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VOLUME 22 , ISSUE 12 ( 2018 ) > List of Articles


Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study

Bhawna Garg, Nirmal Kumar, Pooja Anthwal, Ayush Manchanda

Keywords : Lactate clearance, mortality, pediatric index of mortality-2 score, sepsis bundle, septic shock

Citation Information : Garg B, Kumar N, Anthwal P, Manchanda A. Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study. Indian J Crit Care Med 2018; 22 (12):852-857.

DOI: 10.4103/ijccm.IJCCM_147_18

License: CC BY-ND 3.0

Published Online: 01-06-2018

Copyright Statement:  Copyright © 2018; The Author(s).


Aim: The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock. Methodology: The study was conducted at a tertiary care hospital. Patients aged 1 month–13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged. Results: Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre- and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group. Conclusion: Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.

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  1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR, et al. Epidemiology of severe sepsis in the united states: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-10.
  2. Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003;31:946-55.
  3. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546-54.
  4. Linde-Zwirble WT, Angus DC. Severe sepsis epidemiology: Sampling, selection, and society. Crit Care 2004;8:222-6.
  5. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: A trend analysis from 1993 to 2003. Crit Care Med 2007;35:1244-50.
  6. Kissoon N, Argent A, Devictor D, Madden MA, Singhi S, van der Voort E, et al. World federation of pediatric intensive and critical care societies-its global agenda. Pediatr Crit Care Med 2009;10:597-600.
  7. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.
  8. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-73.
  9. Levy MM, Pronovost PJ, Dellinger RP, Townsend S, Resar RK, Clemmer TP, et al. Sepsis change bundles: Converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med 2004;32:S595-7.
  10. Dellinger RP, Vincent JL. The surviving sepsis campaign sepsis change bundles and clinical practice. Crit Care 2005;9:653-4.
  11. Gao F, Melody T, Daniels DF, Giles S, Fox S. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: A prospective observational study. Crit Care 2005;9:R764-70.
  12. Castellanos-Ortega A, Suberviola B, García-Astudillo LA, Holanda MS, Ortiz F, Llorca J, et al. Impact of the surviving sepsis campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study. Crit Care Med 2010;38:1036-43.
  13. Noritomi DT, Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Leibel F, et al. Implementation of a multifaceted sepsis education program in an emerging country setting: Clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2014;40:182-91.
  14. Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, et al. Surviving sepsis campaign: Association between performance metrics and outcomes in a 7.5-year study. Crit Care Med 2015;43:3-12.
  15. Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, et al. Effect of performance improvement programs on compliance with sepsis bundles and mortality: A systematic review and meta-analysis of observational studies. PLoS One 2015;10:e0125827.
  16. Nguyen HB, Corbett SW, Steele R, Banta J, Clark RT, Hayes SR, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality. Crit Care Med 2007;35:1105-12.
  17. Girardis M, Rinaldi L, Donno L, Marietta M, Codeluppi M, Marchegiano P, et al. Effects on management and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: A pilot study. Crit Care 2009;13:R143.
  18. Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med 2013;14:686-93.
  19. Available from: [Last accsessed 2018 Mar 25].
  20. Phua J, Koh Y, Du B, Tang YQ, Divatia JV, Tan CC, et al. Management of severe sepsis in patients admitted to Asian intensive care units: Prospective cohort study. BMJ 2011;342:d3245.
  21. Samransamruajkit R, Uppala R, Pongsanon K, Deelodejanawong J, Sritippayawan S, Prapphal N, et al. Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP. Indian J Crit Care Med 2014;18:70-6.
  22. Rhodes A, Phillips G, Beale R, Cecconi M, Chiche JD, De Backer D, et al. The surviving sepsis campaign bundles and outcome: Results from the international multicentre prevalence study on sepsis (the IMPress study). Intensive Care Med 2015;41:1620-8.
  23. ARISE Investigators; ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506.
  24. Coba V, Whitmill M, Mooney R, Horst HM, Brandt MM, Digiovine B, et al. Resuscitation bundle compliance in severe sepsis and septic shock: Improves survival, is better late than never. J Intensive Care Med 2011;26:304-13.
  25. Bakker J, Gris P, Coffernils M, Kahn RJ, Vincent JL. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg 1996;171:221-6.
  26. Munde A, Kumar N, Beri RS, Puliyel JM. Lactate clearance as a marker of mortality in pediatric intensive care unit. Indian Pediatr 2014;51:565-7.
  27. Levy MM. Early goal-directed therapy: What do we do now? Crit Care 2014;18:705.
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