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

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] ≥8 mmHg, mean arterial pressure [MAP] ≥65 mmHg, and central venous oxygen saturation [ScvO2] ≥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 ≥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 ScvO2 (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.

Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

“…The overall mortality for our study patients was 26.7%, similar to other recent reports (3,8,27,31,34,35). Patients identified before hospital arrival as Sepsis Alert Protocol patients had significantly decreased mortality and rates of intubation.…”

“…An EMS provider's sepsis knowledge base did not correlate with years of training or experience as an EMS provider. Treatment in the prehospital setting has also been shown to be variable, with up to one third of patients with severe sepsis not receiving an intravenous catheter or intravenous fluid (30,31). A need for increased education and awareness coupled with earlier aggressive resuscitation in the out-of-hospital setting has been recommended previously, and a prehospital severe sepsis screening tool based on consensus definitions has been developed, but not tested (5,12).…”

Severe Sepsis In Prehospital Emergency Care: Analysis Of Incidence, Care, And Outcome

“…Few data or consensus exists to guide pre-hospital treatment or advanced notification of severe sepsis to hospitals (13,35,36), and the National EMS Research Agenda does not yet include topics related to infection or severe sepsis (37,38). Paramedics could facilitate hospital-based triage and care, or affect pre-hospital care by delivery of fluid resuscitation or vasopressors (35), placement of venous access (39), or even administration of antibiotics for suspected sepsis (40). Yet, it is unknown whether the potential time-savings of these interventions would outweigh adverse events, inadvertent treatment, or mistriage.…”

Increased Fluid Administration in the First Three Hours of Sepsis Resuscitation Is Associated With Reduced Mortality

“…[16][17][18][19] On the contrary, anecdotal experience and a few studies show the benefit of out-of-hospital fluid resuscitation by emergency medical services, which suggest that early fluid resuscitation might be better. 20,21 The present study is the first, to our knowledge, to examine the timing of fluid resuscitation in patients with severe sepsis and septic shock within the first 6 h in the ICU. The aim was to evaluate for mortality differences in patients who received adequate fluid resuscitation within the first 3 h (hours 0-3) compared with the latter 3 h (hours 3.1-6) of EGDT.…”