Turning Back the Clock: Prehospital Antibiotics for Patients With Septic Shock*

Abstract

protocols in a medical-surgical ICU and used quantitative cultures to confirm the diagnosis of VAP. It was only quasi-randomized and single center-but found a significant reduction in VAP with CCPC. Three of the trials were published in Chinese and were not accessible in English, but each is smaller with methodologic shortcomings according to Maertens et al (1).Even though maintaining cuff pressure in the range of 20-30 cm H 2 O is the standard practice in most ICUs, one recent quasi-randomized trial in medical ICU patients found no benefit of the usual practice of checking cuff pressure every 8 hours compared with checking it only on intubation and when there was an obvious cuff leak or the endotracheal tube position had changed (10). The occurrence rate of ventilator-associated events, mortality, and hospital length of stay was the same in both groups. Perhaps, the focus on maintaining cuff pressure is unwarranted.Given the uncertainty of the evidence, and, importantly, that none of the devices tested has demonstrated benefit in a prospective, multicenter, randomized clinical trial, it is not yet time to conclude that continuous control of cuff pressure will decrease the occurrence rate of VAP.

Turning Back the Clock: Prehospital Antibiotics for Patients With Septic Shock: Let Us Act at the Right Time

“…Beyond these considerations, we agree with the authors (1) that the prehospital period offers a window of opportunity to save lives of the most frailty patients suffering from septic shock, especially by decreasing time-to-antibiotic therapy administration. Further prospective studies are needed to clarify the equilibrium between the potential benefits versus unintended harms of prehospital antibiotic therapy administration for patients with septic shock.…”

“…Undoubtedly, the effectiveness of an early strategy should be more effective for the sicker and the most frailty patients. Finally, as pointed out by the authors (1), every aspect of the sepsis care cascade must be considered. Although direct ICU admission also contributes to prognosis improvement, prehospital caregivers should also be careful to transport the patient to the adequate facility for sepsis etiologic treatment, that is, for example emergency surgical ward for suspicion of acute peritonitis.…”

The authors reply

“…To the Editor: W e have read with great interest the report by Cuzco et al (1), published in a recent issue of Critical Care Medicine, describing nursedriven patient empowerment intervention (NEI) during ICU discharge that reduced anxiety and depression scores in critically ill survivors. However, we have three concerns related to the trial's primary outcome.…”

“…We thank Jouffroy et al (1) for their letter responding to our editorial (2) on their retrospective analysis of a prehospital septic shock resuscitation bundle used by mobile ICUs in three cities in France. Jouffroy et al (1) reported that patients with septic shock who received both antimicrobials and intravenous fluids in the pre-hospital setting were almost 50% less likely to die compared with patients who did not.…”

“…Our editorial sought to contextualize this finding. We noted that the median interval until antibiotics are administered for sepsis and septic shock in many EDs remains 3 hours or more, reviewed some of the complexities associated with shortening antibiotic administration times in the ED, and how these points make prehospital administration of antibiotics an attractive strategy to speed delivery of antibiotics to the sickest of patients (2). We noted, however, the complexity of interpreting the literature on the association between time-to-antibiotics and mortality in sepsis due to considerable risk of confounding and that, in net, existing studies suggest there may be a benefit of substantially shortening antibiotic delivery times for patients with septic shock, whereas the data are more equivocal for patients without shock (3, 4).…”