Abstract and Introduction
Abstract
Objectives: 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.
Design: 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.
Setting: Non-federal acute care hospitalizations from the Nationwide Inpatient Sample, 1998–2009.
Patients: 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.
Interventions: None.
Measurements and Main Results: 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.
Conclusions: 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.
Introduction
Population-based studies demonstrate that the case-fatality rate associated with severe sepsis has declined steadily during the past decade. Multiple explanations for this change have been posited, including implementation of Surviving Sepsis Campaign guidelines, reduction in nosocomial complications (e.g., venous thromboembolism, stress ulcer bleeding, ventilator-associated pneumonia, or pseudo-improvements (e.g., changing International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] coding practices, or earlier discharge of patients to long-term care hospitals).
Based on the results of a randomized controlled trial by Rivers et al, the Surviving Sepsis Campaign Guidelines recommend early (i.e., within 6 hr) resuscitation in severe sepsis and septic shock. Because measurement of central venous pressure (CVP) and central venous oxygen saturation requires insertion of a central venous catheter (CVC), guideline-recommended, early goal-directed therapy cannot be implemented accurately without a CVC. Thus, study of the CVC in septic shock presents a unique opportunity to evaluate the evolution of utilization patterns and patient outcomes associated with a medical intervention before and after release of supporting evidence and guidelines.
Although Rivers et al demonstrated lower mortality with use of early goal-directed therapy guided by measurements from a CVC, how widely CVCs are used and outcomes associated with CVC use in typical practice in the United States remain unknown. We evaluated nationwide trends in CVC placement and compared mortality associated with early placement of a CVC for patients with septic shock in the 4 years before and 7 years after the publication of the trial by Rivers et al. We hypothesized that early insertion of a CVC in septic shock has increased since publication of the Surviving Sepsis Campaign. Furthermore, we hypothesized that in-hospital mortality associated with early placement of a CVC in septic shock has decreased after evidence-based therapeutic goals based on CVC measurements became widely available in 2001.