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Severe Sepsis: Failure of Protocol-Based Fluid Therapy to Improve Mortality
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A3307 - Severe Sepsis: Failure of Protocol-Based Fluid Therapy to Improve Mortality
Author Block: S. A. Blau1, R. Spector2; 1CHSLI, White Plains, NY, United States, 2GSHMC, Great Neck, NY, United States.
Introduction/Rationale: The clinical management of severe sepsis and septic shock is commonly protocol driven with mandated initial fluid therapy (30 ml/kg), timely administration of appropriate antibiotics, and pressors if needed. In an earlier single hospital study, the beneficial effects of fluid therapy were seen even in patients whose antibiotics were delayed. We review a larger patient cohort, stratifying the patients by age and initial lactate level to determine effects of fluid therapy.
Methods: This retrospective review used our multi-hospital database which included 4898 patients seen between April 2015 and December 2016. We here included only those adult patients who received antibiotics. Patients were stratified by initial lactate into two groups: “low” (lactate 2.0 to 3.9 mmol/L) and “high” (lactate >=4 mmol/L). Patients were stratified by age and described as “young” (18-49 years), “middle” (50-79 years), and “elderly (80 years or older). Appropriate fluid is described as 30 ml/kg within 6 hours of diagnosis. Fisher’s exact test was used to determine statistical significance.
Results: 2731 patients received timely antibiotics. There were 262 “young” patients, 1342 “middle age” patients, and 1127 “elderly” patients. Mortality increased with patient age (8%, 22%, 31%; p=0.0001). For each age group, “high” lactate was associated with increased mortality versus “low” lactate (overall 32% v 19%, p=0.0001). Patients on vasopressors had increased mortality when compared to those not on vasopressors. Compliance with the fluid therapy was poor (48%), but was consistent among the three age groups. Patients receiving fluid had a higher mortality (28%) than those that did not (21%). Fluid therapy was provided more often in the “high” lactate group (72% of 1048 patients vs. 32% of 1683 “low”). 23% of 1299 patients receiving fluids also received vasopressors; only 5% of patients not receiving fluids were on vasopressors (p=0.0001). In patients with “high” lactate and on vasopressors, fluids were associated with a reduction in mortality from 42% to 34%. Fluids decreased the mortality in all patients on vasopressors (51% v 41%), regardless of lactate level, but this difference did not reach statistical significance.
Conclusion: Fluids were withheld in violation of protocol for no obvious reason (retrospective study) and the protocol seems to have been followed predominantly in the most acutely ill. Clinician decision-making may have been predicated on published studies documenting a correlation between fluid volume and mortality or concern of fluid overload. There is a suggestion that fluids might decrease the mortality of patients on vasopressors.
Author Block: S. A. Blau1, R. Spector2; 1CHSLI, White Plains, NY, United States, 2GSHMC, Great Neck, NY, United States.
Introduction/Rationale: The clinical management of severe sepsis and septic shock is commonly protocol driven with mandated initial fluid therapy (30 ml/kg), timely administration of appropriate antibiotics, and pressors if needed. In an earlier single hospital study, the beneficial effects of fluid therapy were seen even in patients whose antibiotics were delayed. We review a larger patient cohort, stratifying the patients by age and initial lactate level to determine effects of fluid therapy.
Methods: This retrospective review used our multi-hospital database which included 4898 patients seen between April 2015 and December 2016. We here included only those adult patients who received antibiotics. Patients were stratified by initial lactate into two groups: “low” (lactate 2.0 to 3.9 mmol/L) and “high” (lactate >=4 mmol/L). Patients were stratified by age and described as “young” (18-49 years), “middle” (50-79 years), and “elderly (80 years or older). Appropriate fluid is described as 30 ml/kg within 6 hours of diagnosis. Fisher’s exact test was used to determine statistical significance.
Results: 2731 patients received timely antibiotics. There were 262 “young” patients, 1342 “middle age” patients, and 1127 “elderly” patients. Mortality increased with patient age (8%, 22%, 31%; p=0.0001). For each age group, “high” lactate was associated with increased mortality versus “low” lactate (overall 32% v 19%, p=0.0001). Patients on vasopressors had increased mortality when compared to those not on vasopressors. Compliance with the fluid therapy was poor (48%), but was consistent among the three age groups. Patients receiving fluid had a higher mortality (28%) than those that did not (21%). Fluid therapy was provided more often in the “high” lactate group (72% of 1048 patients vs. 32% of 1683 “low”). 23% of 1299 patients receiving fluids also received vasopressors; only 5% of patients not receiving fluids were on vasopressors (p=0.0001). In patients with “high” lactate and on vasopressors, fluids were associated with a reduction in mortality from 42% to 34%. Fluids decreased the mortality in all patients on vasopressors (51% v 41%), regardless of lactate level, but this difference did not reach statistical significance.
Conclusion: Fluids were withheld in violation of protocol for no obvious reason (retrospective study) and the protocol seems to have been followed predominantly in the most acutely ill. Clinician decision-making may have been predicated on published studies documenting a correlation between fluid volume and mortality or concern of fluid overload. There is a suggestion that fluids might decrease the mortality of patients on vasopressors.
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