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Septic shock in intermediate care unit: Don’t play with
fire
Marc Leone, Sophie Medam, Djamel Mokart
To cite this version:
Marc Leone, Sophie Medam, Djamel Mokart. Septic shock in intermediate care unit: Don’t play
with fire. Anaesthesia Critical Care & Pain Medicine, Elsevier Masson, 2018, 37 (2), pp.109-110.
�10.1016/j.accpm.2018.02.006�. �hal-01791588�
Editorial
Septic
shock
in
intermediate
care
unit:
Don’t
play
with
fire
InFrance,theactivityof intensivecareunits isframed bya DecreeLaw(De´cretn82002-466du5avril2002,articleR. 6123-35),whichdemandsthatintensivecareunits(ICU)aretheunits wherepatientswithreversiblemultipleorganfailureshouldbe hospitalised.ThisDecree Lawstatesthatthenurse:patientratio mustbeat2:5.ThepublicationofthisDecreeLawrepresenteda realprogressforthegoodofourpatients.
TheliteratureshowsthatincreasingthenursestaffinginICUis associated withimprovedpatient outcomes.Commonly,a high proportionofhoursofnursingcareenhancesthelevelofcarefor hospitalisedpatients[1].Inanobservational,prospective study, Hugonnetet al. suggestedthat 26.7% of all infectionscould be avoided if the nurse-to-patient ratio was above 2.2 [2]. In a retrospective analysis, Needleman et al. found that a reduced registerednursestaffingwasassociatedwithincreasedmortality [3]. Inthesame line, insurgicalward, an increasein a nurses’ workload by one patient was associated with an increased likelihoodofinpatientdyingwithin30daysofadmission by7% [4]. Hence, the workload of nurses is critical for the patient’s outcome.InICU,aratioabove2to3patientspernursedoesnot seemsafeforthequalityofcare[3,5].
InthesameLawDecree,itwasdemandedtoopenintermediate careunitsinmostinstitutions.AtvariancewithICU,theseunits havetomanagestablepatientsatpotentialriskoforganfailure.The nurse:patientratioappearslessclearlyinthoseunits,butscientific societiesrecommenda1:4ratio(http://www.cnerea.fr/UserFiles/ File/national/documents/referentiels/referentiel-usc-definitif.pdf).
Inaninterestingstudy,Meaudreet al. showedthat among 59patientswithsepticshocktreatedinanintermediatecareunit, only16(27%)patientsrequiredtobetransferredtotheintensive careunit[6].Theteamshouldbecongratulatedforthisstudy.The levelofcareseemsexcellentintheirinstitution.Thecompliance to3-hbundleswasremarkable,mostproceduresrangingfrom 90% to 100% rate, the nurse:patient ratio in this unit being, accordingtoguidelines,at1:4.Theseresultsareinlinewitha previousstudyshowingthatthemanagementofelderlypatients
withsepticshock inintermediatecareunitsresultedin better survivalthanexpected[7].
However,thereadersshouldpayattentionbeforetranslating those findings into their institution. First, in this study, the intermediatecareunitandICUworktogetherasthetwopiecesofa puzzle. Admission to intermediate care unit was deliberate in around70%ofcases,but transferbetweenthetwounitsseems constantly a possible option. Of note, 27% of patients were transferredtoICU duringthestudyperiod. Second,theauthors selected a specific, elderly population, in which limits to life-sustaining therapy wereidentified inaround 20% ofcases. The intensityofsepticshockwasprobablymoderateashighlightedthe plasmalactateconcentrations(2.1(2.4)mmol/l)andtheseverity scores.Itseemsthatthevascularfailurewaspredominantinthose patients, without effect on the respiratory system. Only the patientsexhibitingarapidlactateclearance,eveniftheresultdid not reach a significantlevel (P=0.08),were maintained in the intermediate careunit.Moreover, themortalityrateofpatients admittedtointermediatecareunitwasrelativelylow(28.8%),as comparedwiththatofpatientswithsepticshock[8,9].Thus,the conclusionsofthisstudyshouldnotbemisinterpreted.Admission to intermediate careunit remains possible in selectedpatients withsepticshockbutthisstrategyrequiresahighlevelofexpertise intheselection,care,andmanagementofpatients.Thepatients who do not respond to initial care should be immediately transferredtotheclosestICU.Insuchsituation,nurseeducation isthecornerstonefortheearlydecisionofICUtransfer.Infact,it hasbeenshownthatasimplescreeningtoolforsepsisusedaspart ofnursingassessmentrepresentsausefulwayofidentifyingearly sepsis evolution in both medical and surgical patients in an intermediatecareunitsetting[10].
