2026 Southeastern Residency Conference

Title: Tirofiban use following mechanical thrombectomy with emergent stent placement in acute ischemic stroke
Author Names: Taylor Dodd, Mallory Stringer, Eric Shaw
Resident E-mail: [email protected]

Background
Tandem lesions are present in 15-25% of all acute ischemic strokes (AIS) presenting with a large vessel occlusion (LVO) and are associated with increased morbidity and mortality. Treatment of tandem lesions is not standardized, but may include intra-arterial thrombolysis, balloon angioplasty, and/or emergent stent placement during mechanical thrombectomy. Emergent stent placement requires antiplatelet therapy which may include glycoprotein (GP) IIb/IIIa inhibitors (e.g. tirofiban), aspirin, and/or P2Y12 inhibitors. Currently, there is inconsistent data regarding the dosing and duration of tirofiban infusion following mechanical thrombectomy with emergent stent placement in AIS. Retrospective data suggests similar rates of symptomatic intracranial hemorrhage (ICH), mortality, and reperfusion rates with tirofiban use compared to without tirofiban. The study objective is to evaluate the safety and efficacy of tirofiban followed by dual antiplatelet therapy (DAPT) compared to antiplatelet therapy alone in AIS patients post mechanical thrombectomy with emergent stent placement.

Methods
This was a single-center retrospective study conducted at a 711-bed DNV certified comprehensive stroke academic medical center. Adults admitted to the neurovascular intensive care unit (ICU) for AIS following mechanical thrombectomy and emergent stent placement that received tirofiban and/or antiplatelet therapy were included. Protected populations were excluded. The primary outcome was symptomatic ICH, defined as ICH on imaging with any of the following: need for neurosurgical intervention, intubation, decrease in Glasgow Coma Scale score ≥ 2 within 24 hours of tirofiban or DAPT. Secondary outcomes included any ICH, hospital and ICU length of stay (LOS), successful reperfusion (defined as a thrombolysis in cerebral infarction (TICI) score ≥ 2b), neurologic improvement (change in modified Rankin scale (mRS) from admission to discharge), and all-cause mortality.

Results
In this study, 56 patients were included with 27 patients in the tirofiban group and 29 patients in the group without tirofiban. Four patients (14.8%) in the tirofiban group compared to none in the without tirofiban group experienced symptomatic ICH within 24 hours of receiving tirofiban or DAPT (p<0.001). Any ICH was more prevalent in the tirofiban group compared to without tirofiban (51.9% vs. 6.9%, p<0.001). Hospital LOS (6.9 days vs. 6.1 days, p=0.386) and ICU LOS (3.8 vs. 3.7 p=0.444) were similar between groups. Successful reperfusion was achieved in 92% of patients in the tirofiban group compared to 84.6% in the without tirofiban group (p=0.668). Changes in mRS were not statistically different between groups (p=0.733). All-cause mortality was similar between groups (22.2% vs. 20.7%, p=0.837).

Conclusions
In our study population, the use of tirofiban had more ICH compared to patients not receiving tirofiban in AIS patients following mechanical thrombectomy and emergent stent placement.

Background 
Gram-negative bloodstream infections (GN-BSI) are associated with significant morbidity and mortality and traditionally managed with intravenous (IV) antibiotics. However, emerging evidence supports the use of oral (PO) antibiotics as step-down therapy in uncomplicated GN-BSI.1-7 Oral agents such as fluoroquinolones, sulfamethoxazole-trimethoprim, and β-lactams have demonstrated efficacy in this setting.1-2 Transitioning to a PO agent offers several benefits such as reduced cost, easier administration, and less risk of IV-associated complications, which include venous thrombosis, extravasation, and phlebitis.8-9 Despite these potential benefits, data on this practice in critically ill patients remain limited. This study aims to evaluate the safety and efficacy of IV therapy alone versus IV to PO step-down therapy in the treatment of critically ill patients with a GN-BSI. 
 
