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Fluid resuscitation in pre-hospital management of septic shock

Published:February 03, 2018DOI:https://doi.org/10.1016/j.ajem.2018.01.078

      Abstract

      Background

      Septic shock is associated with hypovolemia resulting in organs failure and poor prognosis. The first step in hemodynamic resuscitation relies on early fluid expansion. In this study, we describe qualitative and quantitative fluid resuscitation of septic shock initially managed in a pre-hospital setting by a mobile intensive care unit.

      Methods

      Patients with septic shock who received pre-hospital medical care were retrospectively analysed. Qualitative and quantitative fluid resuscitation performed in the pre-hospital setting were analysed. Applying the "grey zone" concept, we define 3 categories of fluid expansion indexed on ideal body weight (IBW): >20ml/kg, 10-20ml/kg and  < 10ml/kg. The relationship between the pre-specified categories and mortality at day 28 were analyzed.

      Results

      Ninety-five patients were included. The origin of sepsis was mainly pulmonary (68%). Mortality reached 34%. Pre-hospital fluid expansion was performed using serum saline (98%) with a mean of 1158±559ml. An inversed linear relationship between pre-specified categories and mortality was observed. Using logistic regression model, significant association with mortality remained for fluid expansion indexed on IBW: p=0.02, ORa [CI95] = 0.93 [0.89-0.98]. For fluid expansion indexed on IBW < 10ml/kg, the OR [CI95] was 4.03 [1.78-9.41] (p=0.005) whereas for fluid expansion indexed on IBW > 20ml/kg, the OR [CI95] was 0.30 [0.13-0.66] (p=0.01).

      Discussion

      Pre-hospital fluid resuscitation in septic shock is mainly performed using crystalloids with quantitative fluid expansion lower than recommended. Low pre-hospital fluid expansion was associated with increased mortality. Further prospective studies are needed to evaluate the impact of optimized early fluid expansion on mortality in the prehospital management of septic shock.
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