Background: Intravenous vitamin C and thiamine administration may be a potential adjuvant therapy for septic shock. We aimed to investigate the impact of early vitamin C and thiamine administration in septic shock patients. Methods: This retrospective before-and-after cohort study used data extracted from the Korean Shock Society’s prospective septic shock registry. We compared 28-day and in-hospital mortality rates between patients treated with intravenous vitamin C (3 g/12 h or 1.5 g/6 h) and thiamine (200 mg/12 h) <6 h after shock recognition from July through December 2017 (n = 229) and control patients from October 2015 through June 2017 (n = 915) using propensity score matching. Results: The 28-day (18.3% vs. 17.5%; p = 0.76) and in-hospital (16.6% vs. 18.3%; p = 0.55) mortality rates did not differ between treatment and control groups, nor did 28-day (18.5% vs. 17.5%; p = 0.84) and in-hospital (16.7% vs. 18.4%; p = 0.54) mortality rates after matching. In the subgroup analysis, treatment was associated with lower in-hospital mortality rates in patients with albumin <3.0 mg/dL or a Sequential Organ Failure Assessment (SOFA) score >10. Conclusion: Early vitamin C and thiamine administration in patients with septic shock did not improve survival; however, administration could benefit conditions that are more severe, such as hypoalbuminemia or severe organ failure.

(1) Background: Myocardial dysfunction in patients with sepsis is not an uncommon phenomenon, yet reported results are conflicting and there is no objective definition. Measurement of troponin may reflect the state of the heart and may correlate with echocardiographically derived data. This study aimed to evaluate the role of admission and peak troponin-I testing for the identification of sepsis-induced myocardial dysfunction (SIMD) by transthoracic echocardiography (TTE). (2) Methods: This was a retrospective cohort study using a prospective registry of septic shock at an Emergency Department from January 2011 and April 2017. All 1,776 consecutive adult septic shock patients treated with protocol-driven resuscitation bundle therapy and tested troponin-I were enrolled. SIMD was defined as left ventricular (LV) systolic/diastolic dysfunction, right ventricular (RV) diastolic dysfunction, or global/regional wall motion abnormalities (WMA). (3) Results: Of 660 (38.4%) septic shock patients with an elevated hs-TnI (≥0.04 ng/mL) at admission, 397 patients underwent TTE and 258 cases (65%) showed SIMD (LV systolic dysfunction (n = 163, 63.2%), LV diastolic dysfunction (n = 104, 40.3%), RV dysfunction (n = 97, 37.6%), and WMA (n = 186, 72.1%)). In multivariate analysis, peak hs-TnI (odds ratio 1.03, 95% confidence interval 1.01–1.06, p = 0.008) and ST-T wave changes in the electrocardiogram (odds ratio 1.82, 95% confidence interval 1.04–2.39, p = 0.013) were associated with SIMD, in contrast to hs-TnI level at admission. The area under the curve of peak hs-TnI was 0.668. When the peak hs-TnI cutoff value was 0.634 ng/mL, the sensitivity and specificity for SIMD were 58.6% and 59.1%, respectively. 4) Conclusions: About two-thirds of patients with an elevated hs-TnI level have various cardiac dysfunctions in terms of TTE. Rather than the initial level, the peak hs-TnI and ST-T change may be considered as a risk factor of SIMD.

