Estimated plasma volume status is a simple and quick tool that could help define the severity of patients with infection on arrival at the emergency department

BACKGROUND

Infectious states are subtle and rapidly evolving conditions observed daily in the emergency department (ED), and their prognostic evaluation remains a complex clinical challenge. Recently, estimated plasma volume status (ePVS) has been suggested to have a prognostic role in conditions where volemic alteration is central to the pathophysiology. The aim of this study was to verify whether ePVS recorded at ED admission can provide prognostic indications of 30-day mortality in patients with infection.

METHODS

A prospective observational study was performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital. All patients with infection were enrolled. ePVS values were derived from haemoglobin and haematocrit measured on the immediate arrival of patients in the ED. The predictive power of ePVS for 30-day mortality was assessed using a multivariate model adjusted for severity, comorbidity and urgency. Kaplan-Meier analysis was also performed.

RESULTS

Of the 949 patients with infection enrolled in the study (47.9%, SOFA ≥2), 8.9% (84/949) died at 30 days. The median ePVS value was higher in patients who died at 30 days than in patients who survived (5.83 vs. 4.61, p < 0.001). Multivariate analysis revealed that ePVS in both continuous and categorical form around the median was an independent risk factor for 30-day mortality even after adjusting for severity, comorbidity and urgency. Kaplan-Meier analysis confirmed an increased risk of death in patients with high ePVS values.

CONCLUSIONS

ePVS recorded on ED admission of patients with infection was an independent predictor of risk for 30-day mortality.

Association between intravenous fluid administration and endothelial glycocalyx shedding in humans: a systematic review

INTRODUCTION

Several studies have demonstrated associations between greater rate/volume of intravenous (IV) fluid administration and poorer clinical outcomes. One postulated mechanism for harm from exogenous fluids is shedding of the endothelial glycocalyx (EG).

METHODS

A systematic review using relevant search terms was performed using Medline, EMBASE and Cochrane databases from inception to October 2023. Included studies involved humans where the exposure was rate or volume of IV fluid administration and the outcome was EG shedding. The protocol was prospectively registered on PROSPERO: CRD42021275133.

RESULTS

The search yielded 450 articles, with 20 articles encompassing 1960 participants included in the review. Eight studies were randomized controlled clinical trials. Half of studies examined patients with sepsis and critical illness; the remainder examined perioperative patients or healthy subjects. Almost all reported blood measurements of soluble EG components; one study used in vivo video-microscopy to estimate EG thickness. Four of 10 sepsis studies, and 9 of 11 non-sepsis studies, found a positive relationship between IV fluid rate/volume and measures of EG shedding.

CONCLUSIONS

A trend toward an association between IV fluid rate/volume and EG shedding was found in studies of stable patients, but was not consistently observed among studies of septic and critically ill patients.

Effect of intravenous fluid volume on biomarkers of endothelial glycocalyx shedding and inflammation during initial resuscitation of sepsis

PURPOSE

To investigate the effect of IV fluid resuscitation on endothelial glycocalyx (EG) shedding and activation of the vascular endothelium and inflammation.

MATERIALS AND METHODS

A planned biomarker sub-study of the REFRESH trial in which emergency department (ED) patients) with suspected sepsis and hypotension were randomised to a restricted fluid/early vasopressor regimen or IV fluid resuscitation with later vasopressors if required (usual care). Blood samples were collected at randomisation (T0) and at 3 h (T3), 6 h (T6)- and 24 h (T24) for measurement of a range of biomarkers if EG shedding, endothelial cell activation and inflammation.

RESULTS

Blood samples were obtained in 95 of 99 enrolled patients (46 usual care, 49 restricted fluid). Differences in the change in biomarker over time between the groups were observed for Hyaluronan (2.2-fold from T3 to T24, p = 0.03), SYN-4 (1.5-fold from T3 to T24, P = 0.01) and IL-6 (2.5-fold from T0 to T3, p = 0.03). No difference over time was observed between groups for the other biomarkers.

CONCLUSIONS

A consistent signal across a range of biomarkers of EG shedding or of endothelial activation or inflammation was not demonstrated. This could be explained by pre-existing EG shedding or overlap between the fluid volumes administered in the two groups in this clinical trial. Trial registration Australia New Zealand Clinical Trials Registry ACTRN126160000006448 Registered 12 January 2016.

Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup

Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research.

Modified Sequential Organ Failure Assessment score for predicting mortality in emergency department patients with sepsis

OBJECTIVE

Several scoring systems have been proposed for EDs to identify patients at increased risk of mortality from sepsis. The modified Sequential Organ Failure Assessment (mSOFA) score, proposed in 2019, demonstrated a high negative predictive value. We aimed to validate mSOFA and compare its accuracy for predicting 30-day mortality to the simple bedside score, quick SOFA (qSOFA).

