Does early antibiotic administration affect disposition or length of stay in patients with cryptic shock? A retrospective pilot study

Introduction

Recent published literature supports the recommendations of early antibiotic administration for patients with sepsis. However, certain patients with suspected sepsis do not manifest typical symptoms, such as perturbations in blood pressure and heart rate. To identify these high-risk patients, surrogate evidence of hypoperfusion such as hyperlactatemia and decreased central venous oxygen saturation may be employed. These patients are described as being in compensated or 'cryptic shock'. The current study investigates whether early administration of antibiotics affects the ICU or hospital length of stay (LOS) in patients with 'cryptic shock'.

Methods

The current investigation is a retrospective analysis (January 2000–December 2005) of patients evaluated in the emergency department with evidence of cryptic shock. Two hundred and sixty patients were identified. Cryptic shock diagnosis was based upon the lactate level, central venous oxygen saturation and mean arterial pressure (MAP) at the time of presentation to evaluate the impact of early antibiotic administration (antibiotics <1 hour, or antibiotics <3 hours) on disposition and length of stay.

Forty-eight patients were found with a complete set of data with MAP > 65 mmHg and lactate > 4 mmol/l and ScvO₂ < 65 mmHg. Of these, 32 patients were identified with MAP > 90 mmHg, lactate > 4 mmol/l and ScvO₂ < 65 mmHg. Using chi-square and Fisher's exact method, data for the presence of cryptic shock and ICU LOS were analyzed. All tests were two-sided and assessed at the 0.05 type-I error rate.

Results

Patients with MAP > 90 mmHg and elevated lactate had a mean time until antibiotics of 174 minutes, MAP = 95 mmHg and lactate = 7.5 mmol/l, respectively. For patients admitted to the ICU the mean LOS = 5.5 days, and for those admitted to a general ward the mean LOS = 11.1 days. There was no association between early administration of antibiotics (antibiotics <1 hour, or antibiotics <3 hours, P = 0.86 and P = 0.89 respectively) and ICU LOS. When the degree of cryptic shock was stratified based upon a level of lactate > 2.5 mmol/l or lactate > 4 mmol/l, again there was no association with LOS (P = 0.47 and P = 0.33, respectively).

Conclusion

In patients with cryptic shock, with early administration of antibiotics whether administered in <1 hour or < 3 hours there was no statistically significant impact on total hospital LOS or ICU LOS.