Early fluid bolus in adults with sepsis in the emergency department: a systematic review, meta-analysis and narrative synthesis

Abstract

Background Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood. Methods We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors. Results We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)]. Conclusion Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects. PROSPERO Registration ID CRD42021225417.

The Effect of Fluid Initiation Timing on Sepsis Mortality: A Meta-Analysis

“…32 Taken together with our study's findings, one may argue that quality initiatives focusing on the rapid initiation of fluids may be worthwhile and feasible. 33 However, in the example of antibiotic initiation, while findings have suggested that earlier is better, 7,34 a recent meta-analysis did not find a mortality difference when antibiotics were administered within one hour compared to three hours of sepsis onset. 35 As such, antibiotic stewards and others have warned of the potential dangers of overtreatment for undifferentiated patients.…”

Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department: a retrospective cohort study

“…Our study has found that on average just over half of the patients presenting to the ED with sepsis received fluids which is less than optimal, and the average time to first fluids was 1.6 h. Unlike other elements of the Surviving Sepsis Campaign bundle, studies have scarcely explored factors associated with intravenous fluid administration [ 10 ]. Our study has identified a number of factors associated with initiation of intravenous fluids in patients with sepsis in the ED.…”

“…Fluid administration among the suspected infection cohort of this study population has also shown mortality benefits [ 7 ]. However, adherence to these sepsis management guidelines, particularly fluid resuscitation still remains a challenge in the ED [ 8 – 10 ] warranting an exploration of the factors specifically associated with fluid administration. An understanding of these factors is essential to design and implement tailored performance improvement initiatives targeting fluid administration rather than a “one size fits” all approach.…”