METHODS

Over 1 month in 2018, consecutive patients with suspected sepsis were prospectively identified. A retrospective chart review was conducted to calculate both the mSOFA and qSOFA scores for these patients. The primary outcome was 30-day mortality.

RESULTS

There were 252 patients with suspected sepsis identified over the study period. Thirty-day mortality was 13/39 (33.3%) for those with a positive mSOFA and 15/211 (7.1%) for those with a negative mSOFA score. Sensitivity was 46.4% (95% confidence interval [CI] 27.5-66.1%), specificity 88.3% (95% CI 83.3-92.2%), positive likelihood ratio 3.96 (95% CI 2.32-6.78), negative likelihood ratio 0.61 (95% CI 0.43-0.86). The area under the curve (AUC) was 0.74 (95% CI 0.64-0.85). qSOFA sensitivity was 39.3% (95% CI 21.5-59.4%), specificity 91.9% (95% CI 87.5-95.1%), positive likelihood ratio 4.85 (95% CI 2.56-9.18) and negative likelihood ratio 0.66 (95% CI 0.49-0.89). The AUC for qSOFA was 0.81 (95% CI 0.73-0.88). The difference in the AUC was -0.07 (95% CI -0.18 to 0.05), P = 0.25.

CONCLUSIONS

In the present study, neither mSOFA nor qSOFA was adequately sensitive for predicting 30-day mortality, although both scores were highly specific and their overall accuracy was similar. The added complexity of the mSOFA without a significant increase in discriminative ability makes it unlikely to replace qSOFA in the ED setting.

Sepsis

This article provides an overview of the history of the sepsis definitions as well as an overview of the current understanding of the pathogenesis of sepsis. The evolution of the treatment bundles is also presented.

Twenty-four-hour fluid administration in emergency department patients with suspected infection: A multicenter, prospective, observational study

BACKGROUND

To describe 24-hour fluid administration in emergency department (ED) patients with suspected infection.

METHODS

A prospective, multicenter, observational study conducted in three Danish hospitals, January 20 to March 2, 2020. We included consecutive adult ED patients with suspected infection (drawing of blood culture and/or intravenous antibiotic administration within 6 hours of admission). Oral and intravenous fluids were registered for 24 hours.

PRIMARY OUTCOME

24-hour total fluid volume. We used linear regression to investigate patient and disease characteristics' effect on 24-hour fluids and to estimate the proportion of the variance in fluid administration explained by potential predictors.

RESULTS

734 patients had 24-hour fluids available: 387 patients had simple infection, 339 sepsis, eight septic shock. Mean total 24-hour fluid volumes were 3656 mL (standard deviation [SD]:1675), 3762 mL (SD: 1839), and 6080 mL (SD: 3978) for the groups, respectively. Fluid volumes varied markedly. Increasing age (mean difference [MD]: 60-79 years: -470 mL [95% CI: -789, -150], +80 years; -974 mL [95% CI: -1307, -640]), do-not-resuscitate orders (MD: -466 mL [95% CI: -797, -135]), and preexisting atrial fibrillation (MD: -367 mL [95% CI: -661, -72) were associated with less fluid. Systolic blood pressure < 100 mmHg (MD: 1182 mL [95% CI: 820, 1543]), mean arterial pressure < 65 mmHg (MD: 1317 mL [95% CI: 770, 1864]), lactate ≥ 2 mmol/L (MD: 655 mL [95% CI: 306, 1005]), heart rate > 120 min (MD: 566 [95% CI: 169, 962]), low (MD: 1963 mL [95% CI: 813, 3112]) and high temperature (MD: 489 mL [95% CI: 234, 742]), SOFA score > 5 (MD: 1005 mL [95% CI: 501, 510]), and new-onset atrial fibrillation (MD: 498 mL [95% CI: 30, 965]) were associated with more fluid. Clinical variables explained 37% of fluid variation among patients.

CONCLUSIONS

Patients with simple infection and sepsis received equal fluid volumes. Fluid volumes varied markedly, a variation that was partly explained by clinical characteristics.

Early compared to later commencement of vasopressors in the management of Emergency Department patients with sepsis and hypotension, a multi-centre observational study

AIM

To describe and compare early with late vasopressor commencement in emergency department (ED) patients with sepsis and hypotension.

METHODS

This is a sub-study of the ARISE FLUIDS observational study conducted in 70 EDs in Australia and New Zealand. Adults with suspected sepsis and hypotension who received a vasopressor infusion in the first 24 h after ED presentation were included. 'Early' was defined as vasopressor commenced within 2 h from a) sepsis recognition, or b) triage.

