Outcome Of Septic Shock Patients Research Articles

Early Versus Late Initiation of Hydrocortisone in Patients With Septic Shock: A Prospective Study.

Introduction The optimal timing of corticosteroid initiation in septic shock patients is debatable. The Surviving Sepsis Campaign Guidelines recommended adding hydrocortisone to septic shock patients who require a vasopressor with a dose of norepinephrine ≥ 0.25 mcg/kg/min for at least four hours. Nevertheless, the best time to initiate hydrocortisone remains uncertain. Objective Assessing the impact of early (≤3 hours) versus late (>3 hours) initiation of hydrocortisone in septic patients. Methodology We compared the outcomes of septic shock patients who received hydrocortisone within three hours versus those who started treatment after three hours. The inclusion criteria encompassed septic shock patients aged 18 or older who received at least one dose of hydrocortisone. Exclusion criteria included pregnancy, do-not-resuscitate orders, the absence of empirical intravenous antibiotics, recent corticosteroid use, recent cardiac arrest, and a history of adrenal insufficiency. Results Eighty-one patients were included (54% were males). The mean age was 59 years, and 56.8% of patients were in the early group. The time needed to discontinue vasopressors was 25 and 37 hours for the early and late groups, respectively (p = 0.009), and more patients achieved reversal of shock (35 vs. 24 patients) and had shorter ICU stays (17 days vs. 20 days). Conclusion Initiating hydrocortisone early, within three hours, reduced the time needed to discontinue vasopressors among the study population. However, both early and late initiation strategies yielded comparable outcomes in terms of ICU mortality, ICU length of stay, and shock reversal.

Different Concentrations of Albumin Versus Crystalloid in Patients with Sepsis and Septic Shock: A Meta-Analysis of Randomized Clinical Trials.

The best type of resuscitation fluids for sepsis and septic shock patients remains unclear. The aim of this study was to evaluate the efficacy of different concentrations of albumin on reducing the mortality rate of theses patients by meta-analysis. PubMed, EMBASE, and Web of Science databases were used for screening the relevant studies. Randomized controlled trials (RCTs) were eligible if they compared the effects of albumin with crystalloid on mortality in patients with sepsis and septic shock. Data were examined and extracted by two reviewers independently. Any disagreements were resolved by consensus with or without the help from a third reviewer. Data including mortality, sample size of the patients, and resuscitation endpoints were extracted. Meta-analysis was carried based on the corresponding odds ratios with 95% confidence intervals. Eight studies with a total of 5124 septic patients and 3482 septic shock patients were included in this study. Compared with crystalloid, the use of albumin may represent a trend toward reduced the 90-day mortality of septic patients (OR 0.91 [0.80, 1.02]; P = .11) and significantly improved the outcome of septic shock patients (OR 0.85 [0.74, 0.99]; P = .04). Further analysis showed a potentially beneficial role of both 4% to 5% and 20% albumin on reducing the mortality of septic patients. The use of 20% albumin significantly decreased the 90-day mortality of septic shock patients (OR 0.81 [0.67, 0.98]; P = .03), which was better than 4% to 5% albumin and crystalloid. Albumin treatment, particularly 20% albumin, significantly reduced the 90-day mortality in septic shock patients. Both 4% to 5% and 20% of albumin may work better than crystalloid in improving the survival rate of patients with sepsis, but more relative RCTs are required for validation.

Effect of noradrenaline infusion in central venous catheter versus external jugular vein on the outcome of septic shock patients

Effect of noradrenaline infusion in central venous catheter versus external jugular vein on the outcome of septic shock patients

Outcome of Septic Shock Patients treated with Vitamin C and Thiamine: A Prospective Cohort Study

Outcome of Septic Shock Patients treated with Vitamin C and Thiamine: A Prospective Cohort Study

Abstract 212: The Effect Of 33 °C Vs. 36 °C Targeted Temperature Management To The Metabolism Following Out-of-hospital Cardiac Arrest.

