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The Role of Source Control in Septic Patients.

To the Editor: In a recent issue of Critical Care Medicine, we read with interest the article by Martínez et al (1) who investigated the importance of source control in patients with severe sepsis and septic shock. The authors analyzed 3,663 patients with sepsis and septic shock, including 1,173 patients who required surgical or percutaneous source control, and demonstrated that the hospital and ICU mortality of patients requiring source control were lower than that of patients not requiring source control even after adjusting for possible confounders. In addition, the timing of source control did not affect the survival outcome, which contradicts the recent surviving sepsis campaign guidelines suggesting the benefits of performing earlier (< 12 hr) source control. However, several factors that might have affected the reported results should be addressed. First, as indicated in Table 1, almost all patient baseline characteristics were significantly different between patients requiring source control and those not requiring source control. This indicates that the two groups were fundamentally incomparable even after adjusting for available confounders using a sophisticated statistical approach, leading to the conclusion that the results in Tables 3 and 4 and Table S1 are not acceptable. Data analysis aiming at revealing associated factors, after stratification by performance with or without surgical source control (2), would be feasible. Second, the authors showed hospital mortality was lower in patients with source control. However, the large sample size to indicate that these ICU Liberation concepts (www.iculiberation.org) apply to a broad swath of critically ill patients and not just a narrow group. Indeed, we had a lower percentage of patients on mechanical ventilation (23.7%) relative to that of the landmark study by Balas et al (3) (63.2%). When one considers the actual n studied rather than the percentile, our investigation included nearly eight times the number of ventilated patients as the study by Balas et al (3) (1,438 vs 187, respectively). It is nice that when expanded to a sample size this large, both studies found such consistency in message regarding the benefits of this evidence-based approach to implementation of the Pain, Agitation and Delirium (PAD) guidelines for ICU patients. Additionally, our multivariable analysis adjusted for the presence of mechanical ventilation and severity of illness (Acute Physiology and Chronic Health Evaluation III). Thus, our data represent the most robust analysis to date of the relationship between the ABCDEF bundle and outcomes in both ventilated and nonventilated ICU patients. In 2015, the “A” element of the bundle was revised to indicate the initial assessment, prevention, and management of pain (4, 5) to reflect more explicitly the PAD guidelines. Throughout our hospitals, pain was addressed daily on rounds via the C 2 (choice of drugs) bundle element, with an emphasis on analgosedation to achieve adequate pain control. We regret that data on this portion of the project were not recorded with the granularity requested to answer the authors' query, yet we consider this a springboard for inquiry by ongoing and future investigators. The inclusion of the “F” portion of the bundle was embraced by Sutter Health at the time that bundle implementation began. Subsequently, additional research studies have been undertaken, and guidelines (6) produced to help individual hospitals and ICUs better integrate the family into the care team. This integration is likely to take different forms based on the setting, patient population, and culture of patients and unit. In our study, the patient and family were de facto members of the interprofessional team, and as such, were invited to participate in ICU rounds each day. If the family was not present on rounds or declined, the “F” element could otherwise be satisfied if the patient or family engaged at another time of that same day in creation of their loved one’s care plan. Finally, the authors ask to identify which of the ABCDEF bundle elements were found most beneficial. The science and philosophy of bundles (whether in airline industry or medicine) are that the combination and coordinated delivery of all bundle elements provide the greatest benefit. For example, it is not possible to perform a delirium assessments or a successful spontaneous breathing trials or mobilize patients well if they are comatose from over-sedation. These clinical elements are so inextricably linked and interdependent on each other that we do not have confidence mathematically that it would be relevant or doable to tease out the relative importance of one element over another. In keeping with the conclusion of the 51 hospital Keystone project authors’ recent article, these data represent “another layer of evidence that for the ABCDE[F]s, the whole is greater than the sum of the parts.” (7) Dr. Ely received support for article research from the National Institutes of Health. Dr. Barnes-Daly has disclosed that she does not have any potential conflicts of interest. DOI: 10.1097/CCM.0000000000002416 Mary Ann Barnes-Daly, MS, RN, CCRN, DC, Office of Patient Experience, Sutter Health Systems, Sacramento, CA; E. Wesley Ely, MD, MPH, FCCM, Vanderbilt University Medical Center, Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN