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Introduction Prompt treatment of severe sepsis in the Emergency Department reduces deaths, but the role of prehospital fluid resuscitation is unknown. We sought to determine the risk-adjusted association between prehospital fluid administration and hospital mortality among emergency medical services (EMS) patients admitted with severe sepsis. Methods We performed a prospective, observational study of patients hospitalized with severe sepsis on admission among 45,394 adult EMS encounters taken to 15 hospitals from 11/2009 to 12/2010 by a two-tier EMS system in King County, Washington. The region mandated recording of prehospital intravenous catheter and fluid administration in prehospital records, along with detailed demographic, incident, physiologic, and hospital adjustment variables. We determined the effect of prehospital intravenous catheter or fluid versus no catheter or fluid on all-cause mortality using multivariable logistic regression. Results Of all encounters, 1,350 met criteria for severe sepsis on admission, of whom 205 (15%) died by hospital discharge, 312 (23%) received prehospital intravenous fluid, 90 (7%) received a prehospital catheter alone and 948 (70%) did not receive catheter or fluid. EMS administered a median prehospital fluid volume of 500 mL (interquartile range (IQR): 200, 1000 mL). In adjusted models, the administration of any prehospital fluid was associated with reduced hospital mortality (Odds ratio =0.46; 95% Confidence interval: 0.23, 0.88; P =0.02) compared to no prehospital fluid. The odds of hospital mortality were also lower among severe sepsis patients treated with prehospital intravenous catheter alone (Odds ratio =0.3; 95% Confidence interval: 0.17 to 0.57; P

Race has been identified as an important risk factor for the development of sepsis and as a predictor of poor outcomes in sepsis. For example, black individuals have been demonstrated to be nearly twice as likely to develop sepsis and to have greater mortality from sepsis than white individuals. Recent data from a longitudinal cohort, which examined incident hospitalizations for infections occurring among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, contradicts this prior research. Investigators determined that black participants were significantly less likely than white participants to present to the hospital with either infection or sepsis. Although these results are intriguing, they highlight our inadequate understanding of the relationship between race and sepsis and motivate the need for higher quality epidemiologic research to isolate the true role of race in the development of sepsis.

Background To determine the time and temperature stability of whole blood lactate using experimental conditions applicable to the out-of-hospital environment. Findings We performed a prospective, clinical laboratory-based study at an academic hospital. Whole blood lactate was obtained by venipuncture from five post-prandial, resting subjects. Blood was stored in lithium heparinized vacutainers in three temperature conditions: 1) room temperature (20°C), 2) wrapped in a portable, instant ice pack (0°C), or 3) wet ice (0°C). Lactate concentrations (mmol/L) were measured at 0, 5, 10, 20, and 30 minutes after sampling, and compared using repeated measures analysis of variance. Mean baseline lactate among resting subjects (N = 5) was 1.24 mmol/L (95%CI: 0.49,1.98 mmol/L). After 30 minutes, lactate concentration increased, on average, by 0.08 mmol/L (95%CI: 0.02,0.13 mmol/L), 0.18 mmol/L (95%CI: 0.07,0.28 mmol/L), and 0.36 mmol/L (95%CI: 0.24,0.47 mmol/L) when stored in wet ice, ice pack, and room temperature, respectively. The increase in lactate was similar in samples wrapped in portable ice pack or stored in wet ice at all time points (p > 0.05), and met criteria for equivalence at 30 minutes. However, lactate measurements from whole blood stored at room temperature were significantly greater, on average, than wet ice or portable ice pack within five and ten minutes, respectively (p < 0.05). Conclusions Whole blood lactate measurements using samples stored in a portable ice pack are similar to wet ice for up to 30 minutes. These conditions are applicable to the out-of-hospital environment, and should inform future studies of pre-hospital measurement of lactate.

Introduction Little is known about the mechanisms through which intensivist physician staffing influences patient outcomes. We aimed to assess the effect of closed-model intensive care on evidence-based ventilatory practice in patients with acute lung injury (ALI). Methods We conducted a secondary analysis of a prospective population-based cohort of 759 patients with ALI who were alive and ventilated on day three of ALI, and were cared for in 23 intensive care units (ICUs) in King County, Washington. Results We compared day three tidal volume (VT) in open versus closed ICUs adjusting for potential patient and ICU confounders. In 13 closed model ICUs, 429 (63%) patients were cared for. Adjusted mean VT (mL/Kg predicted body weight (PBW) or measured body weight if height not recorded) for patients in closed ICUs was 1.40 mL/Kg PBW (95% confidence interval (CI) = 0.57 to 2.24 mL/Kg PBW) lower than patients in open model ICUs. Patients in closed ICUs were more likely (odds ratio (OR) = 2.23, 95% CI = 1.09 to 4.56) to receive lower VT (≤ 6.5 mL/Kg PBW) and were less likely (OR = 0.30, 95% CI = 0.17 to 0.55) to receive a potentially injurious VT (≥ 12 mL/Kg PBW) compared with patients cared for in open ICUs, independent of other covariates. The effect of closed ICUs on hospital mortality was not changed after accounting for delivered VT. Conclusions Patients with ALI cared for in closed model ICUs are more likely to receive lower VT and less likely to receive higher VT, but there were no other differences in measured processes of care. Moreover, the difference in delivered VT did not completely account for the improved mortality observed in closed model ICUs.