Targeted Temperature Management (TTM) following shockable out-of-hospital cardiac arrest (OHCA) has been recommended. The effect of different targeted temperatures on the human metabolome has not been compared. Elevated levels of metabolites from the Krebs cycle have recently been associated with a poor outcome in OHCA patients. Similarly, decreased levels of the amino acids valine and leucine have been linked with a poor outcome in septic shock patients. Method: From a single center in the randomized clinical TTM trial, we analyzed blood samples from resuscitated unconscious OHCA patients at two timepoints (hospital arrival and 48 hours later) using ultra-performance liquid mass-spectrometry. Patients were randomized to either 33°C or 36°C hypothermia for the first 28 hours. Sixty-one metabolites of the ~3000 compounds detected were prespecified for quantification and analyzed in the current study. Differences (95% CI) in metabolite concentrations from a constrained linear mixed model are reported, and p-values from the interaction term timepoint x TTM arm. Results: Of the 146 patients, 70 (48 %) were randomized to TTM 33°C. The baseline characteristics (age, gender, shockable rhythm, time to return of spontaneous circulation) and outcome (180 days mortality) were similar in the TTM groups. After 48 hours, approx. 24 hours from the cessation of TTM, fourteen metabolites differed significantly between the two groups. Among these, lactate acid (190 μM (74-305 μM), p<0.001 ), pyruvic acid (26 μM (8-44 μM), p<0. 0 1 ), 2-oxoglutaric acid (2.7 μM (1.0-4.4 μM), p<0.01 ) and prostaglandin E2 (0.60 nM (0.24-1.0 nM), p<0.01 ) were increased in the TTM 33 °C arm whereas valine (25 μM (15-35 μM), p<0.001 ) and leucine (14 μM (8.3 - 20 μM), p<0.001 ) were decreased. Conclusion: TTM at 33°C for 24 hours after OHCA results in a prognostically poorer metabolome even 24 hours later compared with TTM at 36°C.

Effect of hydrocortisone on outcome of septic shock patients. A prospective observational study in a tertiary care ICU.

Introduction: Sepsis and septic shock have 10% and 40% mortality in ICU respectively. Early recognition and prompt management of septic shock in ICU can reduce mortality. Further, some studies have suggested that hydrocortisone can impact outcome of septic shock significantly. Methodology: We designed prospective observational study to evaluate the effect of hydrocortisone in septic shock patients. Septic shock was defined according to definition proposed by international consensus definition of septic shock 2016. We excluded those who were less than 18 years and receiving steroids for some other indication at the time of admission to ICU. Primary outcome was to determine mortality in ICU. Secondary outcome was to evaluate length of stay, vasopressor days, vasopressor free days and dose of norepinephrine. Results: We studied 208 cases of septic shock. Median age was 61 years. Out of 208 participants, 106 received hydrocortisone. Out of 102 cases who did not receive hydrocortisone, 56.7% died and 42.3% survived (p=<0.001). There was no effect of hydrocortisone on length of stay, vasopressor days, vasopressor free days (OR: 0.7,0.3,1.1), (p=0.98,0.92,0.93) respectively. Conclusion: We concluded that hydrocortisone reduces mortality in septic shock patients in ICU. Keywords: Sepsis, hypotension, hypovolemia, septic shock

Comparing the demographic data and outcomes of septic shock patients presenting to teaching or non-teaching metropolitan hospitals in the United States.

Studies looking at the effect of hospital teaching status on septic shock related in-hospital mortality are lacking. The aim of this study was to examine the effect of hospital teaching status on mortality in septic shock patients in the United States. This was a retrospective observational study, using the Nationwide Emergency Department Sample Database (released in 2018). All patients with septic shock were included. Complex sample logistic regression was performed to assess the impact of hospital teaching status on patient mortality. A total of 388,552 septic shock patients were included in the study. The average age was 66.93 years and 51.7% were males. Most of the patients presented to metropolitan teaching hospitals (68.2%) and 31.8% presented to metropolitan non-teaching hospitals. Septic shock patients presenting to teaching hospitals were found to have a higher percentage of medical comorbidities, were more likely to be intubated and placed on mechanical ventilation (50.5% vs. 46.9%) and had a longer average length of hospital stay (12.47 d vs. 10.20 d). Septic shock patients presenting to teaching hospitals had greater odds of in-hospital mortality compared to those presenting to metropolitan non-teaching hospitals (adjusted odd ratio [OR]=1.295, 95% confidence interval [CI]: 1.256-1.335). Septic shock patients presenting to metropolitan teaching hospitals had significantly higher risks of mortality than those presenting to metropolitan non-teaching hospitals. They also had higher rates of intubation and mechanical ventilation as well as longer lengths of hospital stay than those in non-teaching hospitals.