Methods 
This is a multicenter retrospective cohort analysis that evaluated adult patients with an uncomplicated GN-BSI who were initiated on appropriate empiric IV antibiotic treatment within 24 hours of their initial blood culture collection. The study included patients who were admitted to an intensive care unit (ICU) within Emory Healthcare (EHC) between May 1, 2023 and May 1, 2025. Patients were excluded if the duration of PO therapy was less than 48 hours, there was polymicrobial growth or presence of an organism other than Enterobacterales or Pseudomonas spp., hospice or comfort care was initiated within 72 hours of initial blood culture, or the organism(s) isolated was not susceptible to an available PO agent. The primary outcome was treatment failure, defined as a composite of 90-day mortality or recurrence of the same causative GN-BSI within 30 days of treatment completion. Secondary efficacy outcomes include ICU and inpatient length of stay, recurrence of GN-BSI within 90 days of treatment completion, emergence of resistance to study antibiotics, antibiotic duration, and IV to PO transition time. Secondary safety outcomes include adverse drug events leading to discontinuation or change in antibiotic therapy. Baseline demographics and outcomes were summarized with descriptive statistics while continuous data was summarized with means and standard deviations. 
 
Results 
Patients were separated into two cohorts based on antibiotic regimen: IV only (n=108) versus IV to PO (n=33). Baseline characteristics differed between groups, with patients in the IV only group demonstrating higher illness severity, depicted by higher median APACHE II (18 vs 14) and Pitt bacteremia scores (3 vs 2). The most common pathogens were Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, Enterobacter cloacae, and Pseudomonas aeruginosa. Pulmonary sources were more prevalent in the IV only group, while genitourinary sources were more common in the IV to PO group. Treatment failure occurred more frequently in the IV only group compared to the IV to PO group (41.7% vs 15.1%). Recurrence of the same causative bacteria within 90 days was similar between groups (4.6% vs 6.1%), as was the emergence of resistance to study antibiotics (7.4% vs 9.1%). ICU and hospital length of stay were longer in the IV only group (13 vs 4 days and 21 vs 11 days). However, total antibiotic duration was longer in the IV to PO group (13 vs 9 days). Adverse drug events were uncommon in both groups. 
 
Conclusions 
While IV to PO step-down therapy was associated with lower rates of treatment failure, further research is needed to optimize treatment by determining appropriate drug selection and timing of transition. For critically ill patients with uncomplicated GN-BSI and adequate source control, this approach appears to be appropriate and may reduce length of stay without compromising effectiveness. These findings align with existing literature supporting PO step-down therapy as a method with comparable efficacy to continued IV therapy. 

Sedation Practices in Patients Undergoing Targeted Temperature Management at 36° C
Grace Clark, Anais Solomon, Joanna Brennan, Bibidh Subedi
AdventHealth Orlando, FL

Background: Targeted temperature management (TTM) is the practice of cooling patients’ core body temperature for comatose patients after cardiac arrest to prevent brain damage. Historically, patients undergoing TTM to a goal of 33° C have been deeply sedated with Richmon Agitation and Sedation Scale (RASS) goals of -4 to -5 to avoid shivering, which increases the cerebral metabolic demand. In 2013, the TTM trial was published, prompting the 2015 ACLS guidelines to include 36° C for TTM. TTM to 36° C reduces shivering and possibly sedation needs. The objective of this study was to characterize sedation practices during TTM at 36° C, focusing on RASS goals and the sedation level achieved.


Methods: This was a multicenter, retrospective cohort study with 75 patients from AdventHealth Central Florida campuses who were enrolled between 4/1/2025 and 9/30/2025. Adult patients 18 years of age or older were included if they received TTM at 36° C after out-of-hospital or in-hospital cardiac arrest. Patients were excluded if they were pregnant, had multiple cardiac arrests, or if they were placed on extracorporeal membrane oxygenation (ECMO). The primary outcome was sedation level achieved measured by the RASS score for five days post cardiac arrest. Secondary outcomes included prescribed RASS goal, if the RASS goal was changed during TTM, sedation medications utilized, cumulative doses of sedative medications, Glascow Coma Scale (GCS) at baseline and on day five, time to extubation, incidence of seizure, incidence of tracheostomy, ICU and in-hospital mortality, and ICU and hospital length of stay.


