Ethan Sterk

Risk factors for mortality in septic patients who received etomidate.

PURPOSE To characterize risk factors for mortality in septic patients who received etomidate for rapid sequence intubation. MATERIALS AND METHODS This study was a retrospective cohort conducted at a large, tertiary, urban, academic medical center that included patients with severe sepsis or septic shock who received etomidate between January 1, 2010, and December 31, 2012. RESULTS A total of 169 patients were included with similar baseline characteristics. There were more men in the nonsurvivor group than in the survivor group (67.1% vs 50.6%, P=.03). Septic shock occurred in 91.5% of nonsurvivors and 69% of survivors (P<.01). Nonsurvivors also had a higher initial lactate of (5.1±4.3 mmol/L vs 3.6±3.4 mmol/L, P=.02) and more vasopressor therapy (91.5% vs 69%, P<.01), required a higher number of vasopressors (2.2±1.1 vs 1.3±1, P<.01), and were administered hydrocortisone (53.7% vs 34.5%, P=.01). Abdominal source of sepsis (P=.048) and number of vasopressors (P=.01) were predictive of 30-day mortality. CONCLUSION An alternative sedative induction agent may be considered for use in rapid sequence intubation in patients on multiple vasopressors or with abdominal source of infection.

Intravenous lidocaine for acute pain: a systematic review

This systematic review evaluates the safety and efficacy of intravenous (IV) lidocaine for the treatment of acute pain in adult patients. The PubMed database was searched for randomized controlled trials, retrospective cohort studies, case series, and case reports evaluating the use of IV lidocaine for the treatment of acute pain in adult patients, published between January 1970 and January 2018. The primary outcome was pain reduction via the Visual Analog Scale, Verbal Rating Scale, or Numeric Rating Scale among patients treated with IV lidocaine and placebo or active controls. Safety outcomes included both nonserious and serious adverse events. A total of 347 titles and abstracts were screened, and after full‐text review, 13 studies met the inclusion criteria involving 512 patients. The four active controls studied were IV morphine, IV ketorolac, IV dihydroergotamine (DHE), and IV chlorpromazine (CPZ). The dosing of IV lidocaine varied among studies between a weight‐based dose of a 1‐ to 2‐mg/kg bolus, a fixed‐bolus dose of 50–100 mg, and a 1‐mg/kg/hour continuous infusion. Monitoring of serum lidocaine concentrations was not done routinely. Intravenous lidocaine had superior efficacy to morphine for renal colic and critical limb ischemia, superior efficacy to DHE for acute migraine, and equivalent efficacy to ketorolac for acute radicular lower back pain. However, lidocaine was less effective than CPZ for the treatment of acute migraine. The most common adverse event reported among all studies were neurologic effects such as altered mental status and slurred speech. Due to the inconsistency in dosing, length of administration, and lack of serum monitoring, the absolute safety of IV lidocaine for acute pain is unknown. Larger, prospective studies are needed before the routine use of IV lidocaine can be recommended for all types of acute pain.

Early Recognition and Treatment of Sepsis After the Addition of Lactate to the Laboratory's Critical Result Call List.

Purpose: Screening of patients with sepsis is needed to increase recognition and allow for earlier interventions. There is no consensus on whether the addition of lactate to the critical result laboratory’s call list should be a standard practice. Materials and Methods: This was a retrospective cohort study that compared management and outcomes of patients with sepsis having lactate ≥4 mmol/L before (group 1) and after (group 2) the addition of a critical result threshold of lactate of ≥4 mmol/L to the critical result laboratory’s call list and its effects on time to antibiotics and intravenous fluids (IVFs). Results: One hundred twenty-one patients were included. Lactate was higher in group 1 (7.0 ± 4.3 vs 5.6 ± 2.0, P = 0.03). More patients in group 2 received hydrocortisone (1.9% vs 22.4%, P = .001). Hospital mortality, 30-day mortality, and 90-day mortality were significantly lower in group 2 (59.3% vs 32.8%, P = .003; 68.5% vs 37.3%, P ≤ .001; 68.5% vs 41.8%, P = .002). There were no significant differences in total volume of IVFs (2400.8 ± 1720.0 vs 2483.7 ± 2155.7, P = 0.83), time to start IVFs (184.0 ± 283.2 vs 115.6 ± 190.5, P = 0.27), or antibiotics (184.8 ± 187.1 vs 133.7 ± 137.4, P = 0.16). Conclusion: Addition of lactate to the critical result laboratory’s call list did not lead to a statistically significant improvement in time to IVFs or antibiotics, although the average time to antibiotics and IVFs decreased by 51.1 and 68.4 minutes, respectively. Hospital mortality, 30-day mortality, and 90-day mortality were lower in group 2, which may be, in part, due to increased recognition of severe sepsis by critical result notification and earlier intervention.