Effect of heart rate control with amiodarone infusion on hemodynamic and clinical outcomes in septic shock patients with tachycardia: a prospective, single-arm clinical study

BackgroundKeeping the heart rate within the normal range has improved the survival of septic shock patients. Amiodarone could target the underlying pathophysiology of sepsis-induced tachycardia. This study aimed to determine whether amiodarone is effective in controlling the heart rate in critically ill patients with septic shock and sustained tachycardia who were receiving vasopressor.MethodsIn this prospective, single-arm cohort study, 46 patients with septic shock and tachycardia were enrolled to receive a loading dose of amiodarone 150 mg, then continuous infusion of 1 mg/min. The primary outcome was the ability of amiodarone in rate control lower than 95 beats per minute (BPM) and maintaining it during 24-h study period. We also recorded the effect of amiodarone on hemodynamic indices as the secondary outcomes.ResultsThe results of the present study indicated a significant decrease in HR in septic shock patients for amiodarone, from 121.0 (116.5, 140.0) at baseline to 91.5(89.3, 108.0) at the end of the study period (p < 0.001). During the study period, a total of 26 (56.52%) of patients achieved the target heart rate lower than 95 BPM and maintained it during study period. Amiodarone decreased HR by 22.8 ± 13.7. While receiving amiodarone infusion, the values for heart rate, mean arterial pressure, cardiac index, norepinephrine infusion rate, and stroke volume index changed significantly between amiodarone initiation and 24-h follow-up (P < 0.001). Amiodarone was well tolerated, because this anti-arrhythmic agent did not increase the need for vasopressor and none of the patients experienced episodes of refractory hypotension.ConclusionThis study showed that amiodarone infusion successfully reduced the heart rate in sepsis-induced tachycardia. The patients had improved hemodynamic state as indicated by an increase in cardiac index and SVI.

DOES EARLY VASOPRESSOR USE IN SEPSIS RESULT IN BETTER OUTCOMES? A SYSTEMATIC REVIEW AND META-ANALYSIS

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Advancements in the management of septic shock have been significant over the past decade, however mortality rates still remain high. The latest sepsis guidelines recommend aggressive fluid therapy followed by vasopressor use in persistently hypotensive patients. The exact timing of vasopressor initiation remains unknown. Recent data suggests that there may be more benefit in starting vasoactive agents earlier or simultaneously along with the fluid of choice. Therefore, we conducted a meta-analysis to evaluate the effect of early versus late vasopressor use on clinical outcomes in septic shock patients. METHODS: PubMed, Cochrane, and Embase databases were searched systematically for studies that compared early versus late vasopressor initiation in septic shock patients and reported our pre-defined primary outcome of short-term mortality. Other inclusion criteria included administration of vasopressors within a 6-hour (h) window, minimum 2 group comparison, > 50 patients, and suffering from septic shock. Study selection, data extraction, and evaluation were performed by two investigators independently. Secondary outcomes that were collected included ICU length of stay, hospital length of stay, the volume of intravenous fluids within the first 6 hours, and time to achieved target mean arterial pressure (≥ 65 mmHg). RESULTS: Of the 601 articles identified, 48 underwent full-text screening and 7 articles with a total of 1,867 patients were included in the meta-analysis. Early vasopressor initiation resulted in decreased short term mortality compared to late vasopressor administration (odds ratio [OR] = 0.54; 95% CI,0.4 to 0.713; P < 0.001; I2 = 30.28%). Secondary outcomes showed time (in hours) to achieve target MAP of 65mmHg was shorter in the early vasopressor group (mean difference: − 1.15; 95% CI, − 1.37 to -0.92; P = <0.001; I2 = 44.58%). There was no difference in ICU length of stay (mean difference = − 0.42; 95% CI, − 0.18 to 1.01; I2 = 86.52%), hospital length of stay (mean difference = − 1.29; 95% CI, − 0.54 to 3.12; I2 = 91.94%), or net fluids in first 6 hours (mean difference = − 295.08; 95% CI, − 717.74 to 127.58; I2 = 97.77%) between the two groups, respectively. CONCLUSIONS: The use of early vasopressors in septic shock patients decreased short-term mortality and time to target MAP of ≥ 65 mmHg. However, no statistically significant difference was shown for hospital length of stay, ICU length of stay, or total net fluids required within the first 6 hours. Further randomized controlled trials are warranted to better address the study question. CLINICAL IMPLICATIONS: Early vasopressor initiation in septic shock patients appears to benefit mortality outcomes. This approach to septic shock management may potentially limit the complications of aggressive fluid resuscitation. These results will encourage clinicians to not delay vasoactive agents use in favor of extensive fluid resuscitation and consequently minimize delays in hypotension correction. DISCLOSURES: No relevant relationships by Tewodros Eguale, source=Web Response No relevant relationships by Mohammad Ghanbar, source=Web Response No relevant relationships by Ethar Makhseed, source=Web Response

