The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi‐centre observational study describing current practice in Australia and New Zealand

Abstract

Objectives To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30‐day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6‐ and 24‐h post‐enrolment, time to antimicrobial administration, intensive care admission, organ support and in‐hospital mortality. Results A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used ( n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre‐enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in‐hospital mortality was 6.2% (95% confidence interval 4.4–8.5%). Conclusion Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

Twenty‐four‐hour fluid administration in emergency department patients with suspected infection: A multicenter, prospective, observational study

“…This is approximately a liter more than the sepsis group in the current study, although few included sepsis patients had systolic blood pressure < 100 mmHg in the current study limiting a direct comparison. ARISE FLUIDS also reported fluid administration for the subgroup of patients with systolic blood pressure < 90 mmHg and lactate ≥ 2 mmol/L (ie, those with septic shock): 5.1 L within 24 hours 23,30 . This amount corresponds quite well to the amount of fluid given to patients with septic shock in the current study, although our estimate is based on only eight patients.…”

“…The Surviving Sepsis Campaign guideline recommends 30 mL/kg for patients with sepsis‐induced hypotension (strong recommendation, low quality of evidence) but does not give any recommendations for patients with infection without hypotension or septic shock 9,20 . In general, fluid therapy is guided by only weak evidence, 9 and studies show marked practice variation 8,21‐23 . For patients not in shock, there is a paucity of evidence‐based recommendations for fluid resuscitation and administration.…”

Short-term outcome and characteristics of critical care for nontrauma patients in the emergency department

“…However, rapid critical care treatment in the ED is probably bene cial for patients in septic shock. Very early continuous infusion of norepinephrine seems to be bene cial in septic shock and leads to shortened ICU stay and earlier restoration of circulation [12][13][14]. If continuous norepinephrine infusion is restricted to ICU settings, delays in shock therapy are probably inevitable.…”

A narrative review of paracetamol‐induced hypotension: Keeping the patient safe

“…The heterogeneous nature of sepsis is a confounding variable, because patients are potentially already compromised by a hypovolaemic state (Semler & Rice, 2016) and vasoplegia (Sharawy, 2014). The syndrome of sepsis itself, though highly variable, requires a varied approach to fluid volume in resuscitation, which is often combined with vasopressor drug administration (Keijzers et al., 2020). Higher‐acuity monitoring and surveillance methods are required to detect instability in the haemodynamically vulnerable patient population to ensure early therapeutic management.…”