Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay - 25/08/16

Doi : 10.1016/j.annemergmed.2016.02.044

Daniel Leisman, BS ^⁎ , Benjamin Wie, BA, Martin Doerfler, MD, Andrea Bianculli, BA, Mary Frances Ward, RN, MS, Meredith Akerman, MS, John K. D’Angelo, MD, Jason A. Zemmel D’Amore, MD
North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore–LIJ School of Medicine, Manhasset, NY

^∗Corresponding Author.

Abstract

Study objective

We evaluate the association of intravenous fluid resuscitation initiation within 30 minutes of severe sepsis or septic shock identification in the emergency department (ED) with inhospital mortality and hospital length of stay. We also compare intravenous fluid resuscitation initiated at various times from severe sepsis or septic shock identification’s association with the same outcomes.

Methods

This was a review of a prospective, observational cohort of all ED severe sepsis or septic shock patients during 13 months, captured in a performance improvement database at a single, urban, tertiary care facility (90,000 ED visits/year). The primary exposure was initiation of a crystalloid bolus at 30 mL/kg within 30 minutes of severe sepsis or septic shock identification. Secondary analysis compared intravenous fluid initiated within 30, 31 to 60, or 61 to 180 minutes, or when intravenous fluid resuscitation was initiated at greater than 180 minutes or not provided.

Results

Of 1,866 subjects, 53.6% were men, 72.5% were white, mean age was 72 years (SD 16.6 years), and mean initial lactate level was 2.8 mmol/L. Eighty-six percent of subjects were administered intravenous antibiotics within 180 minutes; 1,193 (64%) had intravenous fluid initiated within 30 minutes. Mortality was lower in the within 30 minutes group (159 [13.3%] versus 123 [18.3%]; 95% confidence interval [CI] 1.4% to 8.5%), as was median hospital length of stay (6 days [95% CI 6 to 7] versus 7 days [95% CI 7 to 8]). In multivariate regression that included adjustment for age, lactate, hypotension, acute organ dysfunction, and Emergency Severity Index score, intravenous fluid within 30 minutes was associated with lower mortality (odds ratio 0.63; 95% CI 0.46 to 0.86) and 12% shorter length of stay (hazard ratio=1.14; 95% CI 1.02 to 1.27). In secondary analysis, mortality increased with later intravenous fluid resuscitation initiation: 13.3% (≤30 minutes) versus 16.0% (31 to 60 minutes) versus 16.9% (61 to 180 minutes) versus 19.7% (>180 minutes). Median hospital length of stay also increased with later intravenous fluid initiation: 6 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 8 days) versus 8 days (95% CI 7 to 9 days).

Conclusion

The time of intravenous fluid resuscitation initiation was associated with improved mortality and could be used as an easier obtained alternative to intravenous fluid completion time as a performance indicator in severe sepsis and septic shock management.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design

Selection of Participants and Data Collection and Processing

Outcome Measures

Primary Data Analysis

Results

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Please see page 299 for the Editor’s Capsule Summary of this article.
	Supervising editor: Alan E. Jones, MD
	Author contributions: DL, BW, MFW, and JAZD conceived of the study and designed it. MD, MFW, JKD, and JAZD were responsible for the development of the original performance improvement initiative, including the data collection process. DL and BW oversaw the research registry’s data management. MA was the primary statistician consultant. DL and MA determined the analytic strategy and performed all analyses. DL wrote the initial draft of the article, which all authors reviewed and contributed to before submission. DL revised the article, and all authors subsequently reviewed it. MFW and JAZD mentored the project throughout. DL and BW are co-first authors on this study. DL takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist.
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