Clinical impact of visually assessed right ventricular dysfunction in patients with septic shock

We retrospectively analyzed data from the Medical Information Mart for Intensive Care-III critical care database to determine whether visually-assessed right ventricular (RV) dysfunction was associated with clinical outcomes in septic shock patients. Associations between visually-assessed RV dysfunction by echocardiography and in-hospital mortality, lethal arrhythmia, and hemodynamic indicators to determine the prognostic value of RV dysfunction in patients with septic shock were analyzed. Propensity score analysis showed RV dysfunction was associated with increased risk of in-hospital death in patients with septic shock (adjusted odds ratio [OR] 2.15; 95% confidence interval [CI] 1.99–2.32; P < 0.001). In multivariate logistic regression analysis, RV dysfunction was associated with in-hospital death (OR 2.19; 95% CI 1.91–2.53; P < 0.001), lethal arrhythmia (OR 2.19; 95% CI 1.34–3.57; P < 0.001), and tendency for increased blood lactate levels (OR 1.31; 95% CI 1.14–1.50; P < 0.001) independent of left ventricular (LV) dysfunction. RV dysfunction was associated with lower cardiac output, pulmonary artery pressure index, and RV stroke work index. In patients with septic shock, visually-assessed RV dysfunction was associated with in-hospital mortality, lethal arrhythmia, and circulatory insufficiency independent of LV dysfunction. Visual assessment of RV dysfunction using echocardiography might help to identify the short-term prognosis of patients with septic shock by reflecting hemodynamic status.

Clinical Application of Transabdominal Ultrasound Combined with PICCO in Septic Shock Fluid Resuscitation and Its Predictive Value for Survival Outcome

To investigate the clinical value of transabdominal ultrasound combined with pulse index continuous cardiac output (PICCO) in fluid resuscitation of septic shock patients, and to analyze the predictive value of survival outcomes, 68 patients with septic shock were randomly divided into the ultrasound + PICCO group and PICCO group. Compared with before treatment, blood lactic acid (BLA) was cleared, and central venous pressure (CVP) and oxygenation index were significantly increased in all patients. The oxygen binding index, central venous oxygen saturation (ScVO2), and CVP in the ultrasound + PICCO group were increased compared with the PICCO group, while BLA, mechanical ventilation time, total fluid resuscitation input and hospitalization were significantly reduced. The extravascular lung water index and shape change index were positively correlated with sequential organ failure assessment. The combination of extravascular lung water index and shape change index had higher clinical value than each alone in predicting the death of patients with septic shock. The combination of transabdominal ultrasound with PICCO is better at guiding fluid resuscitation in patients with septic shock and has a certain predictive value with respect to the survival outcome of septic shock patients.

Hypercoagulability in Septic Shock Patients With Thrombocytopenia.

