title: Emergency department management of early sepsis: a national survey of emergency medicine and intensive care consultants.
abstract: OBJECTIVE
  Early goal-directed therapy (EGDT) is recommended for sepsis management in current guidelines, but the underpinning evidence is controversial. Clinician beliefs and the capacity to implement all recommended elements of EGDT in emergency departments (EDs) are uncertain. Our study aimed to explore self-reported management of early sepsis by Scottish emergency medicine (EM) and intensive care medicine (ICM) consultants, delineate important differences and determine the guideline recommendations rated most important and deliverable within the ED.
  
  
  METHODS
  A postal survey using a hypothetical patient with septic shock was sent to all EM and ICM consultants practising in Scotland.
  
  
  RESULTS
  67% (76/114) EM and 61% (96/157) ICM consultants responded. Normal saline was preferred by EM respondents ('always/often used': EM 86%, ICM 23%, p<0.0001), whereas ICM respondents preferred Hartmann's solution (EM 42%, ICM 72%, p=0.0164), gelofusin (EM 10%, ICM 63%, p<0.0001) and starch (EM 0%, ICM 24%, p<0.0001). More ICM respondents indicated they used central venous pressure and invasive arterial pressure monitoring in the ED, and initiated vasopressors (EM 57%, ICM 90%, p<0.0001). More ICM consultants used specific haemoglobin transfusion triggers (48% EM, 77% ICM, p=0.0002), but marked variation in haemoglobin triggers and targets was reported. Lactate was rated the most important single resuscitation parameter by both specialties; no ED and only two ICM consultants rated ScVO2 most important.
  
  
  CONCLUSIONS
  Differences in early fluid and vasopressor management of sepsis exist between Scottish ICM and EM consultants. Transfusion practice is highly variable, suggesting clinical uncertainty. Lactate is considered more important than ScVO2 measurement.
authors.affiliation: Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Zoeb
authors.initials: Z
authors.lastname: Jiwaji
authors.affiliation: Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Shirin
authors.initials: S
authors.lastname: Brady
authors.affiliation: Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, Canada.
authors.forename: Lauralyn A
authors.initials: LA
authors.lastname: McIntyre
authors.affiliation: Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Alasdair
authors.initials: A
authors.lastname: Gray
authors.affiliation: University of Edinburgh, Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh, UK.
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Walsh
mesh_terms: D001803:Blood Transfusion / Q000379:methods; D003131:Combined Modality Therapy; D016001:Confidence Intervals; D003253:Consultants; D003422:Critical Care / Q000592:standards / Q000639:trends; D019468:Disease Management; D004635:Emergency Medicine / Q000592:standards / Q000639:trends; D004636:Emergency Service, Hospital; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D019538:Health Care Surveys; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008991:Monitoring, Physiologic; D010101:Oxygen Consumption / Q000502:physiology; D010818:Practice Patterns, Physicians'; D012606:Scotland; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D014662:Vasoconstrictor Agents
keywords: emergency care systems, emergency departments; infection; intensive care; resuscitation