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Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay.
Ann Emerg Med. 2016 09; 68(3):298-311.AE

Abstract

STUDY OBJECTIVE

We evaluate the association of intravenous fluid resuscitation initiation within 30 minutes of severe sepsis or septic shock identification in the emergency department (ED) with inhospital mortality and hospital length of stay. We also compare intravenous fluid resuscitation initiated at various times from severe sepsis or septic shock identification's association with the same outcomes.

METHODS

This was a review of a prospective, observational cohort of all ED severe sepsis or septic shock patients during 13 months, captured in a performance improvement database at a single, urban, tertiary care facility (90,000 ED visits/year). The primary exposure was initiation of a crystalloid bolus at 30 mL/kg within 30 minutes of severe sepsis or septic shock identification. Secondary analysis compared intravenous fluid initiated within 30, 31 to 60, or 61 to 180 minutes, or when intravenous fluid resuscitation was initiated at greater than 180 minutes or not provided.

RESULTS

Of 1,866 subjects, 53.6% were men, 72.5% were white, mean age was 72 years (SD 16.6 years), and mean initial lactate level was 2.8 mmol/L. Eighty-six percent of subjects were administered intravenous antibiotics within 180 minutes; 1,193 (64%) had intravenous fluid initiated within 30 minutes. Mortality was lower in the within 30 minutes group (159 [13.3%] versus 123 [18.3%]; 95% confidence interval [CI] 1.4% to 8.5%), as was median hospital length of stay (6 days [95% CI 6 to 7] versus 7 days [95% CI 7 to 8]). In multivariate regression that included adjustment for age, lactate, hypotension, acute organ dysfunction, and Emergency Severity Index score, intravenous fluid within 30 minutes was associated with lower mortality (odds ratio 0.63; 95% CI 0.46 to 0.86) and 12% shorter length of stay (hazard ratio=1.14; 95% CI 1.02 to 1.27). In secondary analysis, mortality increased with later intravenous fluid resuscitation initiation: 13.3% (≤30 minutes) versus 16.0% (31 to 60 minutes) versus 16.9% (61 to 180 minutes) versus 19.7% (>180 minutes). Median hospital length of stay also increased with later intravenous fluid initiation: 6 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 8 days) versus 8 days (95% CI 7 to 9 days).

CONCLUSION

The time of intravenous fluid resuscitation initiation was associated with improved mortality and could be used as an easier obtained alternative to intravenous fluid completion time as a performance indicator in severe sepsis and septic shock management.

Authors+Show Affiliations

North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY. Electronic address: deleisman@gmail.com.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.North Shore Long Island Jewish Health System, Department of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY.

Pub Type(s)

Journal Article
Observational Study

Language

eng

PubMed ID

27085369

Citation

Leisman, Daniel, et al. "Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay." Annals of Emergency Medicine, vol. 68, no. 3, 2016, pp. 298-311.
Leisman D, Wie B, Doerfler M, et al. Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Ann Emerg Med. 2016;68(3):298-311.
Leisman, D., Wie, B., Doerfler, M., Bianculli, A., Ward, M. F., Akerman, M., D'Angelo, J. K., & Zemmel D'Amore, J. A. (2016). Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Annals of Emergency Medicine, 68(3), 298-311. https://doi.org/10.1016/j.annemergmed.2016.02.044
Leisman D, et al. Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Ann Emerg Med. 2016;68(3):298-311. PubMed PMID: 27085369.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. AU - Leisman,Daniel, AU - Wie,Benjamin, AU - Doerfler,Martin, AU - Bianculli,Andrea, AU - Ward,Mary Frances, AU - Akerman,Meredith, AU - D'Angelo,John K, AU - Zemmel D'Amore,Jason A, Y1 - 2016/04/14/ PY - 2015/10/14/received PY - 2016/02/16/revised PY - 2016/02/19/accepted PY - 2016/4/18/entrez PY - 2016/4/18/pubmed PY - 2017/6/20/medline SP - 298 EP - 311 JF - Annals of emergency medicine JO - Ann Emerg Med VL - 68 IS - 3 N2 - STUDY OBJECTIVE: We evaluate the association of intravenous fluid resuscitation initiation within 30 minutes of severe sepsis or septic shock identification in the emergency department (ED) with inhospital mortality and hospital length of stay. We also compare intravenous fluid resuscitation initiated at various times from severe sepsis or septic shock identification's association with the same outcomes. METHODS: This was a review of a prospective, observational cohort of all ED severe sepsis or septic shock patients during 13 months, captured in a performance improvement database at a single, urban, tertiary care facility (90,000 ED visits/year). The primary exposure was initiation of a crystalloid bolus at 30 mL/kg within 30 minutes of severe sepsis or septic shock identification. Secondary analysis compared intravenous fluid initiated within 30, 31 to 60, or 61 to 180 minutes, or when intravenous fluid resuscitation was initiated at greater than 180 minutes or not provided. RESULTS: Of 1,866 subjects, 53.6% were men, 72.5% were white, mean age was 72 years (SD 16.6 years), and mean initial lactate level was 2.8 mmol/L. Eighty-six percent of subjects were administered intravenous antibiotics within 180 minutes; 1,193 (64%) had intravenous fluid initiated within 30 minutes. Mortality was lower in the within 30 minutes group (159 [13.3%] versus 123 [18.3%]; 95% confidence interval [CI] 1.4% to 8.5%), as was median hospital length of stay (6 days [95% CI 6 to 7] versus 7 days [95% CI 7 to 8]). In multivariate regression that included adjustment for age, lactate, hypotension, acute organ dysfunction, and Emergency Severity Index score, intravenous fluid within 30 minutes was associated with lower mortality (odds ratio 0.63; 95% CI 0.46 to 0.86) and 12% shorter length of stay (hazard ratio=1.14; 95% CI 1.02 to 1.27). In secondary analysis, mortality increased with later intravenous fluid resuscitation initiation: 13.3% (≤30 minutes) versus 16.0% (31 to 60 minutes) versus 16.9% (61 to 180 minutes) versus 19.7% (>180 minutes). Median hospital length of stay also increased with later intravenous fluid initiation: 6 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 8 days) versus 8 days (95% CI 7 to 9 days). CONCLUSION: The time of intravenous fluid resuscitation initiation was associated with improved mortality and could be used as an easier obtained alternative to intravenous fluid completion time as a performance indicator in severe sepsis and septic shock management. SN - 1097-6760 UR - https://www.unboundmedicine.com/medline/citation/27085369/Association_of_Fluid_Resuscitation_Initiation_Within_30_Minutes_of_Severe_Sepsis_and_Septic_Shock_Recognition_With_Reduced_Mortality_and_Length_of_Stay_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0196-0644(16)00148-7 DB - PRIME DP - Unbound Medicine ER -