Faculty Bibliography

BACKGROUND: The study of sepsis is hindered by its heterogeneous time course and evolution. A subgroup of patients with severe sepsis develops shock soon after the initiation of treatment while others present hypotensive. We sought to determine the incidence of hypotension after the initiation of treatment for sepsis, and characterize their clinical features and course. METHODS: A retrospective review of electronic medical record of all septic patients (n = 542) that met the definition of septic shock within 24 hours of admission (2011 - 2012) at an urban Veteran Affairs Hospital was performed. Subjects either had 1) initial normotension (INT) with hypotension developing within 24 hours or 2) initial hypotension (IH). Logistic regression was used to model associated factors of INT/IH. RESULTS: INT occurred in 62 patients (11%) with average initial blood pressure of 120/71 mm Hg and developed hypotension to 79/48 mm Hg. IH was identified in 52 patients (10%) with average presenting blood pressure of 81/46 mm Hg. INT showed evidence of increased sympathetic tone with significantly higher heart rate, blood pressure and temperature. INT patients were younger, more frequently on alpha-blockers, and more likely septic from pneumonia compared to IH patients. INT and IH patients had similar timing of antibiotic initiation, amount of 24-hour fluid resuscitation, vasopressor use, organ dysfunction and mortality at 28 days. Using alpha-blockers, being Caucasian, and having higher temperatures were independent predictors of INT. CONCLUSION: INT is a distinctive presentation of septic shock characterized by rapid deterioration during early treatment. By further studying this subgroup, mediators of septic shock may be identified that clarify pathophysiology and provide timely targeted treatment.

INTRODUCTION: We present an interesting case of medication-induced electrolyte disarray leading to a diagnostic challenge. CASE PRESENTATION: A patient presented with 1 month progressive lethargy, confusion, and polyuria. Past medical history included anal SCC in remission, bipolar disorder treated with lithium, and HIV controlled with HAART including tenofovir. Exam was notable for altered mental status, dry mucous membranes, abdominal tenderness, and copious dilute urine. Initial laboratory results in Table 1. 15 L of free water was repleted over 3 days without change in metabolic disarray. Hypernatremia was consistent with nephrogenic DI as no change occured in low urine osmolarity when given ddAVP. Hypercalcemia with inappropriately normal iPTH (and low PTHrp in setting of SCC) likely worsened free water loss. Lithium induced both of these disorders. Free water loss persisted. A concurrent metabolic acidosis was suspected from tenofovir-induced proximal RTA. Bicarbonate replacement was initiated with continued free water repletion with resultant improvement in mental status and hypercalcemia. Interestingly, once calcium was near normal level, iPTH was rechecked and found to be elevated (>200). By continuing this treatment, as well as discontinuing any offending agents, the patient had recovery from symptoms and near correction of metabolic disarray. DISCUSSION: Nephrogenic DI occurs in up to 20% of chronic lithium patients. It interferes with insertion of aquaporins into apical membranes and decreases density of ADH receptors, leading to free-water loss. It induces hypercalcemia by influencing kidney and parathyroid calcium-sensing receptors, altering the set-point of calcium-PTH axis. Hypercalcemia and elevated PTH result. Furthermore, hypercalcemia can worsen DI by interfering with vasopressin-stimulated water flow, downregulating aquaporins in the collecting ducts, and inhibiting NaCl reabsorption in the medullary thick ascending limb. Complicating matters, the high PTH could have led to bicarbonate loss in urine based on studies in animal models, worsening the tenofovir-induced RTA. CONCLUSIONS: A perpetual cycle of lithium-induced DI and hypercalcemia with tenofovir-induced proximal RTA existed in this patient. Close analysis and attempts to unify all metabolic derangements was needed to help diagnose and treat the persistent symptoms in this patient

OBJECTIVE: Several studies have questioned the effectiveness of rapid-response systems when measured by outcomes such as decreased overall hospital mortality or cardiac arrest rates. We studied an alternative outcome of rapid-response system implementation, namely, its effect on goals of care and designation of do not resuscitate. DESIGN: Retrospective chart review. SETTING: Veterans Administration Hospital in New York City. SUBJECTS: All patients requiring a medical emergency team call. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: : Monthly hospital census and discharge data, death occurrences, and do-not-resuscitate order placements were collected over an 8-year pre-medical emergency team and 5-year post-medical emergency team period. All medical emergency team calls and subsequent transfers to a critical care unit were reviewed and correlated to the placement and timing of do-not-resuscitate orders. Interrupted time-series analysis was used to evaluate the impact of the medical emergency team implementation on the change in trend of do-not-resuscitate orders and the hospital mortality. A total of 390 medical emergency team calls were associated with 109 do-not-resuscitate orders (28%). Of the 209 medical emergency team calls (54%) resulting in transfer to a critical care unit, 66 were associated with do-not-resuscitate orders, 73% of which were obtained after transfer. The odds of becoming do not resuscitate for a patient going to the ICU after the medical emergency team call were 2.9 (95% CI, 1.6-5.5; p = 0.001) times greater than for patients staying on the floors after the medical emergency team call. The medical emergency team implementation significantly changed the trend of do-not-resuscitate orders (p < 0.001) but had no impact on hospital mortality rate (p = 0.638). CONCLUSION: Implementation of a rapid-response system was associated with an increase in do-not-resuscitate order placement. As a sentinel event, medical emergency team activation and transfer to a critical care unit foster consideration of goals of care and frequently results in a transition to a palliative care strategy.