title: Clinical management for patients admitted to a critical care unit with severe sepsis or septic shock.
abstract: BACKGROUND
  The Surviving Sepsis Campaign promotes the use of norepinephrine as the first-line inotropic support for patients presenting with severe sepsis or septic shock in cases of persistent hypotension, despite adequate fluid resuscitation. However, there is little published evidence on how much noradrenaline is administered to such patients when admitted to the intensive care unit (ICU). The authors report the clinical management of this group of patients, with a special focus on the total amount and duration of norepinephrine infusion required.
  
  
  METHODS
  A chart review of the admission records of an ICU in Hong Kong was carried out in 2013. A total of 5000 patients were screened by their diagnosis of severe sepsis or septic shock (in the admissions book) between 1 January 2011 and 31 December 2013. A total of 150 of these were identified and 100 included in the study after simultaneous in-depth reviews of their case notes by two of the investigators. The analysis covers those with severe sepsis or septic shock who required ICU admission for further care. Clinical management and outcomes were analysed.
  
  
  RESULTS
  100 patients (median age 61.6; M/F ratio 2:1) met the inclusion criteria. The mean ICU stay was 13.4 days (range=1-371). 14 patients (14%) died in the ICU, with a 28-day mortality rate of 22%. The mean period of mechanical ventilation was 6.1 days (range=0-137). 91.5% (n=43) of patients had been operated on immediately before admission to the ICU, and the majority of these operations had been of the emergency type (97.7%, n=43). The mean total volumes of crystalloid and colloid administered were 3420ml and 478ml, respectively. The mean wean-off period for norepinephrine infusion was 4234minutes (70.5hours). All patients were prescribed norepinephrine for persistent hypotension despite adequate fluid resuscitation, and the mean total amount administered was 87,211mg. Final multiple linear and logistic regression analysis showed different clinical outcomes associated with different covariates, which included: (1) total amount of crystalloid given, positively associated with the total amount and duration of norepinephrine infusion; (2) duration of mechanical ventilation, positively associated with the type of operation the patient had undergone; (3) 28-day mortality rate, positively associated with the INR.
  
  
  CONCLUSIONS
  What this study adds to knowledge about patients suffering from severe sepsis or septic shock: (1) the mean duration of norepinephrine infusion for septic shock patients in an ICU is almost three days; (2) the more crystalloid is required to correct hypoperfusion, the higher the dosage and longer the duration of norepinephrine infusion will be necessary; (3) the longer the patient's INR, the higher the chances of death within 28 days. Since not all patients have their body weight measured on or after admission to the ICU, we suggest further research into indirect estimation of body weight by other means, such as anthropometric measures, to guide the use of drugs and nutritional support in the ICU. In addition, APACHE scores should be included in further studies to compare the severity of the patient's condition in other research. Furthermore, since this study does not cover university hospital ICUs, we suggest that further research concerning such patients should compare and reflect similarities and differences between public and university hospitals in the territory.
authors: School of Nursing, The University of Hong Kong, Hong Kong Special Administrative Region. Electronic address: alessi@hku.hk.
authors: Wai Keung
authors: WK
authors: Cheung
authors: Intensive Care Unit, Tuen Mun Hospital, Hong Kong Special Administrative Region. Electronic address: cls971@ha.org.hk.
authors: Lai Sheung
authors: LS
authors: Chau
authors: Intensive Care Unit, Tuen Mun Hospital, Hong Kong Special Administrative Region. Electronic address: mii672@ha.org.hk.
authors: Iun Ieng Laurinda
authors: II
authors: Mak
authors: Intensive Care Unit, Tuen Mun Hospital, Hong Kong Special Administrative Region. Electronic address: wmy315@ha.org.hk.
authors: Mei Yi
authors: MY
authors: Wong
authors: Intensive Care Unit, Tuen Mun Hospital, Hong Kong Special Administrative Region. Electronic address: wsl039@ha.org.hk.
authors: Sai Leung
authors: SL
authors: Wong
authors: School of Nursing, The University of Hong Kong, Hong Kong Special Administrative Region. Electronic address: afytiwar@hku.hk.
authors: Agnes Fung Yee
authors: AF
authors: Tiwari
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003422:Critical Care / Q000592:standards*; D064648:Critical Care Nursing / Q000592:standards; D005260:Female; D005440:Fluid Therapy / Q000401:mortality / Q000451:nursing; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000627:therapeutic use; D012121:Respiration, Artificial / Q000451:nursing / Q000706:statistics & numerical data; D018805:Sepsis / Q000401:mortality / Q000451:nursing*; D012772:Shock, Septic / Q000401:mortality / Q000451:nursing; D055815:Young Adult
chemical_list: D009638:Norepinephrine
keywords: Critical care nursing; Norepinephrine; Septic shock; Severe sepsis