Abstract
IntroductionPrompt treatment of severe sepsis in the Emergency Department reduces deaths, but the role of prehospital fluid resuscitation is unknown. We sought to determine the risk-adjusted association between prehospital fluid administration and hospital mortality among emergency medical services (EMS) patients admitted with severe sepsis.MethodsWe performed a prospective, observational study of patients hospitalized with severe sepsis on admission among 45,394 adult EMS encounters taken to 15 hospitals from 11/2009 to 12/2010 by a two-tier EMS system in King County, Washington. The region mandated recording of prehospital intravenous catheter and fluid administration in prehospital records, along with detailed demographic, incident, physiologic, and hospital adjustment variables. We determined the effect of prehospital intravenous catheter or fluid versus no catheter or fluid on all-cause mortality using multivariable logistic regression.ResultsOf all encounters, 1,350 met criteria for severe sepsis on admission, of whom 205 (15%) died by hospital discharge, 312 (23%) received prehospital intravenous fluid, 90 (7%) received a prehospital catheter alone and 948 (70%) did not receive catheter or fluid. EMS administered a median prehospital fluid volume of 500 mL (interquartile range (IQR): 200, 1000 mL). In adjusted models, the administration of any prehospital fluid was associated with reduced hospital mortality (Odds ratio =0.46; 95% Confidence interval: 0.23, 0.88; P =0.02) compared to no prehospital fluid. The odds of hospital mortality were also lower among severe sepsis patients treated with prehospital intravenous catheter alone (Odds ratio =0.3; 95% Confidence interval: 0.17 to 0.57; P <0.01).ConclusionsIn a population-based study, the administration of prehospital fluid and placement of intravenous access were associated with decreased odds of hospital mortality compared with no prehospital catheter or fluid.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0533-x) contains supplementary material, which is available to authorized users.
Highlights
Prompt treatment of severe sepsis in the Emergency Department reduces deaths, but the role of prehospital fluid resuscitation is unknown
Severe sepsis patients receiving fluids were similar in age, sex and prehospital location compared to other groups (Table 1)
In this population-based, observational cohort study of prehospital medical patients admitted with severe sepsis, we found that prehospital fluid administration is associated with a reduced odds of hospital mortality compared to no prehospital fluid, after multivariable adjustment
Summary
Prompt recognition and treatment of severe sepsis and septic shock are keystones of optimal care [1,2,3,4] Such early therapy reduces both absolute and relative hypovolemia and subsequent organ dysfunction. Prehospital fluid could alter sepsis outcomes by directly improving organ perfusion or by altering the process of care after arrival at the emergency department (ED) [9]. The latter is noted in the care of ST elevation myocardial infarction, where EMS electrocardiogram acquisition is a key factor in improving the response after ED arrival [10]. While prehospital resuscitation has been rigorously tested in other time-sensitive syndromes, such as trauma and cardiac arrest [11,12,13], no trial has explored the benefit or harm of fluid resuscitation in prehospital sepsis
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