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, 14 (2), 145-52

Out-of-hospital Fluid in Severe Sepsis: Effect on Early Resuscitation in the Emergency Department

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Out-of-hospital Fluid in Severe Sepsis: Effect on Early Resuscitation in the Emergency Department

Christopher W Seymour et al. Prehosp Emerg Care.

Abstract

Background: Early identification and treatment of patients with severe sepsis improves outcome, yet the role of out-of-hospital intravenous (IV) fluid is unknown.

Objective: To determine if the delivery of out-of-hospital fluid in patients with severe sepsis is associated with reduced time to achievement of goal-oriented resuscitation in the emergency department (ED).

Methods: We performed a secondary data analysis of a retrospective cohort study in a metropolitan, tertiary care, university-based medical center supported by a two-tiered system of out-of-hospital emergency medical services (EMS) providers. We studied the association between delivery of out-of-hospital fluid by advanced life support (ALS) providers and the achievement of resuscitation endpoints (central venous pressure [CVP] > or =8 mmHg, mean arterial pressure [MAP] > or =65 mmHg, and central venous oxygen saturation [ScvO(2)] > or =70%) within six hours after triage during early goal-directed therapy (EGDT) in the ED.

Results: Twenty five (48%) of 52 patients transported by ALS with severe sepsis received out-of-hospital fluid. Data for age, gender, source of sepsis, and presence of comorbidities were similar between patients who did and did not receive out-of-hospital fluid. Patients receiving out-of-hospital fluid had lower out-of-hospital mean (+/- standard deviation) systolic blood pressure (95 +/- 40 mmHg vs. 117 +/- 29 mmHg; p = 0.03) and higher median (interquartile range) Sequential Organ Failure Assessment (SOFA) scores in the ED (7 [5-8] vs. 4 [4-6]; p = 0.01) than patients not receiving out-of-hospital fluid. Despite greater severity of illness, patients receiving out-of-hospital fluid approached but did not attain a statistically significant increase in the likelihood of achieving MAP > or =65 mmHg within six hours after ED triage (70% vs. 44%, p = 0.09). On average, patients receiving out-of-hospital fluid received twice the fluid volume within one hour after ED triage (1.1 L [1.0-2.0 L] vs. 0.6 L [0.3-1.0 L]; p = 0.01). No difference in achievement of goal CVP (72% vs. 60%; p = 0.6) or goal ScvO(2) (54% vs. 36%; p = 0.25) was observed between groups.

Conclusions: Less than half of patients with severe sepsis transported by ALS received out-of-hospital fluid. Patients receiving out-of-hospital IV access and fluids approached but did not attain a statistically significant increase in the likelihood of achieving goal MAP during EGDT. These preliminary findings require additional investigation to evaluate the optimal role of out-of-hospital resuscitation in treating patients with severe sepsis.

Figures

Figure 1
Figure 1
Diagram of cohort construction. ALS = advanced life support; BLS = basic life support; ED = emergency department; EGDT = early goal-directed therapy; EMS = emergency medical services.
Figure 2
Figure 2
Early goal-directed therapy protocol used in the emergency department during the time period of study (2005–2006). ABG = arterial blood gas; ACTH = adrenocorticotropic hormone; APACHE = Acute Physiology and Chronic Health Evaluaton; CVC = central venous catheter; CVP = central venous pressure (mmHg); HgB = hemoglobin (g/dL); HR = heart rate (bpm); IJV = internal jugular vein; IV intravenous; MAP = mean arterial pressure (mmHg); Norepi = norepinephrine; NS = normal saline; PRBCs = packed red blood cells; RR = respiratory rate (breaths/min); SBP = systolic blood pressure (mmHg); SCV = subclavian vein; ScvO2 = central venous oxygen saturation; SIRS = systemic inflammatory response syndrome; Stim = stimulation; T = temperature (°F); WBC = white blood cell count (× 109/L). Lactate level is measured in mmol/L.
Figure 3
Figure 3
Proportion of patients with severe sepsis receiving out-of-hospital fluid, with upper bound of 95% confidence interval. SBP = systolic blood pressure; ED = emergency department; SOFA = Sequential Organ Failure Assessment (score).
Figure 4
Figure 4
Cumulative incidence curve for achievement of mean arterial pressure (MAP) ≥65 mmHg after emergency department (ED) triage during early goal-directed therapy. Log rank test comparing patients with and without out-of-hospital fluid, p = 0.07.

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