Despite thrombocytopenia, patients with sepsis often experience hypercoagulability. However, limited information is available on the prevalence and effect of hypercoagulability in patients with sepsis-induced thrombocytopenia. Hence, we evaluated the prevalence of hypercoagulability and the association between hypercoagulability and clinical outcomes in septic shock patients with thrombocytopenia. Thromboelastography (TEG) was performed prospectively in 1294 patients with septic shock at the emergency department (ED) between January 2016 and December 2019. After excluding 405 patients who did not require resuscitation, refused enrollment, or developed septic shock after ED presentation, 889 patients were included. We defined thrombocytopenia as an admission platelet count lower than 150,000/µl according to SOFA score. We defined hypocoagulability and hypercoagulability as coagulation index (CI)< -3 and >3 on TEG, respectively. Of the 889 septic shock patients (mean age 65.6 ± 12.7 years, 58.6% male), 473 (53.2%) had thrombocytopenia. Eighty-five (18.0%) patients showed hypercoagulable TEG and73 (15.4%) patients showed hypocoagulable TEG. The hypercoagulable TEG group had a significantly higher fibrinogen level and a lower 28-day mortality rate than the normal and hypocoagulable TEG groups (518 vs. 347 and 315 mg/dL; 7.1% vs. 21.1% and 36.8%, P < 0.01, respectively). In multivariate analysis, hypercoagulable TEG was associated with a decreased mortality rate (odds ratio: 0.395; 95% confidence interval, 0.162-0.965). In septic shock patients with thrombocytopenia, hypercoagulability was not uncommon. TEG can quickly distinguish the hypercoagulability and hypocoagulability states and serve as a valuable tool for evaluating the degree and risk in septic shock patients with thrombocytopenia.

Role of thromboelastography in the evaluation of septic shock patients with normal prothrombin time and activated partial thromboplastin time

Coagulopathy is frequent in septic shock and plays a key role in multiple organ dysfunction. The aim of this study is to investigate application values of thromboelastography (TEG) for outcome in septic shock patients with a normal value of prothrombin time (PT) and active partial thromboplastin time (aPTT). Prospective observational study using 1298 consecutive septic shock patients with TEG at admission was conducted at the emergency department (ED) of a tertiary care hospital in South Korea between 2016 and 2019. After excluding overt-disseminated intravascular coagulation (DIC) defined by scoring system, we included patients with a normal value of international normalized ratio ≤ 1.3 and aPTT ≤ 34 s. The primary outcome was 28-day mortality. 893 patients were included and 129 patients with overt DIC were excluded. Of the 764 remaining patients, 414 (54.2%) patients showed normal PT and aPTT (28-day mortality rate, 11.4%). TEG values such as reaction time, kinetic time (K), alpha angle (α), maximum amplitude (MA) and lysis index (LY 30) showed no significant mean difference between the survivor and non-survivor groups. However, hypocoagulable TEG values such as α < 53° (12.0% vs. 23.4%; p = 0.039), and MA < 50 mm (6.3% vs. 21.3%; p = 0.002) were significantly higher in the non-survived group. In multivariate analysis, hypocoagulable state (defined as K > 3 and α < 53 and MA < 50) was independent factors associated with increased risk of death (OR 4.882 [95% CI, 1.698–14.035]; p = 0.003). In conclusion, septic shock patients with normal PT and aPTT can be associated with impaired TEG profile, such as hypocoagulability, associated with increased mortality.

Long-Term Outcomes after Sepsis.

Sepsis is one of the most serious problems in modern medicine. Long-term outcomes in septic shock patients are very discouraging: 75% individuals who survived sepsis and septic shock demonstrate signs of organ failure and experience persistent functional deficit. Acute sepsis and its management in an intensive care unit (ICU) to a great extent determine the pathogenesis of further complications. We believe that the concept of phenoptosis proposed by Prof. Skulachev deserves a special attention from anesthesiologists and ICU doctors. According to this concept, septic shock is a suicidal mechanism of programmed organism death, which protects human population from dangerously infected individuals. The article suggests a potential approach to the sepsis treatment based on the notion that septic shock can be prevented by identification and blockade of receptors involved in the processing of phenoptotic signal induced by lipopolysaccharide and other substances that initiate septic shock. In view of this, the search for agents that can block molecular mechanisms of the phenoptotic signal transmission seems very promising.

Impact of 1-Hour Bundle Achievement in Septic Shock.