Objective Extracorporeal cardiopulmonary resuscitation (ECPR) may be considered as a rescue therapy for patients with refractory cardiac arrest. Identifying patients who might benefit from this potential life-saving procedure is crucial for implementation of ECPR. The objective of this study was to estimate the number of patients who fulfilled a hypothetical set of ECPR criteria and to evaluate the outcome of ECPR candidates treated with conventional cardiopulmonary resuscitation. MethodsWe performed an observational study using data from a prospective registry of consecutive adults (≥18 years) with non-traumatic out-of-hospital cardiac arrest in a tertiary hospital between January 2011 and December 2015. We developed a hypothetical set of ECPR criteria including age ≤75 years, witnessed cardiac arrest, no-flow time ≤5 minutes, low-flow time ≤30 minutes, refractory arrest at emergency department >10 minutes, and no exclusion criteria. The primary endpoint was the proportion of good neurologic outcome of ECPR-eligible patients. ResultsOf 568 out-of-hospital cardiac arrest cases, 60 cases (10.6%) fulfilled our ECPR criteria. ECPR was performed for 10 of 60 ECPR-eligible patients (16.7%). Three of the 10 patients with ECPR (30.0%), but only 2 of the other 50 patients without ECPR (4.0%) had a good neurologic outcome at 1 month.Conclusion ECPR implementation might be a rescue option for increasing the probability of survival in potentially hopeless but ECPR-eligible patients.

Precise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

(1) Background: Sepsis-associated acute kidney injury (AKI) can lead to permanent kidney damage, although the long-term prognosis in patients with septic shock remains unclear. This study aimed to identify risk factors for the development of chronic kidney disease (CKD) in septic shock patients with AKI. (2) Methods: A single-site, retrospective cohort study was conducted using a registry of adult septic shock patients. Data from patients who had developed AKI between January 2011 and April 2017 were extracted, and 1-year follow-up data were analysed to identify patients who developed CKD. (3) Results: Among 2208 patients with septic shock, 839 (38%) had AKI on admission (stage 1: 163 (19%), stage 2: 339 (40%), stage 3: 337 (40%)). After one year, kidney function had recovered in 27% of patients, and 6% had progressed to CKD. In patients with stage 1 AKI, 10% developed CKD, and mortality was 13% at one year; in patients with stage 2 and 3 AKI, the CKD rate was 6%, and the mortality rate was 42% and 47%, respectively. Old age, female, diabetes, low haemoglobin levels and a high creatinine level at discharge were seen to be risk factors for the development of CKD. (4) Conclusions: AKI severity correlated with mortality, but it did not correlate with the development of CKD, and patients progressed to CKD, even when initial AKI stage was not severe. Physicians should focus on the recovery of renal function, and ensure the careful follow-up of patients with risk factors for the development of CKD.

Background Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock. Methods We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED. Results A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088–1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115–1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590–0.952, p = 0.018) and 0.714 (95% CI 0.564–0.904, p = 0.005), respectively. Conclusion Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

(1) Background: Septic shock survivors frequently readmit because of subsequent infection. This study aimed to determine the rate and risk factors for same pathogen sepsis readmissions following hospitalization for septic shock. (2) Methods: We performed this retrospective study using data from a prospective septic shock registry at a single urban tertiary center. All the patients were treated with a protocol-driven resuscitation bundle therapy between 2011 and 2016. We collected data from adult (older than 18 years) patients readmitted with sepsis within 90 days of discharge following hospitalization for septic shock. (3) Results: Among 2062 septic shock patients, 690 were readmitted within 90 days of discharge. After excluding scheduled and non-sepsis admissions, we analyzed the data from 274 (13.3%) patients readmitted for sepsis. Most of the readmissions following septic shock were new infections rather than relapses of the initial infection. The culture-negative rate was 51.4% (141/274), while the same pathogen was isolated in 25% of cases (69/274). Multivariate analysis revealed that previous gram-negative bacteremia (OR, 9.902; 95% CI, 2.843–34.489), urinary tract infection (OR, 4.331; 95% CI, 1.723–10.882) and same site infection (OR, 6.894; 95% CI, 2.390–19.886) were significantly associated with readmission for sepsis caused by the same pathogen. (4) Conclusions: The sepsis readmission rate following the previous hospitalization for septic shock was 13.3% and one-quarter of those patients had the same pathogen isolated. Previous gram-negative bacteremia, and/or same site infection are predisposing factors for recurrent same-pathogen sepsis.

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