Abstract 348: Defining the ’Golden Hour’: How Much Fluid Do Septic Shock Patients Need in the First Hour?

Abstract

Background: Early fluid challenge and antimicrobial administration are essential in the treatment of septic shock (SS) patients. Delayed vascular access can prevent appropriate care for SS patients. Study Objectives: The primary objective of this study was to determine time to adequate vascular access (AVA; either a central venous line or 2 peripheral IV lines) in the treatment of SS in the emergency department (ED). Secondary objectives included determination of time elapsed to empiric antibiotic and IV fluid challenge from time of ED arrival. Methods: A retrospective chart review was conducted including all adult patients admitted to an urban Level II trauma center from the ED with an admission diagnosis of SS between June 1 st , 2011 and September 31 st , 2012. Data on time to AVA, fluid administration, and antibiotic administration were obtained from the electronic medical record. Results: We identified 96 patients who met inclusion criteria. Median time from diagnosis to AVA was 30.5 minutes (mean=75 min, SD=127.0), with 34% of patients still without AVA 1 hour after SS diagnosis. Median time from diagnosis to antibiotic administration was 69.5 minutes (SD=84.9), and only 43.8% of patients received antibiotics within 1 hour of diagnosis. The median volume of IV fluid infused within 1 hour of SS diagnosis was 18.6 mL/kg (SD=14.6). Patients who survived to hospital discharge received significantly more fluid during their first hour in the ED than patients who died prior to hospital discharge (20.1 ml/kg vs. 12.7 ml/kg; t (1)=2.5, p <.05). We observed a 41.5% decrease in mortality among patients who received greater than 10 ml/kg of IV fluid within their first hour in the ED ( p <.01). At later time points (2, 4, or 6 hours after ED arrival), no mortality difference was observed. Conclusion: Early fluid resuscitation within 1 hour of ED arrival is associated with reduced inpatient mortality among septic shock patients. Based upon our data, there appears to be a critical threshold for the volume of IV fluid infused that is related to mortality. Strategies for earlier vascular access and antibiotic administration are needed.