Rationale: Survivors of septic shock have impaired functional status. Volume overload is associated with poor outcomes in patients with septic shock, but the impact of volume overload on functional outcome and discharge destination of survivors is unknown.Objectives: This study describes patterns of fluid management both during and after septic shock. We examined factors associated with volume overload upon intensive care unit (ICU) discharge. We then examined associations between volume overload upon ICU discharge, mobility limitation, and discharge to a healthcare facility in septic shock survivors, with the hypothesis that volume overload is associated with increased odds of these outcomes. Methods:We retrospectively reviewed the medical records of 247 patients admitted with septic shock to an academic county hospital between June 2009 and April 2012 who survived to ICU discharge. We defined volume overload as a fluid balance expected to increase the subject's admission weight by 10%. Statistical methods included unadjusted analyses and multivariable logistic regression.Measurements and Main Results: Eighty-six percent of patients had a positive fluid balance, and 35% had volume overload upon ICU discharge. Factors associated with volume overload in unadjusted analyses included more severe illness, cirrhosis, blood transfusion during shock, and higher volumes of fluid administration both during and after shock. Blood transfusion during shock was independently associated with increased odds of volume overload (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.33-5.27; P = 0.01) after adjusting for preexisting conditions and severity of illness. Only 42% of patients received at least one dose of a diuretic during their hospitalization. Volume overload upon ICU discharge was independently associated with inability to ambulate upon hospital discharge (OR, 2.29; 95% CI, 1.24-4.25; P = 0.01) and, in patients admitted from home, upon discharge to a healthcare facility (OR, 2.34; 95% CI, 1.1-4.98; P = 0.03).Conclusions: Volume overload is independently associated with impaired mobility and discharge to a healthcare facility in survivors of septic shock. Prevention and treatment of volume overload in patients with septic shock warrants further investigation.

Objective Delayed initiation of appropriate antimicrobials is linked to higher sepsis mortality. We investigated inter-physician variation in septic patients’ door-to-antimicrobial time. Design Retrospective cohort study. Setting Emergency department (ED) of an academic medical center. Subjects Adult patients treated with antimicrobials in the ED between 2009 and 2015 for fluid-refractory severe sepsis or septic shock. Patients who were transferred, received antimicrobials prior to ED arrival, or were treated by an attending physician who cared for <5 study patients were excluded. Interventions None. Measurements and Methods We employed multivariable linear regression to evaluate the association between treating attending physician and door-to-antimicrobial time after adjustment for illness severity (APACHE II score), patient age, prehospital or arrival hypotension, admission from a long-term care facility, mode of arrival, weekend or nighttime admission, source of infection, and trainee involvement in care. Among 421 eligible patients, 74% received antimicrobials within three hours of ED arrival. After covariate adjustment, attending physicians’ (N=40) median door-to-antimicrobial times varied significantly, ranging from 71 to 359 minutes (p=0.002). The percentage of each physician’s patients whose antimicrobials began within 3 hours of ED arrival ranged from 0% to 100%. Overall, 12% of variability in antimicrobial timing was explained by the attending physician compared to 4% attributable to illness severity as measured by the APACHE II score (p<0.001). Some but not all physicians started antimicrobials later for patients who were normotensive on presentation (p=0.017) or who had a source of infection other than pneumonia (p=0.006). The adjusted odds of in-hospital mortality increased by 20% for each one hour increase in door-to-antimicrobial time (p=0.046). Conclusions Among patients with severe sepsis or septic shock receiving antimicrobials in the ED, door-to-antimicrobial times varied five-fold among treating physicians. Given the association between antimicrobial delay and mortality, interventions to reduce physician variation in antimicrobial initiation are likely indicated.

Most ARDS patients did not receive LTVV despite implementation of a protocol. ARDS was also recognized in a minority of patients, suggesting an opportunity for improvement of care.

Prehospital ALS but not BLS-only care was associated with faster antibiotic initiation for patients with sepsis without hypotension. Process redesign for non-ALS patients may improve antibiotic timeliness for ED sepsis.

Objective To determine whether cystic fibrosis (CF) is associated with adverse neonatal outcomes in a recent birth cohort in the United States. Study design A retrospective matched cohort study of infants born in Washington State from 1996-2013 was identified through birth certificate data and linked to statewide hospital discharge data. Infants with CF were identified by hospitalization (through age 5 years) in which a CF-specific ICD-9 code was recorded. “Unexposed” infants lacked CF-related ICD-9 codes and were randomly selected among births, frequency-matched to “exposed” infants on birth year. Associations of CF with adverse neonatal outcomes (low birth weight, small for gestational age, pre-term birth and infant mortality) were estimated through Poisson regression. We performed extreme value imputation to address possible ascertainment bias. Results We identified 170 infants with CF and 3,400 unexposed infants. CF was associated with increased relative risk (95% confidence interval) of 3.5 (2.5-4.9), 1.6 (1.1-2.4), 3.0 (2.2-4.0), and 6.8 (1.7-26.5) for low birth weight, small for gestational age, pre-term birth, and infant death, respectively. The estimated relative risks were similar among infants born from 2006-2013, except small for gestational age was no longer associated with CF diagnosis. Results were robust to extreme value imputation and exclusion of infants with meconium ileus. Conclusions Observed associations of CF with low birth weight, pre-term birth and infant death are unlikely to be due to ascertainment bias. Further work is needed to determine how to prevent these adverse neonatal outcomes.

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