Division of Pulmonary & Critical Care Medicine, University of Washington, Seattle, Washington, USA.
Prehosp Emerg Care. 2010 Apr-Jun;14(2):145-52. doi: 10.3109/10903120903524997.
Early identification and treatment of patients with severe sepsis improves outcome, yet the role of out-of-hospital intravenous (IV) fluid is unknown.
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).
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.
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.
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.
早期识别和治疗严重脓毒症患者可改善预后，但院外静脉（IV）补液的作用尚不清楚。
确定严重脓毒症患者院外补液是否与急诊科（ED）实现目标导向复苏的时间缩短有关。
我们对一个大都市三级保健大学附属医院进行的回顾性队列研究进行了二次数据分析，该医院得到了两级院外急救医疗服务（EMS）提供者的支持。我们研究了高级生命支持（ALS）提供者提供院外补液与 ED 中早期目标导向治疗（EGDT）期间 6 小时内实现复苏终点（中心静脉压[CVP]≥8mmHg、平均动脉压[MAP]≥65mmHg 和中心静脉血氧饱和度[ScvO2]≥70%）之间的关系。
在 52 名因严重脓毒症而由 ALS 转运的患者中，有 25 名（48%）接受了院外补液。接受和未接受院外补液的患者在年龄、性别、脓毒症来源和合并症存在方面的数据相似。接受院外补液的患者的院外平均（+/-标准差）收缩压较低（95+/-40mmHg比 117+/-29mmHg；p=0.03），ED 中中位数（四分位距）序贯器官衰竭评估（SOFA）评分较高（7[5-8]比 4[4-6]；p=0.01）。尽管疾病严重程度更高，但接受院外补液的患者在 ED 分诊后 6 小时内达到 MAP≥65mmHg的可能性并未显著增加（70%比 44%，p=0.09）。平均而言，接受院外补液的患者在 ED 分诊后 1 小时内接受的液体量是未接受院外补液的患者的两倍（1.1L[1.0-2.0L]比 0.6L[0.3-1.0L]；p=0.01）。两组之间达到目标 CVP（72%比 60%；p=0.6）或目标 ScvO2（54%比 36%；p=0.25）的差异无统计学意义。
不到一半的由 ALS 转运的严重脓毒症患者接受了院外补液。接受院外 IV 通路和补液的患者在实现 EGDT 期间达到目标 MAP 的可能性有所增加，但没有达到统计学意义。这些初步发现需要进一步研究，以评估院外复苏在治疗严重脓毒症患者中的最佳作用。
