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.
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.
1 The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, MA.
2 Department of Medicine, Boston University School of Medicine, Boston, MA.
3 Center for Health Quality, Outcomes, & Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA.
4 The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH.
5 Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield, MA.
6 Department of Medicine, Tufts University School of Medicine, Boston, MA.
*See also p. 1577.
Dr. Walkey had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept, design, data acquisition, and statistical analysis were performed by Drs. Walkey and Soylemez Wiener. Analysis and interpretation of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content were performed by all the authors.
This work was performed at the Boston University School of Medicine.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).
Supported, in part, by K07 CA138772 (Dr. Soylemez-Wiener) and the Department of Veterans Affairs (Dr. Soylemez-Wiener). No funding organization had a role in the design or conduct of the study.
Dr. Walkey received grant support from the National Institutes of Health (NIH-R21 grant pending). Dr. Soylemez Wiener received grant support from NIH (CA 138772).
Dr. Walkey received support for travel from the Evans Center for Interdisciplinary Biomedical Research (Boston University young investigator Travel Award). Dr. Walkey is employed by the Boston University School of Medicine.
Dr. Lindenauer has disclosed that he does not have any potential conflicts of interest.
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