Fluid resuscitation in pre-hospital management of septic shock

Association between prehospital ROX index with 30-day mortality among septic shock

PURPOSE

Respiratory dysfunction is one of the most frequent symptoms observed during sepsis reflecting hypoxemia and/or acidosis that may be assessed by the ROX index (ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate). This study aimed to describe the relationship between the prehospital ROX index and 30-day mortality rate among septic shock patients cared for in the prehospital setting by a mobile intensive care unit (MICU).

METHODS

From May 2016 to December 2021, 530 septic shock patients cared for by a prehospital MICU were retrospectively analysed. Initial ROX index value was calculated at the first contact with MICU. A Cox regression analysis after propensity score matching was performed to assess the relationship between 30-day mortality rate and a ROX index ≤ 10.

RESULTS

Pulmonary, digestive and urinary sepsis were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality reached 31%. Cox regression analysis showed a significant association between 30-day mortality and a ROX index ≤ 10: adjusted hazard ratio of 1.54 [1.08-2.31], p < 0.05.

CONCLUSIONS

During the prehospital stage of septic shock patients cared for by a MICU, ROX index is significantly associated with 30-day mortality. A prehospital ROX ≤ 10 value is associated with a 1.5-fold 30-day mortality rate increase. Prospective studies are needed to confirm the ability of prehospital ROX to predict sepsis outcome since the prehospital setting.

The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality

BACKGROUND

The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU).

METHODS

Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports.

RESULTS

Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively.

CONCLUSION

A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

Prehospital Sepsis Recognition and Outcomes for Patients with Sepsis by Race and Ethnicity

BACKGROUND

First medical contact for patients with sepsis often initiates in the prehospital setting, yet limited studies have explored the EMS sepsis recognition-mortality relationship. Racial and ethnic minority patients often have worse sepsis outcomes, yet the role of prehospital recognition in this inequity has not been explored. Our objective was to describe prehospital sepsis recognition and hospital mortality, with analysis by patient race and ethnicity.

METHODS

Using linked EMS and hospital records from the 2021 ESO Data Collaborative, we retrospectively analyzed 9-1-1 EMS transports for adult patients with emergency department ICD-10 sepsis diagnosis codes. EMS sepsis recognition was defined as a primary or secondary sepsis impression, use of an electronic health record specialty sepsis form, or a prehospital sepsis alert. We used multivariable logistic regression to assess the association between EMS sepsis recognition and hospital mortality, adjusting for age, sex, race and ethnicity, scene socioeconomic status, and documented clinical characteristics: altered mental status, hypotension, tachypnea, tachycardia, fever. We conducted a secondary analysis of patients who were positive for the quick sequential organ failure assessment (qSOFA) using first prehospital vital signs.

RESULTS

We analyzed 20,172 records for EMS-transported patients with diagnosed sepsis. Overall, 8% of patients were Black, 8% were Hispanic, and 72% were White. Prehospital sepsis recognition was 18%. Prehospital sepsis recognition was similar across racial and ethnic groups (Black: 17.2%, Hispanic: 17.4%, White: 18.1%) and adjusted odds of sepsis recognition did not differ between racial and ethnic groups. Overall mortality was 11% (2,186). Prehospital sepsis recognition was associated with a 18% reduction in adjusted odds of mortality (OR: 0.82, 95% CI: 0.70-0.94). Of patients who were qSOFA positive in the field (n = 2,168), EMS sepsis recognition was 32% and was similar across race and ethnicities. Adjusted odds of mortality were 0.68 (95% CI: 0.53-0.88) when sepsis was recognized in the prehospital setting.

CONCLUSION

EMS identified sepsis in fewer than one in three patients even after limiting to those positive for qSOFA, without differences by race and ethnicity. EMS sepsis recognition was associated with reduced odds of mortality; however, Black patients remained at greater odds of death suggesting additional factors that warrant investigation.

Association between prehospital shock index variation and 28-day mortality among patients with septic shock

PURPOSE

Septic shock (SS) hyperdynamic phase is characterized by tachycardia and low-blood pressure reflecting the relative hypovolemia. Shock index (SI), the ratio between heart rate and systolic blood pressure, is a simple objective tool, usable for SS prognosis assessment. This study aims to evaluate the relationship between prehospital SI variation and 28-day mortality of SS patients initially cared for in prehospital setting by a mobile intensive care unit (mICU).

