RECENT NEWS: Fluid Resuscitation in Septic Shock: An Exploration of Emergency Department and Critical Care Clinician Perceptions and Decision-Making

 

“Yes, administering early quick fluids is always the first step to healing a patient. It’s that bridge that takes you from just diagnosing to treating… I can say that in 98% of my patients, the key to their successful outcomes has been fluids – and early ones.”

Sepsis is a leading cause of in-hospital morbidity and mortality and the most expensive condition treated in US hospitals.1,2 Timely recognition and treatment of sepsis, including early intravenous (IV) fluid resuscitation and administration of antibiotics has been repeatedly demonstrated to improve patient outcomes.1,3,4,5

No studies have been conducted to date to understand the decision-making process for IV fluid resuscitation for septic and septic shock patients in the emergency department. A recently conducted study sought to capture the perceptions, influences and nuances of this process and how they impact approaches to clinical care.

Twenty-five interviews were conducted with physicians, nurse practitioners, and clinical nurses who regularly treat patients with sepsis in the emergency department or in a critical care unit. Semi-structured interview guides included questions developed to assess perceptions of sepsis care and decision-making about fluid resuscitation.

While controversy exists around current guideline evidence and concerns that a “one-size-fits-all” approach will be followed above patient-centered decisions, the results from this study challenge this concern. Participant responses, representing a variety of medical perspectives, were consistent with a significant volume of literature showing that reversal of shock is most successful in the early hours of diagnosis and critical to avoid further morbidity and mortality.6,7,8 Clinicians appear to rely as much or more on their judgment and experience than protocols and guidelines for determining when and how to administer fluids.

 

References

1. Liu VX, et al. (2016). Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values. American Journal of Respiratory and Critical Care Medicine, 193(11), 1264-1270. doi:10.1164/rccm.201507-1489OC.

2. Torio C, Moore B. National Inpatient Costs: The Most Expensive Conditions by Payer, 2013. HCUP Statistical Brief #204. May 2016. Agency for Healthcare Research and Quality. Rockville, MD. [cited 2018 September 10] Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.pdf

3. Burrell AR , et al. (2016). SEPSIS KILLS: early intervention saves lives. Medical Journal of Australia, 204(2). doi:10.5694/mja15.00657.

4. Grek A, et al. (2017). Sepsis and Shock Response Team: Impact of a Multidisciplinary Approach to Implementing Surviving Sepsis Campaign Guidelines and Surviving the Process. American Journal of Medical Quality, 32(5), 500-507. doi:10.1177/1062860616676887.

5. Lee S, et al. (2014). Increased Fluid Administration in the First Three Hours of Sepsis Resuscitation Is Associated With Reduced Mortality A Retrospective Cohort Study. Chest, 146(4), 908 915. doi:10.1378/chest.13-2702.

6. Spiegel R, et al. 2019). The 2018 Surviving Sepsis Campaign’s Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use. Annals of Emergency Medicine, 73(4), 356-358.

7. Leisman D, et al.(2016). Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Annals of Emergency Medicine, 68(3), 298-311. doi:10.1016/j.annemergmed.2016.02.044

8. Pruinelli L, et al. (2018). Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock. Critical Care Medicine, 46(4), 500-505. doi:10.1097/ccm.0000000000002949