Beyond SEP-1 Compliance: Assessing the Impact of Antibiotic Overtreatment and Fluid Overload in Suspected Septic Patients.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) developed the Severe Sepsis and Septic Shock Performance Measure bundle (SEP-1) metric to improve sepsis care, but evidence supporting this bundle is limited and harms secondary to compliance have not been investigated. OBJECTIVE: This study investigates the effect of an emergency department (ED) sepsis quality-improvement (QI) effort to improve CMS SEP-1 compliance, looking specifically at antibiotic overtreatment and harm from fluid resuscitation. METHODS: This was a retrospective observational study conducted between March and July 2021 with patients for whom a sepsis order set was initiated. The primary outcomes included the number of patients treated with antibiotics who were ultimately deemed nonseptic and the number of patients who developed pulmonary edema, with or without need for positive pressure ventilation (PPV), within 48 h of receiving a 30 mL/kg fluid bolus. Data were collected via nonblinded chart reviews, with a free marginal κ-calculation indicating excellent interrater reliability. RESULTS: The study cohort included 273 patients, 170 (62.3%) who were ultimately determined to be septic and 103 (37.7%) who were nonseptic. Of the 103 nonseptic patients, 82 (79.6%) received antibiotics in the ED. Of the 121 patients (44.3%) who received a 30 mL/kg bolus, 5 patients (4.1%) developed pulmonary edema and 0 of 121 patients required PPV within 48 h. CONCLUSIONS: The QI effort led to moderate rates of antibiotic overtreatment and very few patients developed pulmonary edema due to a 30 mL/kg fluid bolus.

Diuretics prescribing in chronic kidney disease patients: physician assessment versus bioimpedence spectroscopy.

INTRODUCTION: The relationship between hypertension and fluid overload in pre-dialysis CKD patients need to be elucidated. Current study aimed to find relationship between fluid overload and hypertension along with prescribed diuretic therapy using bioimpedance spectroscopy (BIS). METHODOLOGY: A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by BIS. RESULTS: A total of 312 CKD patients with mean eGFR 24.5 ± 11.2 ml/min/1.73 m2 were enrolled. Based on OH value ≥7 %, 135 (43.3 %) patients were hypervolemic while euvolemia was observed in 177 (56.7 %) patients. Patients were categorized in different regions of hydration reference plot (HRP) generated by BIS i.e., 5.1 % in region-N (normal BP and fluid status), 20.5 % in region I (hypertensive with severe fluid overload), 29.5 % in region I-II (hypertensive with mild fluid overload), 22 % in region II (hypertensive with normohydration), 10.2 % in region III (underhydration with normal/low BP) and 12.5 % in region IV (normal BP with severe fluid overload). A total of 144 (46 %) patients received diuretics on basis of physician assessment of BP and edema. Maximum diuretics 100 (69.4 %) were prescribed in patients belonging to regions I and I-II of HRP. Interestingly, a similar number of diuretic prescriptions were observed in region II (13 %) and region IV (12 %). Surprisingly, 7 (4.9 %) of patients in region III who were neither hypervolemic nor hypertensive were also prescribed with diuretics. CONCLUSION: BIS can aid clinicians to categorize CKD patients on basis of their fluid status and provide individualized pharmacotherapy to manage hypertensive CKD patients.

Intravenous diuretic day-care treatment for patients with heart failure.

Fluid overload is a common manifestation of decompensated chronic heart failure. This paper reports on a pilot study that investigated whether intravenous (i.v.) furosemide administered on a cardiology day ward for three successive days was effective in improving the symptoms of patients with fluid overload and chronic heart failure. The results showed that 94.1% of patients reported an improvement in their breathlessness, with a marked weight loss in 88.2% of patients. There were no marked changes in blood pressure or renal function. Hospital admission was avoided in 94.1% of cases. The study concluded that i.v. diuretic treatment given in a hospital day-care setting is safe and effective, and that it reduces the need for hospital admissions. As a consequence, this reduces the associated financial costs of hospitalisation.

Cardio-renal syndrome: an entity cardiologists and nephrologists should be dealing with collegially.

