Impact of extended emergency department stay on antibiotic re-dosing delays and outcomes in sepsis.

BACKGROUND: For patients with sepsis and septic shock, the initial administration of antibiotics should occur as soon as possible, preferably within one hour of sepsis recognition. While clinicians are focused on providing first-doses of antibiotics quickly upon presentation, re-dosing issues may arise in patients who have an extended emergency department (ED) length of stay (LOS). Limited studies have been conducted that assess the impact of re-dosing delays. The purpose of this study was to assess the association of an extended ED LOS ≥ 6 h with antibiotic re-dosing delays in patients with sepsis and examine outcomes. METHODS: A retrospective cohort study comparing patients with sepsis with an ED LOS of <6 h to those with an ED LOS of ≥6 h was performed between March 2018 and February 2020. Patients ≥18 years old admitted from the ED with sepsis or septic shock were included. The primary outcome was incidence of delay to the second dose of antibiotics in those with an extended ED LOS compared to those without. Secondary outcomes included intensive care unit (ICU) LOS, hospital LOS, rate of transfer from non-ICU to ICU settings, incidence and duration of mechanical ventilation, and in-hospital mortality. An exploratory analysis compared outcomes in patients with and without a re-dosing delay. RESULTS: Of the 128 patients included, 99 patients had an ED LOS < 6 h and 29 patients had an ED LOS ≥ 6 h. A delay to second dose of antibiotics occurred in 30 (30.3%) patients in the ED LOS < 6 h group versus 7 (24.1%) patients in the ED LOS ≥ 6 h group (p = 0.52). Secondary outcomes did not significantly differ between the two groups. In-hospital mortality was numerically higher in those with a re-dosing delay when compared to those without in the exploratory analysis (18.9% vs. 8.8%, p = 0.11). CONCLUSION: There was no statistically significant difference in the incidence of delays to the second dose of antibiotics among patients with sepsis with an ED LOS of <6 h versus those with an ED LOS of ≥6 h. The high incidence of antibiotic re-dosing delays in both groups, indicates an overall need for improved transitions of care in the ED sepsis population.

The Reemergence of Ketamine for Treatment in Critically Ill Adults.

OBJECTIVES: To assess the evidence and discuss the risks and clinical relevance of ketamine for the treatment of various disease states impacting the adult critically ill population. DATA SOURCES: A literature review was performed using PubMed evaluating primary literature published until August 2018. STUDY SELECTION: Case reports, observational studies (cohort, case-control), and randomized controlled trials involving patients 18 years and older in a nonperioperative setting using either IV or intramuscular ketamine were included for analysis. Uses of ketamine discussed focused on critically ill patients in the ICU and emergency department settings. DATA EXTRACTION: Included studies were evaluated for dosing, outcomes, and adverse effects of ketamine. For each study, the design, population, intervention, investigated outcomes, and results were assessed. DATA SYNTHESIS: The evidence was organized according to use of ketamine, which included pain, sedation, status asthmaticus, alcohol withdrawal syndrome, status epilepticus, and acute behavioral psychologic disturbances. Evaluation of the evidence was based on the included primary literature along with any related guideline recommendations. CONCLUSIONS: Ketamine has suggested potential benefit in several disease states impacting critically ill patients including pain, alcohol withdrawal syndrome, status epilepticus, and acute agitation. Further supporting evidence is needed to validate its use in the setting of critical illness.