This study aimed to address the impact of 1-hr bundle achievement on outcomes in septic shock patients. Secondary analysis of multicenter prospectively collected data on septic shock patients who had undergone protocolized resuscitation bundle therapy at emergency departments was conducted. In-hospital mortality according to 1-h bundle achievement was compared using multivariable logistic regression analysis. Patients were also divided into 3 groups according to the time of bundle achievement and outcomes were compared to examine the difference in outcome for each group over time: group 1 (≤1 h reference), group 2 (1–3 h) and group 3 (3–6 h). In total, 1612 patients with septic shock were included. The 1-h bundle was achieved in 461 (28.6%) patients. The group that achieved the 1-h bundle did not show a significant difference in in-hospital mortality compared to the group that did not achieve the 1-h bundle on multivariable logistic regression analysis (<1 vs. >1 h) (odds ratio = 0.74, p = 0.091). However, 3- and 6- h bundle achievements showed significantly lower odds ratios of in-hospital mortality compared to the group that did not achieve the bundle (<3 vs. >3 h, <6 vs. >6 h, odds ratio = 0.604 and 0.458, respectively). There was no significant difference in in-hospital mortality over time for group 2 and 3 compared to that of group 1. One-hour bundle achievement was not associated with improved outcomes in septic shock patients. These data suggest that further investigation into the clinical implications of 1-h bundle achievement in patients with septic shock is warranted.

Outcomes of end-stage renal disease patients in the PROCESS trial.

ObjectiveIntravenous fluid administration is a main component of sepsis therapy, but physicians are cautious about giving fluids to end‐stage renal disease (ESRD) patients out of concern for causing volume overload. We compared the outcomes of septic shock patients with and without ESRD and evaluated the association between early intravenous fluid administration and outcomes.MethodsWe analyzed patients enrolled in the Protocolized Care for Early Septic Shock (PROCESS) trial, which studied different resuscitation strategies for early septic shock. Stratifying for ESRD, we compared patient characteristics, course of care, and outcomes between ESRD and non‐ESRD. Using multivariable logistic regression, we determined the association between 6‐hour total fluid volume (> = 30 mL/kg vs < 30 mL/kg) from preenrollment and outcomes.ResultsThere were 84 ESRD and 1257 non‐ESRD patients. ESRD patients had a higher median Charlson Comorbidity score (5 vs 2, P < .001), higher median acute physiology and chronic health evaluation (APACHE) II score (26.5 vs 20.0, P < .001), and lower 6‐hour intravenous fluid administration (54.7 vs 68.3 mL/kg, P < .001). Ninety‐day mortality (33.3% vs 29.3%, P = .43) and intubation rate (31.0% vs 33.4%, P = .64) did not differ between groups. Fewer ESRD received > = 30 mL/kg (66.6% vs 86.7% P < .001). For ESRD, receipt of > = 30 mL/kg intravenous fluid did not alter any outcome. For non‐ESRD patients, receiving ≥30 mL/kg of intravenous fluid was associated with increased 90‐day mortality (adjusted odds ratio = 1.64; 95% confidence interval, 1.03‐2.61).ConclusionsIn the PROCESS trial, ESRD patients had similar outcomes to non‐ESRD patients. Although ESRD patients received less intravenous fluid administration, most received over 30 mL/kg in the first 6 hours. In contrast to non‐ESRD patients, receiving ≥30 mL/kg of intravenous fluid was not associated with worse outcomes in ESRD.

The application progress of fluid de-escalation therapy in abdominal infection-induced septic shock

After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.

Assessing the impact of CKD on outcomes in septic shock patients receiving standard Vs reduced initial fluid volume

ObjectiveTo determine if following fluid resuscitation recommendations in the Surviving Sepsis Campaign guidelines affects hospital length of stay (LOS) in chronic kidney disease (CKD) patients who present to the emergency department with sepsis-induced hypotension or septic shock. DesignRetrospective, single center, cohort study. Setting433-bed community hospital with a 35-bed emergency department in central Kentucky. PatientsAdults (≥18 years of age) who presented to the emergency department with severe sepsis or septic shock, as defined by the Centers for Medicare and Medicaid Services (CMS), with documented CKD and at least one episode of hypotension within 6 h of presentation. A total of 106 patients were included in the study. Measurements and main resultsPatients were stratified into two groups based on the total volume of weight-based crystalloid fluid bolus initiated within the first three hours of hypotension onset (<27 mL/kg and ≥ 27 mL/kg). There was a statistically significant reduction in the primary outcome of median LOS among patients who received less than 27 mL/kg of a crystalloid fluid bolus (5.1 vs 7.7 days, p = .003). Likewise, there was a statistically significant reduction in the secondary outcome of total cost per case in the reduced fluid volume cohort (p = .019. No significant differences were found in other secondary outcomes, including vasopressor requirements, ICU admission rate, and normalization of MAP at 6 h. ConclusionThe results of this single-center, retrospective study indicate that CKD patients who receive guideline-directed fluid resuscitation (≥27 mL/kg) for sepsis-induced hypotension or septic shock experience a longer hospital LOS compared to those who receive a reduced initial fluid volume.

