In this episode I’ll:
1. Discuss an article about delays in the 2nd dose of antibiotic for septic patients.
2. Answer the drug information question “Is it OK to give lactated ringers to a septic patient with elevated lactate?”
3. Share a resource for learning about rare disorders.
Article
Lead author: Daniel Leisman
Published in Critical Care Medicine June 2017
Background
A tremendous focus has been placed on the timely delivery of the 1st dose of antibiotic for patients with sepsis. But patients in the emergency department face a transition of care as they are admitted to the hospital around the time their 2nd dose of antibiotic may be due. This study is the first to examine the effects of the timeliness of the 2nd antibiotic dose.
Methods
The study was a retrospective single-center cohort study of a consecutive group of patients admitted from the emergency department with sepsis or septic shock. The authors determined a delay occured if the 2nd antibiotic dose was delayed more than 25% of the dosing interval.
Results
More than 800 patients were included in the study. One-third of the patients experienced a significant delay in administration of the 2nd dose of antibiotic.
The authors conducted a pre-specified analysis to determine factors that were associated with antibiotic delay. A shorter dosing interval length, inpatient boarding in the ED, initial sepsis bundle compliance, and advanced age were all associated with antibiotic delay. Dosing intervals of 6 and 8 hours accounted for 85% of the patients with delayed 2nd antibiotic dose.
A delay in 2nd antibiotic dose was associated with an increased odds ratio for in-hospital mortality and need for mechanical ventilation.
Conclusion
The authors concluded:
Major second dose delays were common, especially for patients given shorter half-life pharmacotherapies and who boarded in the emergency department. They were paradoxically more frequent for patients receiving compliant initial care. We observed association between major second dose delay and increased mortality, length of stay, and mechanical ventilation requirement.
Discussion
Before adopting changes in antibiotic selection, I would repeat a small version of this study locally. If you find delays in the administration of the 2nd dose of antibiotic for septic patients admitted from the ED, consider looking at a systems approach to eliminate the delay. Choosing initial antibiotics that have a longer dosing interval of 12 or 24 hours may be one way to reduce delays to the 2nd dose of antibiotic.
Drug information question
Q: Is it OK to give lactated ringers to a septic patient with elevated lactate?
A: Yes.
Lactated ringers is considered a suitable fluid for resuscitation in sepsis. It is true that lactated ringers will increase the measured serum lactate, but this will not have a deleterious effect on the patient. The lactate found in lactated ringers is not lactic acid, rather it is sodium lactate. This form of lactate will not increase blood pH. Since lactated ringers is a crystalloid solution, it will increase blood volume and directly treat the cause of elevated lactate in sepsis.
Resource
The resource for this episode is the National Organization for Rare Disorders Physician Guides. The NORD Online Physician Guides are a free service of the National Organization for Rare Disorders (NORD) and its medical advisors. The purpose of the NORD Online Physician Guides is to provide a resource for clinicians about specific rare disorders to facilitate the timely diagnosis and treatment of their patients. I find particularly useful the guide on hereditary angioedema.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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