Prehospital antibiotics

While EMS providers may be comfortable bolusing fluid, I wonder if the improvements seen in that JEMS article (as an example) are less due to prehospital antibiotics and more to early recognition of sepsis and therefore aggressive management with fluids. Anecdotally, many of the medics I worked with were pretty lassiez faire with aggressively starting fluids on potentially septic patients, but we also had very short transport times.
 
rescue1 said:
While EMS providers may be comfortable bolusing fluid, I wonder if the improvements seen in that JEMS article (as an example) are less due to prehospital antibiotics and more to early recognition of sepsis and therefore aggressive management with fluids. Anecdotally, many of the medics I worked with were pretty lassiez faire with aggressively starting fluids on potentially septic patients, but we also had very short transport times.
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Actually I’m not sure ggressive fluid administration has ever been associated with improved outcomes.
 
I think the evidence is at best wishy washy, yeah(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5209309/), though there is a study in the works: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576288/

Either way, no one I worked with was giving close to the (controversial but current "best practice") 30mL/kg. I'm just saying I think it would be reasonable to assume the jump from "maybe start fluids if we have time on this maybe septic patient" to "lets try and identify sepsis and make sure we appropriately manage their blood pressure" may introduce some confounders into a study on antibiotics.
 
I agree that most adults may not need even close to 30 mL/kg but the monitoring required otherwise just isn't universally available at this point. In the ideal world fluid resuscitation would be based on responsiveness to 500 mL challenges while being monitored by a PA catheter, NICOM, Flotrac, clearsight, et cetera and then pressors started if hypotensive and not fluid responsive. If they are 3rd spacing and not dilated then pressors are not going to be the solution, however fluid overload also has very serious consequences. Perhaps in the future we will have a more mobile non-invasive product available for the field but to my knowledge there isn't one yet, most EDs don't even guide fluid resuscitation by hemodynamic monitors.

I think the secret sauce for sepsis is going to be clinicians who take sepsis seriously. It seems that every report that comes out and says that vitamin c infusions, steroids, massive fluids, et cetera that is saving all of their patients come out of systems that are already paying very close attention to their patients are are not letting details fall through the cracks.

When initially diagnosed in our ED (either walk in or from the field) we have less than a 1% mortality in overall sepsis cases, less than 4% with severe sepsis, and about 18% with septic shock; and these are mostly from our heme/onc and transplant patients. I think that this is from us being aggressive with their overall management. Early cultures, early antibiotics, early fluids, and very close management. We don't fiddle around with access, if we can't start an IV with traditional methods we have several nurses who are on staff who will start USGPIVs or EJs, or our docs will place a straight angio in the IJ for initial management (rather than take 10 plus minutes to place a central line). If they are difficult access I'm not going to ultrasound a second IV and take up precious time, I can just art stick them for the second set of cultures. We do not hesitate to start pressors. We trend multiple lactates during their resuscitation. Patients are quickly dispositioned to the correct inpatient floor or unit.

If we could start these measures in the field I would bet money that our patients would have better outcomes. Sitting on septic patients does not heal them.
 
Brandon O said:
To me a sincere attempt at a sterile culture requires sterile gloves, a chlorhexadine prep, a hat and mask, and a fresh stick.
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Who is wearing sterile gloves and a cap to draw cultures? I have yet to see someone try that.
 
Tigger said:
My medical director asked for some research on this two years ago when we were talking about adding pre-hospital antibiotics for sepsis and open fractures. We didn't, but we also lack clinical leadership that is willing to do anything that wasn't the standard of care in 2005 unless it sounds sexy. Antibiotics are apparently not sexy. Neither are vasopressors, but dammit we will RSI. Prehospital Ancef for open fractures is around in Colorado, mostly flight but several rural ground services as well.

Anyway,
Greenville EMS in NC has done a fair bit of research on their own pre-hospital sepsis guidelines. Most of it is retrospective, but if nothing else they found that they could draw cultures about as well their hospitals could and that their providers were correctly identifying patients that would benefit from prehospital antibiotics. I've attached some of their materials (all are public record).
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This is Greenville, SC.

The culture debate has already been proven a myth. We have exceeded the ED rates. We are actually at 6 months straight of 0 contamination. The ED's cannot even get this.
The evidence from the hospitals have already showed a reduction in mortality and length of stays.
We already had a Sepsis alert protocol prior to this pilot. So the benefits are showing to come from early abx administration.
 
