脓毒性休克1 h集束化治疗在急诊中的实施情况及预后分析

Implementation ofsepsis 1-hour bundle strategy for patients with septic shock in emergency department:a prognosis analysis

目的明确脓毒性休克患者1 h集束化治疗在急诊科的实施情况及其对预后的影响。方法本研究为回顾性队列分析,纳入2021年9月1日至2023年8月31日期间东南大学附属中大医院急诊医学科收治的脓毒性休克患者为研究对象。脓毒症、脓毒性休克的诊断标准与1 h集束化治疗措施均按照2021版拯救脓毒症运动(surviving sepsis campaign,SSC)指南确定。按1 h集束化治疗措施是否完全执行到位分为完成组和未完成组,收集患者年龄、性别、基础疾病和预后指标等临床资料,行SOFA评分和APACHEⅡ评分。共526例急诊患者被诊断为脓毒性休克,经筛选后最终纳入316例进行后续分析。统计处置采用SPSS 23.0软件。结果研究纳入人群的中位年龄为71.0岁,男性占52.8%。原发感染主要为肺部、胆道系统和腹腔。在纳入的患者中,仅15.5%患者完全执行了1 h集束化治疗,进入完成组;其余84.5%患者均存在不同程度的执行未到位情况,其中液体复苏未执行到位占74.37%(235/267),其次是未在使用抗菌药物前留取了血培养占46.84%(148/267)和未使用广谱抗菌药物占38.61%(122/267)等。本组患者中,住院天数中位数10 d,住院期间病死率为32.8%(104/316)。完成组与未完成组比较,ICU入住率、住院天数和住院病死率差异无统计学意义(P>0.05);2条以上未完成的住院病死率(35.2%),高于仅一条未完成组(32.5%),但差异无统计学意义(P>0.05)。结论脓毒性休克1 h集束化治疗在急诊实施达标率较低,多条治疗措施未完善与预后不良有关,需加强相关质量管理培训。

Objective To clearly identify the clinical practice and outcome of 1-hour bundle of sepsis in emergency department.Methods A retrospective cohort analysis was carried out in this study.Patients with septic shock who had been admitted to the emergency department of Zhongda Hospital Affiliated to Southeast University between September 1,2021 and August 31,2023 were included.The diagnosis of sepsis or septic shock was according to the criteria of sepsis and septic shock from 2021 Surviving Sepsis Campaign Guidelines.The study subjects were divided into completed group and incompleted group according to that 1-hour bundle was performed or not.Pertinent clinical data including patients’age,gender,basic diseases and clinical prognosis were collected.Furthermore,SOFA and APACHEⅡscoring were performed in each patient.Statistical software SPSS 23.0 was used for analysis.Results A total of 526 emergency patients were diagnosed with septic shock during the study period.316 patients were included in the final analysis after screening.The median age of the whole population was 71.0 years and 52.8%were male.The most frequent primary sites of infection were pulmonary,the biliary system and the abdomen.In enrolled patients,the 1-hour bundle was performed in only 15.5%who were included in the completed group.Among the remaining patients,there was one and more treatments was not finished.Fluid resuscitation(74.37%,235/267)ranked the first place.Secondly,blood culture was conducted before using antibiotics(46.84%,148/267).Broad-spectrum antimicrobial agents using was the third common unfinished treatment.A total of 104(32.8%)patients with septic shock died during hospitalization and the median length of hospital stay was 10 days.There were no significant statistical differences in ICU hospitalization,length of hospital stay and hospital mortality between the completed group and the incompleted group.Compared with only one therapy unfinished group,the hospital mortality of two or more unfinished group was increased(35.2%vs.32.5%),but without statistical differences hospital mortality(P>0.05).Conclusion The compliance rate of sepsis 1-hour bundle therapyis still relatively low in emergency department.A poor prognosis may be associated with delays to the initiation of 1-hour bundle therapy.Improvements require further training and quality management for sepsis 1-hour bundle therapy.