management of the septic patient [48] In the first study of Table 11.2, the rate of correct answers on the pretests was 64% and 60% during the evaluation of competencies, while it increased to 83% after the simulation training [47] The 16-item check system was used in the technical part, with an average of seven items In the nontechnical part, the average was 26 out of 35 items, with a high degree of correlation between the technical and the nontechnical parts These scores can establish the high and low degree of skills and knowledge of the students [48] Discussion Simulation is a useful tool used in teaching basic and clinical sciences, as well as surgical procedures [49–51] However, there are some beliefs that limit its use in certain scenarios Simulation is one of the most promising new methods from the cognitive perspective and could be potentially effective [52, 53] A limited number of studies that could answer the main question of this study were found This was probably due to the fact that simulation is a relatively new field requiring more research, not only in sepsis, but also in other scenarios such as coronary syndrome, trauma, and acute respiratory distress syndrome, among others All the studies of this review were epidemiological, observational, analytic, ­longitudinal, of cohorts, and prospective These studies intend to compare the Mah et al Simul Healthcare 2009 USA [47] Authors Journal Year Country Ottestad el at Crit Care Med 2007 USA [46] Objective To develop a scoring system capable of evaluating the management of septic shock, at the individual and group levels Simulation performed by multidisciplinary teams of physicians through mannequin-­ based simulations can improve adherence to measure bundles, by identification of errors with regard to focusing on sepsis This reinforces knowledge and identifies other possible causes of poor results Title Evaluating the management of septic shock using patient simulation Mannequin simulation identifies common surgical intensive care teamwork errors long after introduction of sepsis guideline Prospective cohort study/74 clinicians Study design/ number of participants Retrospective cohort study/ residents of medicine, surgery, and anesthesiology who rotated in intensive care Measurement or method With regard to the management of septic shock, both technical (management guidelines) and nontechnical (team leadership, communication, contingency plans, and use of resources) aspects were evaluated 1-Introduction about sepsis bundles in the hospital 2-Each team was given a training bundle in the treatment of sepsis before the training Twelve teams went through a simulation based on a mannequin of a patient with septic shock The sepsis bundles were evaluated in real time The sessions were recorded on video and analyzed with the team in a debriefing Conclusions Objective measurements of the aptitudes and behavior based on knowledge pertaining to the management of septic shock were carried out The scores identified adequate and poor levels of performance The way the different tasks are carried out during mannequin simulation cannot be explained by insufficient knowledge on the pretest Simulation based on mannequins can be a useful tool in the identification and exploration of these unknown factors Table 11.2  Summary of the main characteristics of the studies that were not included due to low STROBE scores 14 2B Evaluation STROBE of the intervention score 13 158 G Ortiz-Ruiz et al 11  Simulation and Sepsis: What Is the Best Evidence? 159 f­ requency of a certain outcome between two populations, where one is exposed to a certain exposure factor, in this case education through simulation vs other techniques, establishing as outcome of the adherence to the Surviving Sepsis Campaign recommendations The populations were selected as a function of the presence of a certain characteristic, which for the researchers was to be an undergraduate or graduate medical student under training [54] They have previously been used to put in evidence the advantages of simulation, like in this study, whose objective was to determine whether training based on simulation in the insertion of the central venous catheter reduces the incidence of catheter-­related infection It was an observational cohort study in the adult intensive care unit of a university hospital, in which 92 residents of medicine participated The rates of catheter-related infection before the simulation-based educational intervention were compared over a 32-month period There were lower rates of catheter-associated infection after training with simulator (0.50 infections per 1.000 catheter days), compared with the rates found in the same unit before the intervention (3.20 per 1.000 catheter days) (p = 0.001) and compared with the rates found in another intensive care unit of the same hospital during the entire study period (5.03 per 1.000 catheter days) (p = 0.001) The authors concluded that the educational intervention on the insertion of the central venous catheter significantly improves patient outcomes [55] Randomization was used to distribute the population into the study groups, which guarantees that the groups are comparable and homogeneous, that the researcher bias is avoided, and that statistical significance is increased Only two of the studies under analysis were randomized None was masked; only one was multicenter Including several centers in a study allows for rapidly increasing the number of participants, besides having more possibilities of applying the results to different populations These techniques are also common in studies supporting simulation, such as this one, which evaluated the effect of virtual reality training vs a real laparoscopic operation It was a controlled, prospective, randomized, masked clinical trial, carried out in seven gynecology departments within a region of Denmark, in which 24 first- and second-year residents of gynecology and obstetrics were included The group trained by simulator (n = 11) reached a median total score of 33 points (interquartile range 32–36 points), which is equal to the experience acquired after 20–50 laparoscopic procedures, while the control group (n = 10) reached a median total score of 23 points, which is equal to the experience acquired in less than five procedures (p