Emergency Department Management of Sepsis Patients: A Randomized, Goal-Oriented, Noninvasive Sepsis Trial

• Published in: Annals of emergency medicine Vol. 67; no. 3; pp. 367 - 378.e3
• Main Authors: Kuan, Win Sen, Ibrahim, Irwani, Leong, Benjamin S.H., Jain, Swati, Lu, Qingshu, Cheung, Yin Bun, Mahadevan, Malcolm
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.03.2016
• Subjects: Aged; Critical Care - organization & administration; Disease Management; Emergency; Emergency Service, Hospital - organization & administration; Female; Fluid Therapy - methods; Hospital Costs; Hospital Mortality; Humans; Lactates - blood; Length of Stay - statistics & numerical data; Male; Middle Aged; Monitoring, Physiologic - instrumentation; Organizational Objectives; Sepsis - blood; Sepsis - mortality; Sepsis - therapy; Shock, Septic - blood; Shock, Septic - mortality; Shock, Septic - therapy; Singapore - epidemiology; Stroke Volume; Treatment Outcome; Singapore
• ISSN: 0196-0644; 1097-6760; 1097-6760
• DOI: 10.1016/j.annemergmed.2015.09.010

The noninvasive cardiac output monitor and passive leg-raising maneuver has been shown to be reasonably accurate in predicting fluid responsiveness in critically ill patients. We examine whether using a noninvasive protocol would result in more rapid lactate clearance after 3 hours in patients with severe sepsis and septic shock in the emergency department. In this open-label randomized controlled trial, 122 adult patients with sepsis and serum lactate concentration of greater than or equal to 3.0 mmol/L were randomized to receive usual care or intravenous fluid bolus administration guided by measurements of change of stroke volume index, using the noninvasive cardiac output monitor after passive leg-raising maneuver. The primary outcome was lactate clearance of more than 20% at 3 hours. Secondary outcomes included mortality, length of hospital and ICU stay, and total hospital cost. Analysis was intention to treat. Similar proportions of patients in the randomized intervention group (70.5%; N=61) versus control group (73.8%; N=61) achieved the primary outcome, with a relative risk of 0.96 (95% confidence interval [CI] 0.77 to 1.19). Secondary outcomes were similar in both groups (P>.05 for all comparisons). Hospital mortality occurred in 6 patients (9.8%) each in the intervention and control groups on or before 28 days (relative risk=1.00; 95% CI 0.34 to 2.93). Among a subgroup of patients with underlying fluid overload states, those in the intervention group tended to receive clinically significantly more intravenous fluids at 3 hours (difference=975 mL; 95% CI –450 to 1,725 mL) and attained better lactate clearance (difference=19.7%; 95% CI –34.6% to 60.2%) compared with the control group, with shorter hospital lengths of stay (difference=–4.5 days; 95% CI –9.5 to 2.5 days). Protocol-based fluid resuscitation of patients with severe sepsis and septic shock with the noninvasive cardiac output monitor and passive leg-raising maneuver did not result in better outcomes compared with usual care. Future studies to demonstrate the use of the noninvasive protocol-based care in patients with preexisting fluid overload states may be warranted.