1509: IMPACT OF IV PUSH ANTIBIOTICS ON TIME TO EMPIRIC ANTIBIOTIC ADMINISTRATION IN SEPTIC PATIENTS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Prompt identification and appropriate treatment of septic shock has been shown to improve patient outcomes. However, patients with early septic shock may be difficult to recognize due to fluctuations in blood pressure values during the period prior to the requirement for vasopressors. We hypothesized that septic shock patients with blood pressure variability in the first 24 hours of emergency department (ED) presentation would experience a delayed time to vasopressor initiation, with a potential negative impact on organ failure and mortality. The aim of this study was to describe the relationship between blood pressure variability in patients presenting to the ED with early septic shock and time to vasopressor initiation and mortality. Methods: We performed a retrospective review of patients with septic shock and requiring vasopressors within the first 24 hours of admission at UF Health Jacksonville. Patients were excluded if they were less than 18 years old, incarcerated, or did not require vasopressors. Blood pressure variability was defined as each individual fluctuation above or below a systolic blood pressure of 90 mm Hg. The sum of the number of fluctuations above or below systolic blood pressure of 90 mm Hg was then taken and calculated for each patient. Spearman’s correlation coefficients were calculated to evaluate the relationship between blood pressure variability and time to vasopressor initiation. A multivariable logistic regression model was created to determine the association with mortality. Results: A total of 467 patients with septic shock were included. 243 patients (52%) had two or more changes in blood pressure measurements above or below a systolic blood pressure of 90 mmHg, 140 patients (30%) had three or more changes. The mean time to vasopressor initiation was 7.53 hours with a standard deviation of 5.81. The median time to vasopressor initiation was 5.85 hours (interquartile range [IQR] 2.98 – 10.75). There was a positive, significant correlation between blood pressure variability and time to vasopressor initiation (r = 0.51, p < 0.001). Blood pressure variability was not significantly associated with mortality (p = 0.619). Conclusions: In this analysis of septic shock patients we found that patients who exhibited blood pressure variability had an increased time to vasopressor initiation but did not have an increase in mortality. Future studies will evaluate the effect of this delay on subsequent organ dysfunction.

Early recognition of sepsis through emergency medical services pre-hospital screening

BACKGROUND The Surviving Sepsis Campaign implemented a 3-hour bundle including blood cultures, lactate, intravenous fluids, and antibiotics to improve mortality in sepsis. Though difficult to achieve, bundle compliance is associated with decreased hospital mortality. We predict that the implementation of an Emergency Medical Services (EMS) sepsis screening tool will improve 3-hour bundle compliance. OBJECTIVES To determine if pre-hospital sepsis screening improves 3-hour bundle compliance. METHODS Prospective implementation of an EMS sepsis screening tool (June 2016-November 2016) was compared to a historical control (August 2015-March 2016). The protocol was facilitated via communication between nurses and EMS personnel. The primary outcome was 3-hour bundle compliance. Secondary outcomes included time to individual bundle components. RESULTS Of 135 patients screened, 20 were positive and included in the study, and subsequently compared to 43 control patients. Baseline demographics were similar, except median Sequential Organ Failure Assessment (SOFA) score was higher for the pre-EMS tool group (5 [interquartile range (IQR) 2-8] vs. 2 [IQR 1-4], p < 0.01). Three-hour bundle compliance was significantly higher in the EMS tool group (80% vs. 44.2%, p < 0.01). The pre-EMS tool group had lower median time to lactate (15 [IQR 0-35] vs. 46 min [IQR 34-57], p < 0.001), 30 mL/kg IV fluids (6.5 [IQR 0-38] vs. 46 min [IQR 27.5-72], p < 0.001), and, although not significant, antibiotics (63.5 [IQR 44-92] vs. 72 min [IQR 59.5-112], p = 0.26). CONCLUSION Implementation of an EMS sepsis screening tool resulted in improved 3-hour bundle compliance compared to retrospective control.