Results: All 75 patients were included in analysis. The average age of our patients was 62 years old with 68% being male. Witnessed arrests occurred in 77.3% of patients with 25.3% having a shockable rhythm initially. The median time to ROSC in witnessed arrests was 12 minutes. Around 61.3% of patients received vasoactive agents within 1 hour of hospital admission. The median RASS achieved was -2.5 on day 1 and 0 on days 2-5. The most common RASS goals were -1 to -2 (73.3%) and 0 to -1 (14.7%), with 29.3% of patients having their RASS goals changed during TTM. The most common continuous sedation medications were fentanyl (78.67%), propofol (76%), midazolam (58.67%), and dexmedetomidine (30.67%). The cumulative daily dose for dexmedetomidine increased over the first 72 hours, while fentanyl, midazolam, and propofol doses decreased. Patients were on sedative continuous infusions for a median of 36 hours with a TTM median duration of 72 hours. The number of patients on continuous sedation was 67 (89.3%), 48 (64%), 38 (50.7%), 25 (33.3%), and 16 (21.3%) respectively for days 1-5. The number of patients on as needed sedation was 8 (10.7%), 11 (14.7%), 11 (14.7%), 8 (10.7%), and 7 (9.3%) respectively for days 1-5. Around 37% of patients had TTM discontinued early with 5.3% of them due to the patient following commands. Median GCS was 15 at baseline and 10 on day 5. Seizures occurred in 19 people (25.3%) for a median of 2.63 days. Shivering occurred in 11 people (14.7%) and 8 people (10.7%) received tracheostomy. The median time to extubation was 2.7 days. The median lengths of stay were 4 days for the ICU and 7 days for the whole hospitalization. Mortality occurred in 46 cases (61.3%) with all the patients dying during their ICU stay.


Conclusions: Our study found that most patients undergoing TTM at 36° C had lower sedation targets prescribed and achieved than have been historically attained. Most patients were able to complete the full 72 hours of TTM. Further prospective studies are warranted to evaluate optimal sedation target in this demographic.

Presentation Objective: Analyze current targeted temperature management (TTM) sedation practices within AdventHealth Central Florida division.

Background: Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection among patients with decompensated cirrhosis. Ceftriaxone remains a widely used first line empiric therapy; however, shifts in epidemiology and rising antimicrobial resistance have raised concerns regarding treatment failure in this population. A key challenge in SBP management is that up to 60% of cases are culture negative, necessitating reliance on peritoneal fluid cytology for diagnosis and assessment of therapeutic response. In patients with culture negative SBP who fail to respond to ceftriaxone, evidence-based guidance for antibiotic escalation is lacking, resulting in substantial variability in clinical practice. Evaluation of outcomes in patients with culture negative SBP empirically treated with ceftriaxone may help identify risk factors for treatment failure and inform the effectiveness of commonly employed escalation strategies.
Objective: This study aims to determine the success rates of the following antibiotic escalation strategies used after ceftriaxone failure: carbapenem-sparing regimens (cefepime, or piperacillin-tazobactam), carbapenem regimens, carbapenem-sparing + broad gram-positive coverage (vancomycin, linezolid, or daptomycin), or carbapenem + broad gram-positive coverage. A secondary aim is to identify risk factors associated with ceftriaxone treatment failure in the patient population.
Methods: This is a retrospective cohort study conducted at a tertiary referral hospital from June 2022 to December 2025. Adult patients were included if they had culture negative SBP, defined as an ascitic polymorphonuclear (PMN) count ≥250 cells/µL, were primarily treated with ceftriaxone, and underwent a repeat paracentesis ≥48 hours later to assess treatment response (or had resolution of ascites). Patients were excluded if they had secondary peritonitis, non-cirrhotic peritonitis, or received ≥ 24 hours of alternative antibiotics prior to ceftriaxone. For the primary outcome, we evaluated response rates across the 4 antibiotic escalation groups. Treatment success was defined as a ≥25% reduction in PMN count on repeat paracentesis. For the secondary endpoint, we planned to evaluate risk factors associated with treatment failure and compare patient outcomes.
Results: A total of 69 patients with culture-negative SBP were included. The median age was 55 years (IQR 47–66), 67% were male, and the most common etiology of cirrhosis was alcohol-related (41%). Median MELD-Na score was 22 (IQR 17–28). The median time from admission to SBP diagnosis was 20 hours (IQR 1–69), and 86% of patients received ceftriaxone 2g. Ceftriaxone failure occurred in 5 patients (7.2%). All five received antibiotic escalation: four were treated with a carbapenem-based regimen, and one received cefepime with metronidazole. Among patients with documented PMN response data, reductions ranged from 31% to 89%. Two patients in the ceftriaxone failure group died in-hospital (40%) compared to 4 patients (6%) in the success group. Median hospital length of stay was longer in the failure group (14 days [IQR 10–16] vs. 8 days [IQR 6–18]), as was duration of antibiotic therapy (9 days [IQR 7–13] vs. 5 days [IQR 4–6]). In an exploratory analysis of potential risk factors, nosocomial SBP was identified in 20% of failures and 27% of successes. Prior anti-pseudomonal antibiotic exposure within 90 days was more prevalent among ceftriaxone failures compared to successes (40% vs. 23%). The small sample size precluded formal statistical comparison for all outcomes.
Conclusion: Ceftriaxone failure was uncommon in our cohort of culture-negative SBP, occurring in approximately 7% of patients. Ceftriaxone failure was associated with prolonged hospitalization, extended antibiotic exposure, and higher in-hospital mortality. Prior broad-spectrum antibiotic use emerged as a potential risk factor warranting further investigation in larger cohorts. These findings underscore the need for larger prospective studies to establish evidence-based escalation strategies.

