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Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study.

ABSTRACT: In 2001, a randomized trial showed decreased mortality with early, goal-directed therapy in septic shock, a strategy later recommended by the Surviving Sepsis Campaign. Placement of a central venous catheter is necessary to administer goal-directed therapy. We sought to evaluate nationwide trends in: 1) central venous catheter utilization and 2) the association between early central venous catheter insertion and mortality in patients with septic shock.We retrospectively analyzed the proportion of septic shock cases receiving an early (day of admission) central venous catheter and the odds of hospital mortality associated with receiving early central venous catheter from years 1998 to 2001 compared with 2002 to 2009.Non-federal acute care hospitalizations from the Nationwide Inpatient Sample, 1998-2009.A total of 203,481 (population estimate: 999,545) patients admitted through an emergency department with principal diagnosis of septicemia and secondary diagnosis of shock.None.From 1998 to 2009, population-adjusted rates of septic shock increased from 12.6 cases per 100,000 U.S. adults to 78 cases per 100,000. During this time, age-adjusted hospital mortality associated with septic shock declined from 40.4% to 31.4%. Early central venous catheter insertion increased from 5.7% (95% confidence interval 5.1% to 6.3%) to 19.2% (95% confidence interval 18.7% to 19.5%) cases with septic shock, with an increased rate of early central venous catheter placement identified after 2007. The rate of decline in age-adjusted hospital mortality was significantly greater for patients who received an early central venous catheter (-4.2% per year, 95% confidence interval -3.2, -4.2%) as compared with no central venous catheter (-2.9% per year, 95% confidence interval -2.3, -3.5%; p = 0.016). Hospital mortality associated with early central venous catheter insertion significantly decreased from a multivariable-adjusted odds ratio of 1.29 (95% confidence interval 1.14-1.45) prior to 2001 to an adjusted odds ratio of 0.87 (95% confidence interval 0.84-0.90) after 2001.Placement of a central venous catheter early in septic shock has increased three-fold since 1998. The mortality associated with early central venous catheter insertion decreased after publication of evidence-based instructions for central venous catheter use.

SUBMITTER: Walkey AJ

PROVIDER: S-EPMC3780984 | biostudies-literature | 2013 Jun

REPOSITORIES: biostudies-literature

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Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study.

Walkey Allan J AJ Wiener Renda Soylemez RS Lindenauer Peter K PK

Critical care medicine 20130601 6

<h4>Objectives</h4>In 2001, a randomized trial showed decreased mortality with early, goal-directed therapy in septic shock, a strategy later recommended by the Surviving Sepsis Campaign. Placement of a central venous catheter is necessary to administer goal-directed therapy. We sought to evaluate nationwide trends in: 1) central venous catheter utilization and 2) the association between early central venous catheter insertion and mortality in patients with septic shock.<h4>Design</h4>We retrosp ...[more]

PMID: 23507718

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Project description:Clinical guidelines recommend norepinephrine as initial vasopressor of choice for septic shock, with dopamine suggested as an alternative vasopressor in selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia. We sought to determine practice patterns and outcomes associated with vasopressor selection in a large, population-based cohort of patients with septic shock that allows for assessment of outcomes in clinically important subgroups.We performed a retrospective cohort study to determine factors associated with choice of dopamine as compared with norepinephrine as initial vasopressor for patients with septic shock. We used propensity score matching to compare risk of hospital mortality based on initial vasopressor. We performed multiple sensitivity analyses using alternative methods to address confounding and hospital-level clustering. We investigated interaction between vasopressor selection and mortality in clinical subgroups based on arrhythmia and cardiovascular risk.Enhanced administrative data (Premier, Charlotte, NC) from 502 U.S. hospitals during the years 2010-2013.A total of 61,122 patients admitted with septic shock who received dopamine or norepinephrine as initial vasopressor during the first 2 days of hospitalization.None.Norepinephrine (77.6%) was the most frequently used initial vasopressor during septic shock. Dopamine was preferentially selected by cardiologists, in the Southern United States, at nonteaching hospitals, for older patients with more cardiovascular comorbidities and was used less frequently over time. Patients receiving dopamine experienced greater hospital mortality (propensity-matched cohort: n = 38,788; 25% vs 23.7%; odds ratio, 1.08; 95% CI, 1.02-1.14). Sensitivity analyses showed similar results. Subgroup analyses showed no evidence for effect modification based on arrhythmia risk or underlying cardiovascular disease.In a large population-based sample of patients with septic shock in the United States, use of dopamine as initial vasopressor was associated with increased mortality among multiple clinical subgroups. Areas where use of dopamine as initial vasopressor is more common represent potential targets for quality improvement intervention.

