CHA Family Medicine Residency

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Number Needed to Treat in Severe Sepsis and Septic Shock to Save a Life = 4.

"7 out of 10" graphic

~3 of 10 people in the ICU are “non-survivors” of severe sepsis and septic shock. What can we do to maximize their chances?

Teaching Pearl: In severe sepsis and septic shock, only 7 out of 10 survive.  the NNT for antibiotics (in general is 4.)  There is good evidence to consider broadening coverage if: there are risk factors of surgery or prior antibiotic use.

The prevalence-adjusted pathogen-specific number needed to treat (PNNT) with appropriate antimicrobial therapy to prevent one patient death was lowest for MDR bacteria (multidrug-resistant bacteria) (PNNT = 20) followed by Candida species (PNNT = 34), methicillin-resistant Staphylococcus aureus (PNNT = 38), Pseudomonas aeruginosa (PNNT = 38), Escherichia coli (PNNT = 40), and methicillin-susceptible S. aureus (PNNT = 47).

Conclusions: Our results support the importance of appropriate antimicrobial treatment as a determinant of outcome in patients with severe sepsis and septic shock. Our analyses suggest that improved targeting of empiric antimicrobials for multidrug-resistant bacteria, Candida species, methicillin-resistant S. aureus, and P. aeruginosa would have the greatest impact in reducing mortality from inappropriate antimicrobial treatment in patients with severe sepsis and septic shock.

They note a few other risk factors identifies by multivariate logistic regression analysis as: resistance to cefepime, resistance to meropenem, and presence of multidrug resistance, but these are less useful clinically since they can only be determined post-hoc.

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CPR in elderly (worth a read)

Take home point: when obtaining code-status on patients, ask them the following question.

“Would you be interested in hearing the statistics from people your age who underwent CPR?”

A 2014 study that compiled the results of thousands-of-smaller-studies of close to half-a-million patients showed that:
More than half of the patients who survived CPR eventually died before hospital discharge.
In an MBTA bus of 50 identical patients who are elderly and received in-hospital CPR:
for 70 to 79 years old: About 9 out of 50 survive CPR and leave the hospital
for 80 to 89 years old: About 8 out of 50 survive CPR and leave the hospital
for 90 years and older: About 6 out of 50 survive CPR and leave the hospital
Data on social and functional outcome after surviving CPR were scarce and contradictory.

MBTA bus

Only about six to nine of you are getting off this bus before its final destination.”
(Disclaimer: this graphic is solely to illustrate the statistic, NOT to include in the counseling of your patients!)

Van Gijn, MS., et al. (2014) The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review. Age and Ageing. 43: 456–463

Background: physicians are frequently confronted with the question whether cardiopulmonary resuscitation (CPR) is a medically appropriate treatment for older people. For physicians, patients and relatives, it is important to know the chance of survival and the functional outcome after CPR in order to make an informed decision.
Methods: a systematic search was performed in MEDLINE, Embase and Cochrane up to November 2012. Studies that were included described the chance of survival, the social status and functional outcome after in-hospital CPR in older people aged 70 years and above.
Results: we identified 11,377 publications of which 29 were included in this review; 38.6% of the patients who were 70 years and older had a return of spontaneous circulation. More than half of the patients who initially survived resuscitation died in the hospital before hospital discharge. The pooled survival to discharge after in-hospital CPR was 18.7% for patients between 70 and 79 years old, 15.4% for patients between 80 and 89 years old and 11.6% for patients of 90 years and older. Data on social and functional outcome after surviving CPR were scarce and contradictory.
Conclusions: the chance of survival to hospital discharge for in-hospital CPR in older people is low to moderate (11.6– 18.7%) and decreases with age. However, evidence about functional or social outcomes after surviving CPR is scarce. Prospective studies are needed to address this issue and to identify pre-arrest factors that can predict survival in the older people in order to define subgroups that could benefit from CPR.
Keywords: CPR, geriatrics, inpatient, prognosis, systematic review, elderly