Despitetheselimitations,theseresultsshouldbeconsidered withattentionbecausetheyopennewhorizonsforthe manage-mentofcriticallyillpatients.Somewhere,theysuggestthatwecan resuscitate patients outside thewalls of ICU. In the same line, Hallengrenetal.showedthat,inpatientsadmittedtointermediate care unit, norepinephrine can be initiated on a peripheral line [7].ThistypeofmanagementcouldbeusefulduringtimesofICU bedshortage[11],ortoavoidovercrowdingICUwithpatientswho donotrequirethislevelofcare.Thisalsoservestounburdenthe conventional wards to intermediate severity patients, avoiding delayingtheinitiationoftreatmentsbyanadequatescreeningof septicsigns[10].
Inconclusion,weshouldkeepinmindthatthequalityofcare largelydependsonthenursestaffing.Increasingtheworkloadof nurseswouldresultinpooroutcomesforourpatients,andtreating AnaesthCritCarePainMed37(2018)109–110
ARTICLE INFO
Keywords:
Intermediatecareunit Workload
Septicshock Care
https://doi.org/10.1016/j.accpm.2018.02.006
2352-5568/ C 2018Socie´te´ franc¸aised’anesthe´sieetdere´animation(Sfar).PublishedbyElsevierMassonSAS.Allrightsreserved.
patientswithsepticshockinintermediatecareunitcanrepresenta setback.However,themeritoftheexcellentstudyofMeaudreetal. isprobablytoshowthatvascularfailureinelderlysepticpatients canbetreatedwithoutdelay,outsidetheICUwalls,especiallyin thecontextofICUbedshortage.
Disclosureofinterest
Theauthorsdeclarethattheyhavenocompetinginterest. References
[1]NeedlemanJ,BuerhausP,MattkeS,StewartM,ZelevinskyK.Nurse-staffing levelsandthequalityofcareinhospitals.NEnglJMed2002;346:1715–22.
[2]HugonnetS,ChevroletJC,PittetD.Theeffectofworkloadoninfectionriskin criticallyillpatients.CritCareMed2007;35:76–81.
[3]NeedlemanJ,BuerhausP,PankratzVS,LeibsonCL,StevensSR,HarrisM.Nurse staffingandinpatienthospitalmortality.NEnglJMed2011;364:1037–45. http://dx.doi.org/10.1056/NEJMsa1001025.
[4]AikenLH,SloaneDM,BruyneelL,VandenHeedeK,GriffithsP,BusseR,etal. NursestaffingandeducationandhospitalmortalityinnineEuropean coun-tries:aretrospectiveobservationalstudy.Lancet2014;383:1824–30.http:// dx.doi.org/10.1016/S0140-6736(13)62631-8.
[5]AmaravadiRK,DimickJB,PronovostPJ,LipsettPA.ICUnurse-to-patientratiois associatedwithcomplicationsandresourceuseafteresophagectomy. Inten-siveCareMed2000;26:1857–62.
[6]MeaudreE,NguyenC,ContargyrisC,MontcriolA,d’ArandaE,EsnaultP,etal. Managementofsepticshockinintermediatecareunit.AnaesthCritCare PainMed2017.http://dx.doi.org/10.1016/j.accpm.2017.07.004 [pii:S2352-5568(16)30122-9].
[7]HallengrenM,A˚strandP,EksborgS,BarleH,FrostellC.Septicshockandtheuse ofnorepinephrineinanintermediatecareunit:Mortalityandadverseevents. PLoSOne2017;12:e0183073.http://dx.doi.org/10.1371/journal.pone.0183073. [8]MedamS,ZieleskiewiczL,DuclosG,BaumstarckK,LoundouA,AlingrinJ,etal. Riskfactorsfordeathinsepticshock:aretrospectivecohortstudycomparing trauma and non-trauma patients. Medicine (Baltimore) 2017;96:e9241. http://dx.doi.org/10.1097/MD.0000000000009241.
[9]AuchetT,RegnierMA,GirerdN,LevyB.Outcomeofpatientswithsepticshock and high-dose vasopressor therapy. Ann Intens Care 2017;7:43. http:// dx.doi.org/10.1186/s13613-017-0261-x.
[10]GyangE,ShiehL,ForseyL,MaggioP.Anurse-drivenscreeningtoolfortheearly identificationofsepsis inanintermediate careunitsetting.J HospMed 2015;10:97–103.http://dx.doi.org/10.1002/jhm.2291.
[11]OrsiniJ,BlaakC,YehA,FonsecaX,HelmT,ButalaA,etal.Triageofpatients consultedforicuadmissionduringtimesoficu-bedshortage.JClinMedRes 2014;6:463–8.http://dx.doi.org/10.14740/jocmr1939.
MarcLeone*,SophieMedam Departmentofanaesthesiaandintensivecare,hoˆpitalNord, Aix-Marseilleuniversite´,AP–HM,chemindesBourrely,13015Marseille, France DjamelMokart Departmentofanaesthesiaandintensivecare,institutPaoli-Calmettes, 13009Marseille,France *Correspondingauthor E-mailaddress:marc.leone@ap-hm.fr(M.Leone).
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