METHODS

From April 6th, 2016 to December 31st, 2020, 406 patients with SS requiring prehospital mICU were retrospectively analyzed. Initial SI, i.e. first measurement after mICU arrival to the scene, and final SI, i.e. last measurement of the prehospital stage, were used to calculate delta SI (initial SI-final SI) and to define positive and negative delta SI. A survival analysis after propensity score matching compared the 28-day mortality of SS patients with positive/negative delta SI.

RESULTS

The main suspected origins of infection were pulmonary (42%), digestive (25%) and urinary (17%). The 28-day overall mortality reached 29%. Cox regression analysis revealed a significant association between 28-day mortality and delta SI. A negative delta SI was associated with an increase in mortality (adjusted hazard ratio (HRa) of 1.88 [1.07-3.31] (p = 0.03)), whereas a positive delta SI was associated with a mortality decrease (HRa = 0.53 [0.30-0.94] (p < 10-3)).

CONCLUSION

Prehospital hemodynamic delta SI among SS patients cared for by a mICU is associated with 28-day mortality. A negative prehospital delta SI could help physicians to identify SS with higher risk of 28-day mortality.

Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients

Background

Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage.

Methods

From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality.

Results

Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h⁻¹, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10^–3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10^–3.

Conclusion

In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality

BACKGROUND

Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. Methods: From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Results: Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). Conclusion: In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.

Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock

INTRODUCTION

Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS.

METHODS

From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage.

RESULTS

Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01).

CONCLUSION

In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock

BACKGROUND

Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes.

METHODS

From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate.

RESULTS

Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70 ± 14 years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41 ± 2.50 mmol.l^-1 vs 1.65 ± 2.88 mmol.l^-1, p = 0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance > 10% (HRa [CI95] = 0.49 [0.26-0.92], p = 0.028) and prehospital blood lactate clearance < 10% (HRa [CI95] = 2.04 [1.08-3.84], p = 0.028).

CONCLUSION

A prehospital blood lactate clearance < 10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.

Pre-Hospital Lactatemia Predicts 30-Day Mortality in Patients with Septic Shock-Preliminary Results from the LAPHSUS Study

Background: Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, the clinical picture alone is not sufficient for assessing disease severity and outcomes. Because blood lactate level is included in the clinical criteria of SS it should be considered to improve the assessment of its severity. This study aims to investigate the relationship between pre-hospital blood lactate level and 30-day mortality in patients with SS. Methods: From 15 April 2017 to 15 April 2019, patients with SS requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were prospectively included in the LAPHSUS study, an observational, non-randomized controlled study. Pre-hospital blood lactate levels were measured at the time of first contact between the patients and the MICU. Results: Among the 183 patients with septic shock requiring action by the MICU drawn at random from LAPHSUS study patients, six (3%) were lost to follow-up on the 30th day and thus 177 (97%) were analyzed for blood lactate levels (mean age 70 ± 14 years). Pulmonary, urinary and digestive infections were probably the cause of the SS in respectively 58%, 21% and 11% of the cases. The 30-day overall mortality was 32%. Mean pre-hospital lactatemia was significantly different between patients who died and those who survived (respectively 7.1 ± 4.0 mmol/L vs. 5.9 ± 3.5 mmol/L, p < 10⁻³). Using Cox regression analysis adjusted for potential confounders we showed that a pre-hospital blood lactate level ≥ 4 mmol/L significantly predicted 30-day mortality in patients with SS (adjusted hazard ratio = 2.37, 95%CI (1.01–5.57), p = 0.04). Conclusion: In this study, we showed that pre-hospital lactatemia predicts 30-day mortality in patients with septic shock handled by the MICU. Further studies will be needed to evaluate if pre-hospital lactatemia alone or combined with clinical scores could affect the triage decision-making process for those patients.

Opportunities for achieving resuscitation goals during the inter-emergency department transfer of severe sepsis patients by emergency medical services: A case series

PURPOSE

This study aimed to describe the care provide by Emergency Medical Services (EMS) to severe sepsis patients being transferred between acute care hospitals and identify how that care contributes to sepsis care goals.

METHODS

This was a single-center retrospective cohort study conducted at a 60,000-visit Midwestern academic emergency department, using run reports from 13 ambulance services transferring from 9 hospitals.