Heart failure may lead to acute kidney injury and vice versa. Chronic kidney disease may affect the clinical outcome in terms of cardiovascular morbidity and mortality while chronic heart failure may cause CKD. All these disorders contribute to the composite definition of cardio-renal syndromes. Renal impairment in HF patients has been increasingly recognized as an independent risk factor for morbidity and mortality; however, the most important clinical trials in HF tend to exclude patients with significant renal dysfunction. The mechanisms whereby renal insufficiency worsens the outcome in HF are not known, and several pathways could contribute to the "vicious heart/kidney circle." Traditionally, renal impairment has been attributed to the renal hypoperfusion due to reduced cardiac output and decreased systemic pressure. The hypovolemia leads to sympathetic activity, increased renin-angiotensin-aldosterone pathways and arginine-vasopressin release. All these mechanisms cause fluid and sodium retention, peripheral vasoconstriction and an increased congestion as well as cardiac workload. Therapy addressed to improve renal dysfunction, reduce neurohormonal activation and ameliorate renal blood flow could lead to a reduction in mortality and hospitalization in patients with cardio-renal syndrome.

[The homeostasis assessment by hemorrhagic shock].

The comparative analysis of different protocols of infusion therapy of the hemorrhagic shock stage III was performed. The infusion of the colloid solution of hydroxiethylstarch 200/0.5 and non-balanced crystalloid 0.9% solution of natrium chloride leads to the development of negative changes in homeostasis. Whereas infusion of the 4% solution of the modified gelatin and balanced crystalloid solition (sterofundin) allows to avoid the registered changes in electrolyte and alkaline balance.

The role of peripheral ultrafiltration in the management of acute decompensated heart failure.

Heart failure is a common and highly morbid condition associated with recurrent hospitalizations for disease decompensation. As such, heart failure is a growing public health concern from both a utilization and cost perspective. The current standard of care for the management of volume overload symptoms is underpinned by a diuretic-based treatment regimen. There is now increasing data to suggest that this approach may be counterproductive and result in progression of cardiac and renal disease with resultant higher mortality rates. Peripheral ultrafiltration is emerging as a viable, and in some cases preferred, option for sodium and fluid removal. Initial research trials have shown that this treatment modality results in improved clinical, biochemical and quality of life parameters. Moreover, these benefits are durable over the long term with decreased recidivism and health care utilization at 1 year. It remains unclear whether these benefits will translate into hard cardiovascular endpoints; greater adoption of this technology coupled with newer clinical trials will help researchers and clinicians identify the optimal strategy for treating symptoms of volume overload among heart failure patients.

Clinical pharmacy services in a rehabilitation facility.

Clinical pharmacy services provided by pharmacists to patients in a rehabilitation facility through a contracted arrangement with a local hospital are described. Two staff pharmacists from a community hospital oversee the drug-distribution process and provide clinical services at a 40-bed private rehabilitation facility. During alternate four-week periods, each pharmacist works at the rehabilitation facility; the other four-week period is spent in traditional drug-distribution activities at the hospital. The hospital is reimbursed for clinical services separately from drug-distribution services; by keeping records of the time spent in clinical activities at the facility, the pharmacists have obtained increased reimbursement for these services since initiation of this program. Clinical services provided by pharmacists at the institute include patient education, drug-therapy monitoring and consultation, drug information activities, and management of drug therapy in selected patients. In 1982, pharmacists provided 230 drug-therapy consultations to physicians and received referrals for drug-therapy management of 47 patients on warfarin sodium, 46 on antihypertensive drugs, and 27 on phenytoin sodium. The provision of a variety of clinical pharmacy services to patients in a rehabilitation facility offers a unique and professionally rewarding practice.

[Rationalization of infusion therapy (author's transl)]. / Rationalisierung der Infusionstherapie

Infusions are a principal cost factor for hospital dispensaries. The demands of modern infusion therapy are gone into from the point of view of the anesthesist. Opportunities for rationalization arise through producing them in the hospital dispensaries and their problems relating to GMP provisions are described. An alternative solution by reduction of the ready made supply from the industry is discussed.