Peak said:
The current recommendation is to start antibiotics for open fractures within one hour of identification, so even if transport was only 30 minutes when you look at the time it takes to prepare antibiotics prehospital administration can be beneficial.
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I was looking around, EAST guidelines seem to say 3 hours, but I see your point for sure
 
reaper said:
This is Greenville, SC.

The culture debate has already been proven a myth. We have exceeded the ED rates. We are actually at 6 months straight of 0 contamination. The ED's cannot even get this.
The evidence from the hospitals have already showed a reduction in mortality and length of stays.
We already had a Sepsis alert protocol prior to this pilot. So the benefits are showing to come from early abx administration.
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Has this been published anywhere?
 
Sort of a sidebar thread hijack here, but are any in-hospital folks (specifically in The States) doing steroid therapy with the severe sepsis groups in their respective ICU’s?

It makes total and complete sense, and having admittedly stumbled across it the other day while reviewing some of my ASTNA’s prep guide notes, I was wondering about it’s usefulness and what all our in-hospital folks on here have to say about it.

Ironically enough, Weingart did a quick promo podcast on it alongside of another doc from Ireland re: steroid administration in the severely septic patient.

Apparently it will be the subject at an upcoming critical care conference overseas as well.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224490/

https://itunes.apple.com/us/podcast...esuscitation/id314020330?mt=2&i=1000399359288
 
VentMonkey said:
Sort of a sidebar thread hijack here, but are any in-hospital folks (specifically in The States) doing steroid therapy with the severe sepsis groups in their respective ICU’s?

It makes total and complete sense, and having admittedly stumbled across it the other day while reviewing some of my ASTNA’s prep guide notes, I was wondering about it’s usefulness and what all our in-hospital folks on here have to say about it.

Ironically enough, Weingart did a quick promo podcast on it alongside of another doc from Ireland re: steroid administration in the severely septic patient.

Apparently it will be the subject at an upcoming critical care conference overseas as well.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224490/

https://itunes.apple.com/us/podcast...esuscitation/id314020330?mt=2&i=1000399359288
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The ADRENAL trial result was discussed at the Critically Care Reviews conference in Belfast just recently. The gist was no improvement in mortality with steroid therapy, but decrease in surrogate clinical endpoints like ventilator days and I believe vasopressor requirements. There is a lot of debate now within the intensivist community now whether this trial result provides evidence to administer or not to administer steroids.

The chief investigator of ADRENAL presented at this conference and the video of it should be posted on the website shortly, if it hasn’t yet been.
 
My understanding is that there's no evidence for empiric steroid therapy.

The only interventions that have been proven to improve outcomes are timely (not necessarily early) antibiotic administration and appropriate supportive care. Of course "supportive care" is broad and is where much of the controversy is found. Aggressive fluid? Early pressors? Vitamin C? Vent strategies? Steroids?

Lots of septic patients will get steroids, of course, because at some point they'll show signs of adrenal fatigue. That's where you'll see the benefits of reduced pressor needs, etc.
 
Peak said:
Who is wearing sterile gloves and a cap to draw cultures? I have yet to see someone try that.
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That's because it is institution dependent.

There is a sweet spot that balances feasibility with sterility. I have seen departments whose protocol for cultures was so stringent that cultures often simply didn't happen. On the other hand there are places that don't bother with any real effort at sterility (and also draw lots of samples from lines), and contamination is widespread. These are both less than desirable.

Simple barrier precautions and fresh sticks for all draws are fairly low-hanging fruit and the minimum standard in my opinion. I do think it is a bit much to dismiss the importance of this from the field or emergency department. It has no relevance there anyway. It becomes relevant when we're trying to tailor therapy several days later.

VentMonkey said:
Sort of a sidebar thread hijack here, but are any in-hospital folks (specifically in The States) doing steroid therapy with the severe sepsis groups in their respective ICU’s?
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Do you mean in general?

It is a more or less universal practice; disagreement is just on how/when to apply it. The most common method is to wait for the patients who are the sickest, i.e. on escalating doses of multiple pressors. Often it's something you throw into the kitchen sink as they circle the drain, if that's not too mixed of a metaphor.

Hydrocortisone 50mg q6h is fairly standard. Some people load with more (100mg, 200mg) up front. Most don't do an ACTH stimulation test in these critically ill patients, and it is not recommended, although it is sometimes used for less-ill convalescing patients who continue to look a little adrenally wan.

No agreement yet on whether any of this should change after the recent ADRENAL trial.
 
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