Community-acquired septic shock:: early management and outcome in a nationwide study in Finland

Aim: To determine how the early treatment guidelines were adopted, and what was the impact of early treatment on mortality in septic shock in Finland. Methods: This study was a sub-analysis of a prospective observational investigation of severe sepsis and septic shock in Finland (Finnsepsis). All patients with severe sepsis over 4 months in 24 intensive care units were included in the Finnsepsis study. Patients with community-acquired septic shock, admitted directly from the emergency department to the intensive care unit, were included in the sub-study. The following treatment targets were evaluated: measurement of lactate during the first 6 h; analysis of blood culture before antibiotics; commencement of antibiotics within 3 h; attainment of a mean arterial pressure of >= 65 mmHg, central venous pressure of >= 8 mmHg and central venous oxygen saturation of >= 70% or mixed venous oxygen saturation of >= 65% during the first 6 h. Results: Of the 92 patients who fulfilled the inclusion criteria, six reached all treatment targets and 33 reached four or more targets (group >= 4). The hospital mortality of group >= 4 was 24% (8/33), compared with 42% (25/59) for those who reached three or fewer targets (group <= 3) (P = 0.08). The 1-year mortality rates of group >= 4 and group <= 3 were 36% and 59% (P = 0.04), respectively. In logistic regression analysis, a delayed initiation of antimicrobials was associated with an unfavourable outcome (P = 0.04). Conclusions: Compliance with international guidelines for the early treatment of septic shock was poor in Finnish hospitals. A failure to diagnose early and to start appropriate treatment was reflected in the high mortality. The delayed start of antibiotics was the most important individual variable leading to a high mortality in this nationwide study.