Optimizing Rabies Post-Exposure Management: Assessing Immunoglobulin Use and Vaccination Follow Up   

Quartney Gilliam, Mckenzie Hodges, Bianca Rivera-Ramirez, Aayush Patel 

Piedmont Columbus Regional Midtown, Columbus, GA 

Background: Rabies is a viral infection that is fatal without timely and proper intervention. Transmission most commonly occurs through the bite of an infected animal, with dogs representing the predominant source of human exposure. Current guidelines emphasize rapid and comprehensive post-exposure prophylaxis (PEP), which includes immediate wound cleansing, prompt administration of human rabies immunoglobulin (HRIG), and initiation of the vaccine series. Although PEP is highly effective when given appropriately and on time, its real-world implementation is often challenged by system level and institutional barriers. These include delays in starting treatment, late or missed doses of HRIG or vaccines, variability in provider adherence to protocols, poor patient follow-up, as well as significant strain on both patients and the healthcare system when navigating multiple visits across different facilities, possibly leading to confusion and fragmented care. To help reduce unnecessary repeat emergency department visits and improve continuity of care, patients presenting to Piedmont Columbus Regional Midtown (PCRM) or Piedmont Columbus Northside (PCN) emergency departments may be referred to Midtown Medical Clinic (MMC), a transitional care clinic, for follow-up rabies vaccinations. This study aims to evaluate the effectiveness of the current institutional rabies PEP protocols implemented at both PCRM as well as PCN, identify gaps in its application, and explore strategies to improve adherence, timeliness, and patient outcomes after a potential rabies exposure. 

Methodology: We conducted an IRB‑approved retrospective chart review of patients presenting to the emergency departments of PCRM or PCN from January 1, 2025, to December 31, 2025. This review included all patients who presented with a chief complaint of an animal-related bite or scratch. Patients were excluded if they transferred to another facility after evaluation or PEP initiation, left against medical advice, refused vaccination, or had insufficient documentation to determine exposure type, treatment, or follow‑up. The primary outcome measured adherence to CDC rabies PEP guidelines by determining whether eligible patients received indicated HRIG and/or vaccine and identifying both missed treatment and treatment given to patients who did not meet criteria. The secondary outcomes evaluated instances where clinical criteria for initiating rabies PEP were not met, follow-up compliance, and the rate and factors associated with referral to MMC for follow-up care. The outcomes were assessed using descriptive statistics.

Results: Among 200 screened patients (157 adults and 43 pediatric patients), eligibility for rabies post‑exposure prophylaxis (PEP) was identified in 42% of adults and 56% of pediatric patients. Among eligible patients, 77% of adults and 50% of pediatric patients were initiated on PEP, while 9% of ineligible adults and 10% of ineligible pediatric patients received PEP. Follow‑up after PEP initiation varied, with 25% of adults and 43% of pediatric patients completing the full vaccination series, and differences in follow‑up location observed based on the site of initial presentation.

Conclusions: In this evaluation adult rabies PEP initiation largely aligned with CDC guidance with most eligible adults receiving therapy and minimal use among those without indications. In contrast, initiation among pediatric patients meeting eligibility criteria was inconsistent. Across both age groups completion of the rabies vaccination series remained challenging, highlighting persistent barriers to follow‑up after initial PEP initiation.