RESULTS

177 patients (mean age 68 years) received vasopressors and had a lactate of 3.0 (IQR 2.0-4.9) mmol/L and APACHE II score of 17.8 (SD 6.3). 110 (62%) received a single agent vasopressor with noradrenaline being the most common (n = 74) and 67 (38%) received multiple vasopressors, most commonly metaraminol then noradrenaline (20.3%, n = 36). One-third (34.7%, n = 62) had vasopressors started via a peripheral line. Vasopressors were started within 2 h of sepsis recognition in 74 patients and within 2 h of triage in 24 patients. Both early groups had a higher lactate (3.5 vs. 2.9mmol/L and 5.0 vs. 2.9mmol/L, both p <0.05) and received lower fluid volumes prior to vasopressor commencement (2.0 vs. 2.85 L and 1.55 vs. 2.4 L, both p <0.001), compared to patients receiving vasopressors later. No differences in duration of vasopressor infusion, need for organ support or in-hospital mortality were found.

CONCLUSION

Early vasopressor commencement was associated with the administration of lower intravenous fluid volumes but not with duration of vasopressor use, organ support or mortality. Large prospective studies addressing this question are required.

Challenges in the recognition and management of paediatric sepsis - The journey

Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.

Pharmacoepidemiology of metaraminol in critically ill patients with shock in a tertiary care hospital

BACKGROUND

Metaraminol is increasingly used as a vasopressor in critically ill patients. Nevertheless, there remains limited evidence to support its use in international guidelines for management of shock.

OBJECTIVES

The aim of the study was to describe the pharmacoepidemiology of metaraminol in critically ill patients with shock.

METHODS

A retrospective observational study was conducted in an intensive care unit (ICU) in Sydney, Australia. Patients admitted during a 1-year time frame who received metaraminol intravenous infusions for management of shock were included.

RESULTS

A total of 152 patients were included. When metaraminol was used, it was the most common first-line vasopressor started for management of shock (97%, n = 147) and was used as monotherapy in 53% (n = 81) of patients. The median duration of metaraminol infusion in the ICU was 7 h (interquartile range [IQR] = 3 to 19), and the median maximum metaraminol infusion rate in the ICU was 4.0 mg/h (IQR = 2.5 to 6.0). Peripheral vasopressor infusions were used in 96% (n = 146/152) of patients for a median duration of 7 h (IQR = 2 to 18). In all these cases, the peripheral vasopressor used was metaraminol (100%, n = 146/146). Patients were commonly switched from metaraminol to noradrenaline infusions after insertion of a central venous catheter (R2 = 0.89). Patients treated with metaraminol monotherapy had a lower Acute Physiology and Chronic Health Evaluation III score (58 vs 68; median difference = -9, 95% confidence interval = -16 to -3; p < 0.01) and a shorter duration of overall vasopressor use in the ICU (12 vs 39 h, median difference = -24 h, 95% confidence interval = -31 to -18; p < 0.01) than those treated with combination vasopressors. No extravasation injury was reported in the study cohort.

CONCLUSIONS

Metaraminol is often administered as a first-line peripheral vasopressor in the ICU and is used as a single agent in patients with lower severity of shock.

Research capacity of Australian and New Zealand emergency medicine departments

BACKGROUND

Large, multicentre studies are required in emergency medicine to advance clinical care and improve patient outcomes. The Australasian College for Emergency Medicine clinical trials network is available to researchers to assist with facilitating large, multicentre research. However, there is no current information about the research capacity of emergency departments (EDs) in Australia and New Zealand.

METHODS

All EDs accredited for emergency medicine training in Australia and New Zealand were eligible to participate. Research leads or ED directors were invited via email and telephone to complete a survey. Data were collected regarding the presence of a research lead; their research experience; available research resources including colleagues, funding, departmental paid research time; publications; and research culture.

RESULTS

One hundred and twelve responses were received on behalf of 122 (84%) sites (10 satellite plus main) from a possible 143 sites with all types of hospitals and regions represented. Research leads were identified at 66 (59%) sites; 32 (29%) had a director of emergency medicine research. A wide range of research was underway. Ninety-six sites (66%) contributed data to multicentre projects. Twenty-one centres (17%) were highly productive with multiple resources (skilled colleagues, funding, staffing), a positive research culture and high-volume output. Sixty to seventy centres (50-58%) had limited resources, experienced an unsupportive research culture and authored manuscripts infrequently. Paid time for research directors was associated with increased research outputs.

DISCUSSION

ACEM sites have the capacity to undertake large multicentre studies with a varied network of sites and researchers. While some sites are well equipped for research, the majority of EDs had minimal research output.

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand

OBJECTIVES

To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension.

METHODS

This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality.

RESULTS

A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%).

CONCLUSION

Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.