Project description:BackgroundAn increase in the incidence of central venous catheter (CVC)-associated deep venous thrombosis (CADVT) has been reported in pediatric patients over the past decade. At the same time, current screening guidelines for venous thromboembolism risk have low sensitivity for CADVT in hospitalized children. This study utilized a multimodal deep learning model to predict CADVT before it occurs.MethodsChildren who were admitted to intensive care units (ICUs) between December 2015 and December 2018 and with CVC placement at least 3 days were included. The variables analyzed included demographic characteristics, clinical conditions, laboratory test results, vital signs and medications. A multimodal deep learning (MMDL) model that can handle temporal data using long short-term memory (LSTM) and gated recurrent units (GRUs) was proposed for this prediction task. Four benchmark machine learning models, logistic regression (LR), random forest (RF), gradient boosting decision tree (GBDT) and a published cutting edge MMDL, were used to compare and evaluate the models with a fivefold cross-validation approach. Accuracy, recall, area under the ROC curve (AUC), and average precision (AP) were used to evaluate the discrimination of each model at three time points (24 h, 48 h and 72 h) before CADVT occurred. Brier score and Spiegelhalter's z test were used measure the calibration of these prediction models.ResultsA total of 1830 patients were included in this study, and approximately 15% developed CADVT. In the CADVT prediction task, the model proposed in this paper significantly outperforms both traditional machine learning models and existing multimodal deep learning models at all 3 time points. It achieved 77% accuracy and 90% recall at 24 h before CADVT was discovered. It can be used to accurately predict the occurrence of CADVT 72 h in advance with an accuracy of greater than 75%, a recall of more than 87%, and an AUC value of 0.82.ConclusionIn this study, a machine learning method was successfully established to predict CADVT in advance. These findings demonstrate that artificial intelligence (AI) could provide measures for thromboprophylaxis in a pediatric intensive care setting.

Project description:ObjectiveCrowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).MethodsWe conducted a retrospective observational study from 2008-2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU.ResultsOf 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08).ConclusionIn a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

Project description:IntroductionVenous-to-arterial carbon dioxide difference (Pv-aCO2) may reflect the adequacy of blood flow during shock states. We sought to test whether the development of Pv-aCO2 during the very early phases of resuscitation is related to multi-organ dysfunction and outcomes in a population of septic shock patients resuscitated targeting the usual oxygen-derived and hemodynamic parameters.MethodsWe conducted a prospective observational study in a 60-bed mixed ICU in a University affiliated Hospital. 85 patients with a new septic shock episode were included. A Pv-aCO2 value ? 6 mmHg was considered to be high. Patients were classified in four predefined groups according to the Pv-aCO2 evolution during the first 6 hours of resuscitation: (1) persistently high Pv-aCO2 (high at T0 and T6); (2) increasing Pv-aCO2 (normal at T0, high at T6); (3) decreasing Pv-aCO2 (high at T0, normal at T6); and (4) persistently normal Pv-aCO2 (normal at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities at day-28 using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and Pv-aCO2. Finally, we calculated the mortality risk ratios at day-28 among patients attaining normal oxygen parameters but with a concomitantly increased Pv-aCO2.ResultsPatients with persistently high and increasing Pv-aCO2 at T6 had significant higher SOFA scores at day-3 (p < 0.001) and higher mortality rates at day-28 (log rank test: 19.21, p < 0.001) compared with patients who evolved with normal Pv-aCO2 at T6. Interestingly, a poor agreement between cardiac output and Pv-aCO2 was observed (r2 = 0.025, p < 0.01) at different points of resuscitation. Patients who reached a central venous saturation (ScvO)2 ? 70% or mixed venous oxygen saturation (SvO2) ? 65% but with concomitantly high Pv-aCO2 at different developmental points (i.e., T0, T6 and T12) had a significant mortality risk ratio at day-28.ConclusionThe persistence of high Pv-aCO2 during the early resuscitation of septic shock was associated with more severe multi-organ dysfunction and worse outcomes at day-28. Although mechanisms conducting to increase Pv-aCO2 during septic shock are insufficiently understood, Pv-aCO2 could identify a high risk of death in apparently resuscitated patients.

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Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study.

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Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study.

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