title: 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] > or =8 mmHg, mean arterial pressure [MAP] > or =65 mmHg, and central venous oxygen saturation [ScvO(2)] > or =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 > or =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 ScvO(2) (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.
authors.affiliation: Division of Pulmonary & Critical Care Medicine, University of Washington, Seattle, Washington, USA. seymoc@u.washington.edu
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Seymour
authors.forename: Colin R
authors.initials: CR
authors.lastname: Cooke
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.forename: Julie
authors.initials: J
authors.lastname: Hylton
authors.forename: Tom D
authors.initials: TD
authors.lastname: Rea
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Goss
authors.forename: David F
authors.initials: DF
authors.lastname: Gaieski
authors.forename: Roger A
authors.initials: RA
authors.lastname: Band
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D042241:Early Diagnosis; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D018805:Sepsis / Q000175:diagnosis / Q000628:therapy*; D012720:Severity of Illness Index