The overarching goals of early sepsis management include early recognition, appropriate antibiotic therapy and source control, maintenance of hemodynamic stability, and supportive care of organ dysfunction. Despite increasing awareness of the global burden of sepsis, and general agreement on the goals of management, there is ongoing controversy regarding the implementation of specific treatment strategies to optimize patient outcomes. This article will address five current points of controversy in the management of sepsis and septic shock. These include optimal timing of antibiotics in patients with potential sepsis, the role of glucocorticoids in septic shock, vitamin C as a novel therapy for sepsis, the ideal intravenous fluid for resuscitation, and the optimal balance of fluid resuscitation and vasopressor administration in septic shock. For each of these topics, we review relevant literature, discuss areas of controversy, and present our current approach to management.

BACKGROUND AND OBJECTIVES: Hospital-associated venous thromboembolism (HA-VTE) is a leading cause of preventable in-hospital mortality in adults. Our objective was to describe HA-VTE and evaluate risk factors for its development in adults admitted to a children's hospital, which has not been previously studied. We also evaluated the performance of commonly used risk assessment tools for HA-VTE. METHODS:A case-control study was performed at a freestanding children's hospital. Cases of HA-VTE in patients $18 years old (2013-2017) and age-matched controls were identified. We extracted patient and HA-VTE characteristics and HA-VTE risk factors on the basis of previous literature. Thrombosis risk assessment was performed retrospectively by using established prospective adult tools (Caprini and Padua scores).RESULTS: Thirty-nine cases and 78 controls were identified. Upper extremities were the most common site of thrombosis (62%). Comorbid conditions were common (91.5%), and malignancy was more common among case patients than controls (P 5 .04). The presence of a central venous catheter (P , .01), longer length of stay (P , .01), ICU admission (P 5 .005), and previous admission within 30 days (P 5 .01) were more common among case patients when compared with controls. Median Caprini score was higher for case patients (P , .01), whereas median Padua score was similar between groups (P 5 .08).CONCLUSIONS: HA-VTE in adults admitted to children's hospitals is an important consideration in a growing high-risk patient population. HA-VTE characteristics in our study were more similar to published data in pediatrics.

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OBJECTIVES: Pediatric Hospital Medicine fellowship programs need to abide by Accreditation Council for Graduate Medical Education requirements regarding communication and supervision. Effective communication is critical for safe patient care, yet no prior research has explored optimal communication practices between residents, fellows, and attending hospitalists. Our objective is to explore communication preferences among pediatric senior residents (SRs), Pediatric Hospital Medicine fellows, and hospitalists on an inpatient team during clinical decision-making. METHODS: We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys adapted from prior research, 1 for each population: 200 hospitalists, 20 fellows, and 380 SRs. The instruments included questions about communication preferences between the SR, fellow, and hospitalist during clinical scenarios. We calculated univariate descriptive statistics and examined paired differences in percent agreement using χ2 tests, accounting for clustering by institution. RESULTS: Response rates were: 53% hospitalists; 100% fellows; 39% SRs. Communication preferences varied based on role, scenario, and time of day. For most situations, hospitalists preferred more communication with the fellow overnight and when a patient or family is upset than expressed by fellows (P < .01). Hospitalists also desired more communication between the SR and fellow for an upset patient or family than SRs (P < .01), but all respondents agreed the SR should call the fellow for adverse events. More fellows and hospitalists felt that the SR should contact the fellow before placing a consult compared with SRs (95%, 86% vs 64%). CONCLUSIONS: Hospitalists, fellows, and SRs may have differing preferences regarding communication, impacting supervision, autonomy, and patient safety. Training programs should consider such perspectives when creating expectations and communication guidelines.

Background: Clinical data on novel coronavirus COVID-19 arising from early cases in Hubei province revealed high incidence of cardiac complications, especially arrhythmias, amongst infected. We present a case series describing the clinical course of three COVID-19 positive patients, which were amongst the first cases of the COVID-19 outbreak in NSW. Case 1: Male in early-80's from nursing home with comorbid ischaemic cardiomyopathy presents with a 3-day history of dyspnoea. Viral swabs confirmed COVID-19. Febrile on presentation with marked elevation in inflammatory markers. 72-hours into admission, patient developed recurrent ventricular tachycardia (VT). Despite maximal supportive and medical therapy, patient deteriorated clinically with increasing VT burden resulting in death. Case 2: Male in mid-50's presents with lethargy, myalgia and a subacute history of low-grade fever. Mild dyspnoea on presentation with subsequent development of profound hypoxia in the ensuing 24-48 hours. Blood tests showed rapid rise in inflammatory markers with renal impairment. Imaging showed widespread interstitial lung changes consistent with acute respiratory distress syndrome. Patient was intubated and bronchial lavage cultures confirmed COVID-19. Patient received anti-viral and corticosteroid therapy with subsequent improvement. Case 3: Female in late-80's from nursing home without significant background history. Reported mild coryzal symptoms but was screened for given close contact with COVID-19 positive patient. Swabs confirmed COVID-19 positivity. 48-hours into admission, patient developed fever which was managed conservatively. Blood tests showed mildly elevated inflammatory markers. She remained otherwise well and was discharged following negative viral testing. Conclusion: COVID-19, recently declared a pandemic, has a highly variable clinical presentation and outcomes.

Background: Takotsubo's cardiomyopathy and spontaneous coronary artery dissection (SCAD) are important non-atherosclerotic causes for acute coronary syndrome (ACS) to consider in young people presenting with ACS. They share similar epidemiological features (younger age of onset and female preponderance) and are thought to be driven by similar hormonal/ sympathetic pathways. Despite this, there have been few cases where both SCAD and Takotsubo presented together. The Case: A 56 year old woman presented to a regional hospital with an inferior ST segment elevation myocardial infarct. She was a distant ex-smoker, and had well controlled hypertension. Cardiac troponins were elevated to 13,557 ng/ L. She proceeded to have trans-thoracic echocardiography (TTE) which demonstrated moderate apical hypokinesis and ballooning. Coronary angiography noted severe tubular stenosis to the distal left circumflex artery. The left ventriculogram showed pathognomonic findings of Takotsubo's cardiomyopathy with apical ballooning and hyperdynamic basal function. Medical management was commenced, with the use of dual antiplatelets, cardioselective beta-blockers, and angiotensin converting enzyme inhibitors. Repeat coronary angiogram 4 weeks following initial presentation demonstrated resolution of her SCAD findings and apical ballooning syndrome. Importance of this Study: This case describes a rare presentation of concomitant SCAD and Takotsubo cardiomyopathy, describing our management approach to this presentation and its effective outcome. The case highlights similarities in the underlying pathophysiology of these conditions and raises questions to be addressed in future studies.

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