Moreover, we sought to assess if such a project sellectchem could improve the outcome of patients with severe sepsis/septic shock admitted to an intensive care unit (ICU).Materials and methodsDesign, setting and populationThis prospective observational study enrolled consecutive patients with a diagnosis of severe sepsis/septic shock admitted to an ICU of the 780-bed University Hospital of Modena from January 2005 to June 2007. The study was approved by the local ethical committee and the need for informed consent was waived in view of the observational and anonymous nature of the study. The ICU consists of nine beds and approximately 800 adult patients are admitted annually (70% surgical patients). Staffing at any time consists of one attending physician, one resident physician and three to four nurses.

The inclusion criteria were: a) documented or suspected infection; b) two or more systemic inflammatory response syndrome criteria [13] and c) the onset of an organ dysfunction related to infection: gas exchange impairment (partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) < 250 mmHg), mean arterial pressure (MAP) below 65 mmHg, acute renal dysfunction (1.5-fold baseline creatinine increase or urine output < 0.5 ml/Kg/h for two hours), total bilirubin above 4 mg/dL, platelet count below 80,000 cells/mm3 (or a 100,000 cells/mm3 decrease) or lactate blood concentration above 4.0 mM. Patients with persistence of MAP below 65 mmHg after an adequate fluid infusion (see below) were classified as having septic shock.

Patients with severe decompensated chronic liver disease included in the waiting list for liver transplantation were excluded from the study.Data collectionData collection began one month after the start of an in-hospital educational program on sepsis (see below) and only the first episode of severe sepsis/septic shock was considered in each patient. The management of patients was evaluated by analysis of interventions and sepsis bundles [3]. We identified five resuscitation (6-hours bundle) and four management (24-hours bundle) interventions: blood cultures collection before antibiotic administration; empiric antibiotic therapy within three hours from diagnosis; control of infection source within six hours; adequate fluid resuscitation before vasopressor administration; central venous oxygen saturation (ScvO2) above 70% within six hours; blood glucose median below 150 mg/dL in the first 24 hours; low-dose hydrocortisone administration Dacomitinib in association with vasopressor support; recombinant human activated protein C (rhAPC) if administration indicated; plateau inspiratory pressure below 30 cmH2O in patients with acute lung injury (ALI)/adult respiratory distress syndrome (ARDS).