Literature Review: IV Fluid for Severe Sepsis Patients

   Seymour CW, Cooke CR, Mikkelsen ME, et al. Out-of-hospital fluid in severe sepsis: Effect on early resuscitation in the emergency department. Preh Emerg Care 14(2): 145-152, Apr-Jun 2010.

ABSTRACT

   Early identification and treatment of patients with severe sepsis improves outcome, yet the role of out-of-hospital intravenous 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.

   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 providers. We studied the association between delivery of out-of-hospital fluid by advanced life support providers and the achievement of resuscitation endpoints (central venous pressure [CVP] greater than or equal to 8 mmHg, mean arterial pressure [MAP] greater than or equal to 65 mmHg, and central venous oxygen saturation [ScvO₂] greater than or equal to 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. Patients receiving out-of-hospital fluid had lower out-of-hospital mean systolic blood pressure (95 vs. 117) and higher median Sequential Organ Failure Assessment (SOFA) scores in the ED (7 vs. 4) 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 greater than or equal to 65 mmHg within six hours after ED triage (70% vs. 44%). On average, patients receiving out-of-hospital fluid received twice the fluid volume within one hour after ED triage (1.1 L vs. 0.6 L). No difference in achievement of goal CVP (72% vs. 60%) or goal ScvO₂ (54% vs. 36%) was observed between groups.

   Conclusions--Fewer 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.

COMMENT

   The identification and treatment of patients with severe sepsis has evolved tremendously over the last several years. In-hospital studies have shown that early and very aggressive fluid resuscitation (on the order of several liters) improves initial hemodynamic status and eventual outcomes. This study is intriguing but not definitive. It suggests that prehospital fluids will result in earlier improvement, but the changes were not quite statistically significant. It makes sense that this would work, and future studies will likely conclude that the earlier the fluids are started, the earlier the patient improves. We'll also learn more about how this may improve outcomes.

   The second part is the challenge of identification. Many sepsis patients have suggestive histories and physical findings, but sepsis can also be quite subtle and only diagnosed with lab tests. These authors reported that fewer than 50% of severe sepsis patients received fluids, which could be from the difficulty in diagnosis, short transport times, no IV, or withholding fluids from patients with borderline vital signs. As we learn more about the prehospital treatment of sepsis, this will improve. Additional studies will clarify the role and process of prehospital sepsis treatment.