Contact: [email protected]

Background: Stroke complicates up to 20% of traumatic blunt cerebrovascular injuries (BCVI), with the highest risk occurring within 72 hours of injury, underscoring the importance of prompt antithrombotic therapy. Current guidelines from the Eastern Association for the Surgery of Trauma and the Western Trauma Association recommend antithrombotic therapy but differ in preferred agents and dosing strategies. Prisma Health Richland’s (PHR) institutional guideline recommends aspirin monotherapy for BCVI grades I–III without specifying dose. Data comparing aspirin dosing in BCVI are limited. One retrospective study reported a 3.5% stroke rate with aspirin 81 mg, compared with previously reported rates of 2–8% using aspirin 325 mg. We sought to compare the incidence of ischemic stroke among patients with traumatic BCVI treated with aspirin 81 mg versus 325 mg. 
  
Methods: We conducted a retrospective cohort study of adult patients with traumatic BCVI treated with aspirin monotherapy at PHR from February 27, 2021 to September 30, 2025. Patients with stroke prior to aspirin initiation during index admission, inconsistent aspirin dosing within the first 7 days, or grade V BCVI were excluded. The primary outcome was ischemic stroke within 90 days of injury. Secondary outcomes included time to aspirin initiation, adherence to repeat imaging guidelines, worsening intracerebral hemorrhage (ICH), worsening solid organ injury, gastrointestinal (GI) bleeding, and in-hospital mortality. Baseline characteristics were compared using appropriate univariate analyses. Multivariable logistic regression was performed to evaluate the association between aspirin dose and ischemic stroke, adjusting for BCVI grade and time to aspirin initiation. 
  
Results: This study included 130 patients with a traumatic BCVI who were treated with aspirin therapy for stroke prevention. Of those included, 106 patients (81.5%) received aspirin 325 mg and 24 patients (18.5%) received aspirin 81 mg. Baseline characteristics were similar between the two treatment groups, with the majority being African American males. The most common mechanism of injury was motor vehicle collision (73.8%), followed by injury due to a fall (16.2%) and assault (1.5%). Concomitant traumatic brain injury was present in 46.2% of patients, while 13.8% of patients also had a solid organ injury. During the study period, 12 patients (9.2%) experienced an ischemic stroke. Ten of these patients received aspirin 325 mg, while 2 patients received aspirin 81 mg (p=1). Multivariate logistic regression with covariates BCVI grade and time to aspirin initiation demonstrated no different in the incidence of ischemic stroke with aspirin 325 mg (aOR 0.831, 95% CI 0.951-1.003). The majority of patients (94.6%) had repeat imaging completed within the 7-day timeframe indicated in our local BCVI guidelines. A new or worsening ICH occurred in 22 patients, the majority being in the aspirin 325 mg group (n=19; p=0.764), and a GI bleed occurred in 5 patients, all of whom received aspirin 325 mg (p=0.584). The overall mortality rate was 9.2% with 8 patients in the aspirin 325 mg group and 4 patients in the aspirin 81 mg group dying during the study period (p=0.225) 
 
Conclusion: This retrospective cohort study found that patients with a traumatic BCVI were more frequently treated with aspirin 325 mg compared to 81 mg, however, there was no significant difference in the primary outcome comparing the incidence of ischemic stroke between these two treatment groups. There was a non-significantly higher incidence of new or worsening ICH and GI bleed in the aspirin 325 mg group. These findings suggest that a larger study with more variance in aspirin treatment may be beneficial to validate a correlation between aspirin dose and incidence of ischemic stroke. 

Evaluation of Serum Phosphate Levels in ICU Patients Undergoing Continuous Renal Replacement Therapy
Katherine Fonfara, Eric Pyles, Rebecca Falter
AdventHealth Orlando, Orlando, FL
Background: Severe hypophosphatemia is associated with serious adverse effects such as skeletal muscle weakness, respiratory insufficiency, cardiac rhythm disturbances, and delirium. These complications have been linked to worsening clinical outcomes including failed extubations, increased time on mechanical ventilation, and increased intensive care unit (ICU) and hospital length of stay. Patients on continuous renal replacement therapy (CRRT) are at increased risk of experiencing hypophosphatemia and the corresponding complications.

Iatrogenic hypophosphatemia represents a modifiable risk factor that may potentially improve patient outcomes. This study aims to evaluate phosphate replacement strategies in critically ill patients on CRRT and characterize incidence and severity of hypophosphatemia. 