Hemodynamic and skin perfusion is associated with successful enteral nutrition therapy in septic shock patients.

Enteral nutrition is controversial in hemodynamically unstable patients. This study aimed to evaluate the association between hemodynamic and skin perfusion parameters and enteral nutrition therapy (NT) outcomes in septic shock patients. Ventilated adults with septic shock were evaluated at bedside upon admission (H0), and at 12h (H1), 24h (H2) and 48h (H3) for mean arterial pressure (MAP), heart rate, urine output, lactate levels, mottling score, capillary refill time (CRT), central-to-toe temperature gradient and norepinephrine dose. Two groups were stratified: NT success (NTS) (≥20kcal/kg or 11kcal/kg for obese in the first ICU week) or NT failure (NTF). A generalized linear model and generalized estimating equations were performed. Over a 19-month period, 2167 admissions were assessed and 141 patients were analyzed (63.5±15.0 years, SAPS-3 75±12, 102 [72%] in the NTS vs. 39 [28%] in NTF). At 12h, the failure group showed more severe mottling scores, higher lactate levels, norepinephrine dose and central-to-toe temperature gradient. Mottling score at 12h was a predictor of NT failure (RR 1.28 95%CI [1.09-1.50], p=.003). Over 48h, higher mottling scores, lactate levels and norepinephrine dosage, % of patients with central-to-toe temperature gradient and CRT ≥3s were observed in the failure group and higher urine output and MAP values were observed in the success group. Early improvement in hemodynamic and skin perfusion parameters was associated with success in nutrition therapy, and mottling score at 12h was a risk factor for nutrition therapy failure. This data could support the recommendation to start NT after hemodynamic and perfusion goals are achieved and to proactively evaluate bedside parameters while implementing NT in critical care setting.

Does the time between ordering and administering the first dose of antibiotic influences outcome in septic shock patients?

Background &amp; Objectives: It is generally believed that significant delay in administering antibiotics in severely septic patients and those with septic shock increases mortality. However, most studies were retrospective and/or of questionable design. Moreover, the starting times from which delays were measured varied and often seemed somewhat amorphous. We assessed the duration of time between antibiotics being ordered and first administered among patients with newly diagnosed septic shock in a Saudi intensive care unit (ICU), and its effects on 30-day mortality and the rate of major complications. We also sought to identify any time threshold at which the mortality rate clearly increased.&#x0D; Methodology: Data were prospectively collected on 96 patients ≥14-years-old (male/ female = 49%; mean age 62.1 y) admitted to our ICU and followed for ≥30 days, or until hospital discharge or death. The time between ordering and administering the first dose of antibiotics after diagnosis of septic shock was recorded and its impact upon survival and major complications analyzed.&#x0D; Results: Fifty of 96 patients died within the ICU. Unexpectedly, mortality rate declined steadily between &lt; one min (60%) and 5 h delay (44%), but rose sharply beyond five hours (p &lt; 0.001). Time delay did not significantly influence the rate of any major complication other than death.&#x0D; Conclusions: Our results call into question recent conclusions that delays administering antibiotics beyond one to two hours result in significantly increased mortality. Further prospective, large scale studies are necessary to clarify this issue.&#x0D; Citation: Algethamy HM, Arab AA, Morish A, Meriky LH, Numan MS, Alotaibi AF. Does the time between ordering and administering the first dose of antibiotic influence outcomes in septic shock patients? Anaesth pain &amp; intensive care 2019;23(3):--