RESULTS

39 patients were included in the final cohort, transferred by 13 ambulance services from 9 hospitals. Included patients were adults with severe sepsis transferred by ambulance between 2009 and 2014. Thirty-nine patients were included in this cohort. 41% (n = 12) of patients received an adequate fluid bolus of 30 mL/kg (median 42.9 mL/kg crystalloid fluid, IQR 8.0 mL/kg) prior to tertiary care arrival. Seventeen percent (n = 2) of patients completed the adequate bolus during transfer time. Broad-spectrum antibiotics were initiated during transfer in 2 patients.

CONCLUSIONS

EMS sepsis care during transfer was limited. EMS crews primarily continued treatments previously initiated and did not take additional steps toward resuscitation targets. Data suggests the inter-emergency department transfer period may provide an opportunity to continue working toward treatment targets, though the time is currently underutilized.

Pre-hospital mechanical ventilation in septic shock patients

BACKGROUND

Mechanical ventilation can cause deleterious effects on the lung and thus alter patient's prognosis. The aim of this study was to describe the characteristics of prehospital mechanical ventilation in patients with septic shock requiring mechanical ventilation in the prehospital setting.

METHODS

Patients with septic shock subjected to pre-hospital intubation and mechanical ventilation by a mobile intensive care unit were consecutively included and retrospectively analysed. Septic shock was defined according to the international sepsis-3 consensus conference. Patient's characteristics, interventions, prehospital ventilatory parameters and outcome were retrieved from medical records. The association between the tidal volume indexed on ideal body weight (VTIBW) and mortality at day 28 was evaluated.

RESULTS

Fifty-nine patients were included. Septic shock was mainly associated with pulmonary (64%) infection. Mean pre-hospital VTIBW was 7 ± 1 ml.kg^-1 in the overall population. Mortality reached 42%. The AUC of VTIBW was 0.83 [0.72-0.94]. Using logistic regression model including: age, prehospital mean blood pressure, volume infused in the prehospital setting, FiO₂ and length of stay in the intensive care unit, the association with mortality remained significant for VTIBW (OR adjusted [CI95] = 4.11 [1.89-10.98]), VTIBW >8 ml·kg^-1 (OR adjusted [CI95] = 8.29 [2.35-34.98]) and VTIBW <8 ml·kg^-1 (OR adjusted [CI95] = 0.12 [0.03-0.43]).

CONCLUSION

In this retrospective study, we observed an association between mortality at day 28 and prehospital VTIBW in pre-hospital mechanically ventilated patients with septic shock. A VTIBW <8 ml·kg^-1 was associated with a decrease and a VTIBW >8 ml·kg^-1 with an increase in mortality.

Skin mottling score and capillary refill time to assess mortality of septic shock since pre-hospital setting

OBJECTIVES

The early identification of septic shock patients at high risk of poor outcome is essential to early initiate optimal treatments and to decide on hospital admission. Biomarkers are often used to evaluate the severity. In prehospital settings, the availability of biomarkers, such as lactate, is restricted. In this context, clinical tools such as skin mottling score (SMS) and capillary refill time (CRT) are more suitable. In this study, we describe prehospital SMS and CRT's ability to predict mortality of patients with septic shock initially cared in the prehospital setting by a mobile intensive care unit.

METHODS

Patients with septic shock who received prehospital medical care admitted to the intensive care unit were retrospectively analyzed.

RESULTS

Sixty-three patients were included. The origin of sepsis was mainly pulmonary (67%). Overall mortality reached 36%. No significant difference was observed in the duration of prehospital medical care between alive and deceased patients. Mean prehospital value of SMS was 3 ± 2 and mean prehospital value of CRT was 5 ± 1 s. A significant association was found between mortality and prehospital SMS (p = 0.02, OR[CI95] = 1.50 [1.08-2.15]) and prehospital CRT (p = 0.04, OR[CI95] = 1.53 [1.04-2.37]). After adjusting for confounding factors using propensity score, the relative risk of death was 6.58 for SMS > 2 and 2.03 for CRT > 4 s.

CONCLUSION

In this study, we report an association between prehospital SMS and CRT, and mortality of patients with septic shock. SMS and CRT are simple tools that could be used to optimize the triage and to decide early intensive care admission.