Emergency department sepsis screening tool decreases time to antibiotics in patients with sepsis

Abstract Recent literature has highlighted the importance of early identification and treatment of sepsis; however, limited data exists to help recognize sepsis in the emergency department (ED) through use of a screening tool. The purpose of this study was to evaluate the impact of a sepsis screening tool implemented in an academic medical center ED on compliance with the 3‐hour sepsis bundle. This was a retrospective cohort study that included a total of 115 patients, of which 58 were in the pre‐tool group and 57 were in the post‐tool group. There was no difference in 3‐hour bundle compliance between groups (36.2% vs. 47.4%, P = 0.26). There was no difference in the following bundle components: lactate (79.3% vs. 80.7%, P = 0.85), blood cultures (86.2% vs. 96.5%, P = 0.09), blood cultures before administering antibiotics (91.4% vs. 100%, P = 0.57) and adequate fluids administration (44.7% vs. 41.9%, P = 0.820). A significantly higher number of patients received antibiotics within 3 h in the post‐tool group (58.6% vs. 89.5%, P < 0.001). Statistically significant secondary outcomes included average time to antibiotics (P = 0.04), administering antibiotics within an hour (P > 0.001), and ICU length of stay (P = 0.03). There was no difference in 30‐day mortality, however mortality was numerically lower in the post‐tool group (36.2% vs. 26.3%, P = 0.25). Although implementation of an ED sepsis screening tool did not increase 3‐hour bundle compliance, it did increase the proportion of patients receiving timely antimicrobial therapy and demonstrated a trend towards decreased mortality.

1406: IMPACT OF THE EMERGENCY DEPARTMENT SEPSIS SCREENING TOOL ON OUTCOMES IN PATIENTS WITH SEPSIS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) peak in December with 6088 daily admissions). In comparison, the lowest number of daily severe sepsis hospitalizations was seen in September at 5193 hospitalizations per day. Mortality was higher in winter months (27.5% in Dec-Feb vs 26.0% Mar-May vs 24.7% Jun-Aug vs 25.2% in Sep-Nov; p<0.001) with peak mortality in Jan at 28%. Use of mechanical ventilation was also higher in winter months and lowest in summer (34% in Dec-Feb vs 33% in Mar-May vs 31.5% in Jun-Aug vs 32% in Sep-Nov; p<0.001). On adjusted analysis, winter months (Dec-Feb) were independently associated with 11% increased risk of mortality in comparison to summer (Jun-Aug) (OR 1.11:95% CI 1.10–1.12). Conclusions: Severe sepsis hospitalizations are more common during winter and are also associated with higher mortality in winter. Further studies are needed to better understand the reasons behind these seasonal variations.

1433: TIME SPENT IN THE EMERGENCY DEPARTMENT DOES NOT IMPACT OUTCOMES IN SEPTIC PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) exogenous VP resolves. Hypothesis: Discontinuation of VP before NE will result in more frequent development of clinically significant hypotension. Methods: his retrospective, cohort study compared discontinuation of NE and VP in medical ICU patients in the recovery phase of septic shock from May 2014 to June 2016. Difference in clinically significant hypotension after NE or VP discontinuation, defined as NE dose increase after VP discontinuation or NE or VP added back after discontinuation, was evaluated with Chi-square test. Linear regression was performed, examining the effect of agent discontinuation on clinically significant hypotension. Baseline variables were examined for a bivariate relationship with clinically significant hypotension; those with p<0.2 were included in the model (VP discontinued first, age, HR at septic shock onset, positive culture, and SOFA score at 72 hours). Results: NE and VP were discontinued first in 92 and 62 patients, respectively. APACHE II scores at 24 hours (28.1 vs 28.9, p=0.62) and SOFA scores at 72 hours (7.6 vs 7.9, p=0.68) were similar. In unadjusted analysis, when VP was discontinued first, more clinically significant hypotension developed (10.4 vs 67.8%, p<0.001). There was no difference in ICU duration (174 vs 216 h, p=0.18) or hospital duration (470 vs 473 h, p=0.98). NE discontinued and VP discontinued first groups had similar in-hospital (35 vs 52%, p=0.12) and 28-day mortality (30 vs 46%, p=0.22). The VP discontinued first group had a longer duration of NE (63.7 vs 96.7 h, p=0.02) but a shorter duration of VP (55.9 vs 38.2 h, p=0.07). In adjusted analysis, discontinuing VP first was associated with increased clinically significant hypotension (: 25.2, p<0.001). Conclusions: Discontinuing VP before NE resulted in more frequent development of clinically significant hypotension. VP should be discontinued last in patients with septic shock.