RESUMEN
OBJECTIVE: To test the hypothesis that interhospital transfer causes significant delays in the administration of appropriate antibiotics and compliance with the completion of Surviving Sepsis Bundle elements. DESIGN: Single-center retrospective cohort study. SETTING: A comprehensive 60,000-visit emergency department at a 711-bed Midwestern academic medical center. PATIENTS: Patients with severe sepsis and septic shock treated between 2009 and 2014 were identified by International Classification of Diseases,9th Revision, Clinical Modification, codes, then divided into two cohorts: 1) transfer patients who arrived at the tertiary academic center after receiving care in a local community hospital and 2) control patients who presented directly to the tertiary academic center emergency department. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: One hundred ninety-three patients were included. Transfer patients were more likely to require surgery in the hospital (p < 0.001) and require ICU care (p = 0.001) but had similar illness severity based on (Acute Physiology and Chronic Health Evaluation II, 17.7 vs 17.5; p = 0.662). Antibiotic administration at 1 and 3 hours was comparable between the two cohorts, but initial antibiotic appropriateness was lower in transfer patients (34% vs 79%; p < 0.001). Transfer patients were less likely to have fluid resuscitation started by 3 hours (54% vs 89%; p < 0.001), but they were not less likely to receive an adequate fluid bolus (30 mL/kg) by the time of hospital admission (p = 0.056). There were no differences in ICU length of stay or mortality. CONCLUSIONS: Interhospital transfer significantly delays administration of appropriate initial antibiotics and resuscitation therapy. Future studies are needed to identify strategies of providing regional sepsis care prior to transfer to tertiary centers and to continue care pathways during the interhospital transfer process.
Asunto(s)
Antibacterianos/administración & dosificación , Servicio de Urgencia en Hospital/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Sepsis/tratamiento farmacológico , APACHE , Centros Médicos Académicos , Adulto , Anciano , Antibacterianos/uso terapéutico , Femenino , Fluidoterapia/métodos , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sepsis/mortalidad , Sepsis/terapia , Choque Séptico/mortalidad , Choque Séptico/terapia , Factores de TiempoRESUMEN
The Pd(2)X(2)(&mgr;-S)(dpm)(2) complexes (2) (X = I, Br) react with halogens to yield PdX(2)(dpm) (3) and elemental sulfur. Kinetic and mechanistic studies on the X = I system in CHCl(3) reveal that the reaction proceeds via addition of I(2) to give Pd(2)I(4)(dpm)(2) (4c), which then undergoes unimolecular decomposition to generate PdI(2)(dpm) (3c); the liberated sulfur concatenates to form elemental S(8). The addition reaction is in the stopped-flow time regime and is first-order in both 2c and I(2), with DeltaH() = 32 +/- 1 kJ mol(-)(1) and DeltaS() = -91 +/- 3 J K(-)(1) mol(-)(1). The slower decomposition reaction of 4c is first order in 4c, with DeltaH() = 80 +/-1 kJ mol(-)(1) and DeltaS() = -26 +/- 3 J K(-)(1) mol(-)(1). Byproduct PdX(2)(dpm(S)) (5) [dpm(S) = Ph(2)PCH(2)P(S)Ph(2)] also forms under some conditions via reaction of 3 with an S(n)() species (n < 8). Complexes 5 (X = Cl (a), Br (b), I (c)) were also synthesized directly, and the structure of the 5c species, as well as of [Pd(dpm(S))(2)]Cl(2), were determined by X-ray analyses that reveal the envelope configuration of the five-membered chelate ring.