title: Primary fluid bolus therapy for infection-associated hypotension in the emergency department.
abstract: OBJECTIVE
  The physiological changes associated with fluid bolus therapy (FBT) for patients with infection-associated hypotension in the emergency department (ED) are poorly understood. We describe the physiological outcomes of FBT in the first 6 hours (primary FBT) for patients presenting to the ED with infection-associated hypotension.
  
  
  METHODS
  We studied 101 consecutive ED patients with infection and a systolic blood pressure (SBP)<100 mmHg who underwent FBT in the first 6 hours.
  
  
  RESULTS
  We screened 1123 patients with infection and identified 101 eligible patients. The median primary FBT volume given was 1570 mL (interquartile range, 1000- 2490 mL). The average mean arterial pressure (MAP) did not change from admission to 6 hours in the whole cohort, or in patients who were hypotensive on arrival at the ED. However, the average MAP increased from its lowest value during the first 6 hours (66 mmHg [SD, 10 mmHg]) to its value at 6 hours (73 mmHg [SD, 12 mmHg]; P<0.001). The mean heart rate, body temperature, respiratory rate and plasma creatinine level decreased (P<0.05). In patients who were severely hypotensive (SBP<90 mmHg) on arrival at the ED, the MAP increased from 54 mmHg (SD, 8 mmHg) to 70 mmHg (SD, 14 mmHg) (P<0.001). At 6 hours, however, SBP was still <100 mmHg in 44 patients and <90 mmHg in 17 patients. When noradrenaline was used, in 10 patients, hypotension was corrected in all 10 and the MAP increased from 58 mmHg (SD, 9 mmHg) to 75 mmHg (SD, 13 mmHg).
  
  
  CONCLUSIONS
  Among ED patients admitted to an Australian teaching hospital with infection, hypotension was uncommon. FBT for hypotension was limited in volumes given and failed to achieve a sustained SBP of >100 mmHg in 40% of cases. In contrast, noradrenaline therapy corrected hypotension in all patients who received it.
authors.affiliation: Department of Surgical Sciences, Hedenstierna Laboratory, Section of Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden. rinaldo.bellomo@austin.org.au.
authors.forename: Miklos
authors.initials: M
authors.lastname: Lipcsey
authors.affiliation: Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Chiong
authors.affiliation: Department of Cardiology, Northern Hospital, Melbourne, VIC, Australia.
authors.forename: Ivan
authors.initials: I
authors.lastname: Subiakto
authors.affiliation: Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Kaufman
authors.affiliation: Department of Adult Intensive Care, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
authors.forename: Antoine G
authors.initials: AG
authors.lastname: Schneider
authors.affiliation: Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Bellomo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007022:Hypotension / Q000209:etiology / Q000628:therapy*; D007239:Infections / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome