BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3‐hour bundle of care for patients with sepsis (i.e., blood cultures, broad‐spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3‐hour bundle and risk‐adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3‐hour bundle completed within 3 hours. The median time to completion of the 3‐hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3‐hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk‐adjusted in‐hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3‐hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk‐adjusted in‐hospital mortality. (Funded by the National Institutes of Health and others.)

Supplement to: Time to treatment and mortality during mandated emergency care for sepsis.

Rationale: Recent retrospective evidence suggests the efficacy of early norepinephrine administration during resuscitation; however, prospective data to support this assertion are scarce.Objectives...

https://www.atsjournals.org/doi/pdf/10.1164/rccm.201806-1034OC

Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial.

Background: Sepsis is a deadly disease worldwide Effective treatment strategy of sepsis remains limited There still was a controversial about association between preadmission metformin use and mortality in sepsis patients with diabetes We aimed to assess sepsis-related mortality in patients with type 2 diabetes (T2DM) who were preadmission metformin and non-metformin users Methods: The patients with sepsis and T2DM were included from Medical Information Mart for Intensive Care -III database Outcome was 30-day mortality We used multivariable Cox regression analyses to calculate adjusted hazard ratio (HR) with 95% CI Results: We included 2,383 sepsis patients with T2DM (476 and 1,907 patients were preadmission metformin and non-metformin uses) between 2001 and 2012 The overall 30-day mortality was 201% (480/2,383); it was 219% (418/1,907), and 130% (62/476) for non-metformin and metformin users, respectively After adjusted for potential confounders, we found that preadmission metformin use was associated with 39% lower of 30-day mortality (HR = 061, 95% CI: 046-081, p = 0007) In sensitivity analyses, subgroups analyses, and propensity score matching, the results remain stable Conclusions: Preadmission metformin use may be associated with reduced risk-adjusted mortality in patients with sepsis and T2DM It is worthy to further investigate this association

/pdf/association-between-preadmission-metformin-use-and-outcomes-4wc6xuxk5e.pdf

Association Between Preadmission Metformin Use and Outcomes in Intensive Care Unit Patients With Sepsis and Type 2 Diabetes: A Cohort Study.

Sepsis represents an important global health burden due to its high mortality and morbidity. The rapid detection of sepsis is crucial in order to prevent adverse outcomes and reduce mortality. However, the diagnosis of sepsis is still challenging and many efforts have been made to identify reliable biomarkers. Unfortunately, many investigated biomarkers have several limitations that do not support their introduction in clinical practice, such as moderate diagnostic and prognostic accuracy, long turn-around time, and high-costs. Complete blood count represents instead a precious test that provides a wealth of information on individual health status. It can guide clinicians to early-identify patients at high risk of developing sepsis and to predict adverse outcomes. It has several advantages, being cheap, easy-to-perform, and available in all wards, from the emergency department to the intensive care unit. Noteworthy, it represents a first-level test and an alteration of its parameters must always be considered within the clinical context, and the eventual suspect of sepsis must be confirmed by more specific investigations. In this review, we describe the usefulness of basic and new complete blood count parameters as diagnostic and prognostic biomarkers of sepsis.

The Value of a Complete Blood Count (CBC) for Sepsis Diagnosis and Prognosis

Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.

/pdf/management-of-sepsis-and-septic-shock-in-the-emergency-4m5rr951xc.pdf

Management of sepsis and septic shock in the emergency department.

Prognostic value of an inflammatory biomarker-based clinical algorithm in septic patients in the emergency department: An observational study.

Measurement of central venous pressure (CVP) can be a useful clinical tool. However, the formal utility of CVP measurement in preventing mortality in septic patients has never been proven. The Medical Information Mart for Intensive Care III (MIMIC-III) database was searched to identify septic patients with and without CVP measurements. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the relationship between CVP measurement and 28-day mortality, and propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) were employed to validate our findings. A total of 10,275 patients were included in our study, of which 4516 patients (44%) underwent CVP measurement within 24 h of intensive care unit (ICU) admission. The risk of 28-day mortality was reduced in the CVP group (OR 0.60 (95% CI 0.51–0.70; p < 0.001)). Patients in the CVP group received more fluid on day 1 and had a shorter duration of mechanical ventilation and vasopressor use, and the reduction in serum lactate was greater than that in the no CVP group. The mediating effect of serum lactate reduction was significant for the whole cohort (p = 0.04 for the average causal mediation effect (ACME)) and patients in the CVP group with an initial CVP level below 8 mmHg (p = 0.04 for the ACME). CVP measurement was associated with decreased risk-adjusted 28-day mortality among patients with sepsis and was proportionally mediated through serum lactate reduction.

/pdf/central-venous-pressure-measurement-is-associated-with-4m6yrrlgto.pdf

Central venous pressure measurement is associated with improved outcomes in septic patients: an analysis of the MIMIC-III database.

The optimal timing of lactate measurement for septic patients in the intensive care unit (ICU) remains controversial, and whether initiating and repeating the lactate measurement earlier could make a difference for septic patients with an elevated lactate level remains unexplored. This was a retrospective observational study that included septic patients with an initial lactate level > 2.0 mmol/L after ICU admission, and all data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The main exposure of interest was the early lactate measurement, which was defined as an initial lactate level measurement within 1 h after ICU admission. The primary outcome was 28-day mortality. A total of 2642 eligible subjects were enrolled, including 738 patients who had initial lactate measurements completed within 1 h (EL group) and 1904 patients who had initial lactate measurements completed more than 1 h after ICU admission (LL group). A significant beneficial effect of early lactate measurement in terms of 28-day mortality was observed: the adjusted odds ratio (OR) was 0.69 (95% CI 0.55–0.87; p = 0.001), and the mediation effect of the time to initial vasopressor administration was significant (average causal mediation effect (ACME) − 0.018; 95% CI − 0.005 approximately to − 0.036; p   2.0 mmol/L. A shorter time to the initial vasopressor administration may contribute to this relationship. Repeating the lactate measurement within 3 h after the initial measurement is appropriate for patients whose lactate levels were measured within 1 h of admission.

/pdf/early-lactate-measurement-is-associated-with-better-outcomes-b9z9gdipcx.pdf

Early lactate measurement is associated with better outcomes in septic patients with an elevated serum lactate level.

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Prognostic value of an inflammatory biomarker-based clinical algorithm in septic patients in the emergency department: An observational study.

Central venous pressure measurement is associated with improved outcomes in septic patients: an analysis of the MIMIC-III database.

Early lactate measurement is associated with better outcomes in septic patients with an elevated serum lactate level.