Methods: This evaluation was a single-center, retrospective study comparing rates of hypophosphatemia in adult patients requiring CRRT and those not on CRRT admitted to the ICU at a large community hospital. Patients who were admitted to an ICU and receiving CRRT for 24 hours or more were included in the treatment group. The control group included patients admitted to an ICU and not requiring CRRT. Patients with end-stage renal disease on chronic dialysis, nocturnal CRRT/sustained low-efficiency dialysis (SLED), or with confounding metabolic conditions were excluded from either group. The primary outcome was the percentage of hypophosphatemic levels, defined as serum phosphate level less than 1.9 mg/dL. Secondary outcomes included percentage of severe hypophosphatemic levels, defined as serum phosphate level less than 1.0 mg/dL, in-hospital mortality, hospital length of stay, ICU length of stay, and time requiring mechanical ventilation. A post-hoc subgroup analysis was conducted to compare the primary outcome based on average CRRT flow rates. 

Results: A total of 100 patients were included in the study, with 50 patients included in each group. The baseline demographics were similar between both groups except home diuretic use, and baseline phosphorus and serum creatinine levels. In the control group, the median baseline phosphorus level was 3.1 mmol/L (IQR 2.6-3.8), and the median baseline serum creatinine was 1.0 mg/dL (IQR 0.8-1.2). In the CRRT group, the median baseline phosphorus level was 5.4 mmol/dL (IQR 4.2-6.4), and the median baseline serum creatinine was 2.9 mg/dL (IQR 2.2-4.1). 

Regarding the primary outcome, the CRRT group had a significantly higher median percentage of hypophosphatemic levels compared with the control group (10.8% [0-29.3] vs 0% [0], p < 0.001). For the secondary outcomes, there was no difference in the median percentage of severely hypophosphatemic levels between groups (0% [0] in both groups, p = 0.317). The median hospital length of stay was longer in the CRRT group compared with the control group (14 days [7-24.8] vs 4.5 days [3-9.5], p < 0.001). Similarly, the median ICU length of stay was longer in the CRRT group (8 days [5-14] vs 3 days [2-7], p < 0.001). The median ventilator duration was also significantly longer in the CRRT group (4 days [3-8] vs 1 day [1-2], p < 0.001). In-hospital mortality was significantly higher in the CRRT group with 62% of patients dying during admission compared with 18% in the control group (p < 0.001). In the subgroup analysis of the CRRT group, there was no difference in percentage of hypophosphatemic levels across flow rate groups (< 20 ml/kg/h, 20-25 ml/kg/h, and > 25 ml/kg/h). 

Conclusions: Patients receiving CRRT were associated with a significantly greater percentage of hypophosphatemic phosphate measurements compared with control group. The CRRT group had higher phosphate levels at baseline and was associated with increased phosphate depletion. No association was observed between CRRT dialysate flow rate and the percentage of hypophosphatemic levels. These findings support the need for close phosphorus monitoring as well as early phosphorus supplementation.

Background:
Sepsis is a life-threatening condition caused by a dysregulated host response to infection, and septic shock represents its most severe form, carrying a high mortality risk. Intravenous (IV) hydrocortisone is recommended by the Surviving Sepsis Guidelines for patients requiring ongoing vasopressor support despite adequate fluid resuscitation. However, the optimal discontinuation strategy remains unclear as current guidelines do not specify whether hydrocortisone should be tapered or abruptly discontinued. Existing literature is limited and conflicting, and practice variability persists. This study evaluates the impact of hydrocortisone tapering versus abrupt discontinuation on recurrence of septic shock.
Methods:
This single-center, retrospective cohort study was conducted at Atrium Health Wake Forest Baptist Medical Center. Adult patients admitted to the Medical Intensive Care Unit (ICU) between September 2024 and August 2025 who received ≥ 8 doses or ≥48 hours of IV hydrocortisone for septic shock were included. Patients were categorized into two groups: taper (any dose reduction prior to discontinuation) or no taper (abrupt discontinuation). Resolution of shock was defined as maintaining a mean arterial pressure ≥65 mmHg without vasopressor support for ≥12 hours.
The primary outcome was recurrence of septic shock, defined as vasopressor reinitiation within 72 hours or escalation in vasopressor or hydrocortisone therapy. Secondary outcomes included duration of vasopressor therapy, ICU length of stay, hospital length of stay, and incidence of hyperglycemia (≥180 mg/dL). Continuous variables were analyzed using Wilcoxon rank-sum tests, and categorical variables using chi-square or Fisher’s exact tests, as appropriate.
Results:
A total of 43 patients were included (no taper n=30; taper n=13). Baseline characteristics were similar between groups, with no statistically significant differences in age, sex, vasopressor requirements, or severity markers.
Recurrence of septic shock occurred in 30% of the no-taper group and 38% of the taper group (p=0.7), demonstrating no statistically significant difference between strategies. Median duration of vasopressor therapy was similar (136 hours vs 123 hours; p=0.6).
There were no significant differences in secondary outcomes, including ICU length of stay (8 vs 7 days; p>0.9), hospital length of stay (18 vs 16 days; p=0.8), or incidence of hyperglycemia (70% vs 69%; p>0.9).
Conclusions:
In this retrospective cohort study, tapering of hydrocortisone did not reduce the recurrence of septic shock compared to abrupt discontinuation. No differences were observed in vasopressor duration, length of stay, or hyperglycemia. These findings suggest that routine tapering of hydrocortisone may not provide clinical benefit in this population. Prospective studies are warranted to confirm these findings and inform guideline recommendations.

