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Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department.

机译：严重脓毒症的院外液体：对急诊科早期复苏的影响。

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BACKGROUND: Early identification and treatment of patients with severe sepsis improves outcome, yet the role of out-of-hospital intravenous (IV) fluid is unknown. OBJECTIVE: To determine if the delivery of out-of-hospital fluid in patients with severe sepsis is associated with reduced time to achievement of goal-oriented resuscitation in the emergency department (ED). METHODS: We performed a secondary data analysis of a retrospective cohort study in a metropolitan, tertiary care, university-based medical center supported by a two-tiered system of out-of-hospital emergency medical services (EMS) providers. We studied the association between delivery of out-of-hospital fluid by advanced life support (ALS) providers and the achievement of resuscitation endpoints (central venous pressure [CVP] > or =8 mmHg, mean arterial pressure [MAP] > or =65 mmHg, and central venous oxygen saturation [ScvO(2)] > or =70%) within six hours after triage during early goal-directed therapy (EGDT) in the ED. RESULTS: Twenty five (48%) of 52 patients transported by ALS with severe sepsis received out-of-hospital fluid. Data for age, gender, source of sepsis, and presence of comorbidities were similar between patients who did and did not receive out-of-hospital fluid. Patients receiving out-of-hospital fluid had lower out-of-hospital mean (+/- standard deviation) systolic blood pressure (95 +/- 40 mmHg vs. 117 +/- 29 mmHg; p = 0.03) and higher median (interquartile range) Sequential Organ Failure Assessment (SOFA) scores in the ED (7 [5-8] vs. 4 [4-6]; p = 0.01) than patients not receiving out-of-hospital fluid. Despite greater severity of illness, patients receiving out-of-hospital fluid approached but did not attain a statistically significant increase in the likelihood of achieving MAP > or =65 mmHg within six hours after ED triage (70% vs. 44%, p = 0.09). On average, patients receiving out-of-hospital fluid received twice the fluid volume within one hour after ED triage (1.1 L [1.0-2.0 L] vs. 0.6 L [0.3-1.0 L]; p = 0.01). No difference in achievement of goal CVP (72% vs. 60%; p = 0.6) or goal ScvO(2) (54% vs. 36%; p = 0.25) was observed between groups. CONCLUSIONS: Less than half of patients with severe sepsis transported by ALS received out-of-hospital fluid. Patients receiving out-of-hospital IV access and fluids approached but did not attain a statistically significant increase in the likelihood of achieving goal MAP during EGDT. These preliminary findings require additional investigation to evaluate the optimal role of out-of-hospital resuscitation in treating patients with severe sepsis.
机译：背景：严重败血症患者的早期识别和治疗可改善结局，但院外静脉输液的作用尚不清楚。目的：确定重症败血症患者的院外输液是否与急诊科（ED）实现目标导向复苏的时间缩短有关。方法：我们在一个大都市，三级医疗，大学医疗中心进行了一项回顾性队列研究的二级数据分析，该医疗中心由院外急诊医疗服务（EMS）提供者两层系统提供支持。我们研究了高级生命支持（ALS）提供者提供的院外积液与复苏终点的达成之间的联系（中心静脉压[CVP]>或= 8 mmHg，平均动脉压[MAP]>或= 65 ED中早期目标导向治疗（EGDT）进行分诊后的6小时内，mmHg和中心静脉血氧饱和度[ScvO（2）]>或= 70％）。结果：52例经严重脓毒症治疗的ALS患者中有25例（48％）接受了院外液体治疗。接受和不接受院外输液的患者之间的年龄，性别，败血症来源和合并症的数据相似。接受院外积液的患者的院外平均收缩压（+/-标准偏差）较低（95 +/- 40 mmHg对117 +/- 29 mmHg; p = 0.03）和中位数较高（在四分位数范围内）ED的序贯器官衰竭评估（SOFA）评分（7 [5-8]对4 [4-6]; p = 0.01）比未接受医院外积液的患者高。尽管疾病的严重程度更高，但接受ED诊治后六小时内接受院外液体治疗的患者仍接近，但在MAP>或= 65 mmHg的可能性方面未达到统计学上的显着提高（70％对44％，p = 0.09）。平均而言，接受ED鉴别诊断后一小时内，接受院外液体治疗的患者接受的液体量为两倍（1.1 L [1.0-2.0 L]与0.6 L [0.3-1.0 L]; p = 0.01）。两组之间在目标CVP（72％vs. 60％; p = 0.6）或目标ScvO（2）（54％vs. 36％; p = 0.25）的实现上没有差异。结论ALS运送的严重脓毒症患者中，不到一半接受了院外液体治疗。接受院外静脉输液和输液的患者已接近，但在EGDT期间实现目标MAP的可能性没有统计学上的显着提高。这些初步发现需要进一步调查，以评估院外复苏在治疗严重脓毒症患者中的最佳作用。

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