The association between intravenous fluid resuscitation and mortality in older emergency department patients with suspected infection

Sin Y Ko,Bas De Groot,Laura C Blomaard,Annemieke Ansems,Simon P Mooijaart,Laura M Esteve Cuevas,Merel Willeboer,Jacinta A Lucke

doi:10.1186/s12245-018-0219-2

Abstract

ObjectiveRecent studies suggest that hypotension thresholds in current guidelines might be too low for older patients due to arterial stiffening, possibly leading to insufficient fluid resuscitation. We compared intravenous (IV) fluid volumes that older (≥ 70 years) and younger (< 70 years) patients with suspected infection with similar initial systolic blood pressure (SBP) received in the emergency department (ED) and investigated whether this was associated with in-hospital mortality in older patients.MethodsThis was an observational multicenter study using an existing database in which consecutive ED patients hospitalized with suspected infection were prospectively included. We first compared the fluid volumes older and younger ED patients received per initial SBP category. Patients were then stratified into two SBP categories (≤ or > 120 mmHg; 120 has been suggested to be a better threshold) and thereafter into three fluid volume categories: 0–1 L, 1–2 L, or > 2 L. In each SBP and fluid category, case-mix-adjusted in-hospital mortality was compared between older and younger patients, using multivariable logistic regression analysis.ResultsThe included 981 (37%) older and 1678 (63%) younger ED patients received similar IV fluid volumes per initial SBP category. Older patients with an initial SBP > 120 mmHg had a higher adjusted OR of 2.06 (95% CI 1.02–4.16), in the 0–1 L category, while this association was not found in the higher fluid categories of 1–2 L or > 2 L. In the SBP ≤ 120 mmHg category, this association was also absent.ConclusionThis hypothesis-generating study suggests that older patients with suspected infection may need higher fluid volumes than younger patients, when having a seemingly normal initial SBP.

Highlights

Fluid resuscitation is an important aspect of sepsis treatment [1,2,3,4]
In the group receiving low fluid volumes, case-mix-adjusted mortality was twice as high in older compared to younger patients with a “seemingly normal” systolic blood pressure (SBP) of > 120 mmHg suggesting that older patients may need higher fluid volumes during emergency department (ED) resuscitation
In conclusion, this study suggests that older patients receive similar amount of fluids as younger patients do during ED resuscitation regardless of initial SBP while older patients were observed to have twice more adjusted odds for case-mix-adjusted in-hospital mortality compared to their younger control patients, when they received < 1 L of fluids, while presenting with an initial SBP > 120 mmHg

Summary

Introduction

Fluid resuscitation is an important aspect of sepsis treatment [1,2,3,4]. the correct timing and the appropriate volumes for resuscitation in the emergency department (ED) is still an active area of debate [5]. Research about fluid resuscitation in the ED, where most patients are in the early stages of sepsis, i.e., before onset of acute organ failure, are scarce. This is especially a problem for older patients as they need higher systolic blood pressures for adequate perfusion due to arterial stiffening [6]. Because of their blunted heart rate response, their cardiac output mainly depends on cardiac filling pressures with adequate preload [7].

Methods

Results

Discussion

Conclusion