Authors: Mikayla Texido, Jill Dunning, Caitlin Thomas
Purpose/Background: Hyperglycemia is commonly seen and associated with adverse outcomes among hospitalized patients, especially in the intensive care unit (ICU) because these patients are more vulnerable to poor outcomes. Previous trials demonstrate that improved glycemic management can reduce hospital complications, infections, and costs. In the critical care setting, guidelines recommend continuous intravenous (IV) insulin infusion as the preferred method for achieving specific glycemic goals while avoiding hypoglycemia. Despite these recommendations, there are limited studies that directly compare the safety and efficacy of IV insulin to subcutaneous (SubQ) insulin for glycemic management in the critical care setting. This study aims to evaluate patients who were eligible for IV insulin administration through an electronic glucose management system (eGMS) and compare those who were managed with IV insulin via eGMS versus those managed with SubQ insulin.
Methodology: This was a single center, retrospective chart review conducted at AdventHealth Orlando that evaluated patients in the ICU who received glycemic management with either IV or SubQ insulin from June 18, 2025, to August 18, 2025. Adult patients with either two consecutive blood glucose values ≥180 mg/dL or one blood glucose ≥300 while admitted to the cardiac, neuro, medical, surgical, or multi-system ICU were included. Patients were excluded if they were managed on IV insulin utilizing eGMS for less than 6 hours, were managed with IV insulin without eGMS, had cardiovascular surgery within 30 days prior to inclusion, or were being treated with insulin for diabetic ketoacidosis, hyperosmolar hyperglycemic state, or hyperkalemia. Patients managed with IV insulin through eGMS utilization were compared to those managed with SubQ insulin. The primary outcome was the percentage of blood glucose values within a goal range of 70-180 mg/dL. A total of 774 blood glucose values would provide 80% power to detect a 10% difference. Secondary efficacy endpoints included the time until blood glucose was in range, median blood glucose, and ICU length of stay in both groups, with time on eGMS and percent of successful transitions from IV to SubQ additionally evaluated in the IV group. Safety endpoints included the incidence of hypoglycemia (BG <70 mg/dL) and severe hypoglycemia (BG <40 mg/dL).
Results: Of the 431 patients screened, 149 patients met inclusion criteria and no exclusion criteria with 74 in the IV group and 75 in the SubQ group. The IV group had a total of 3,997 individual blood glucose values while the SubQ group had 1,599. Of the patients included, 82 (55.0%) were male, the median A1c was 6.7%, and the median blood glucose on ICU admission was 198 mg/dL. Blood glucose was within the goal range of 70-180 mg/dL in 79.9% of the measurements in the IV group versus 61.2% in the SubQ group (p<0.001). The median blood glucose in the IV group was 146 mg/dL versus 173 mg/dL in the SubQ group (p<0.001). Of patients who were able to maintain their blood glucose within goal range for at least 6 consecutive hours, the median time to blood glucose within goal range was 6.3 hours in the IV group (n=72) versus 14.0 hours in the SubQ group (n=60; U=1011; p<0.001). The patients in the IV group had a longer median ICU length of stay (7.5 days vs. 4.0 days; U=1877.5; p<0.001) and there were no incidences of severe hypoglycemia in either group.
Conclusion: Hyperglycemic patients admitted to the ICU had a higher percentage of blood glucose values within the goal range of 70-180 mg/dL with intravenous insulin administered via eGMS compared to patients managed with subcutaneous insulin.