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International Journal of Emergency Medicine
Published in: International Journal of Emergency Medicine 1/2019

Open Access 01-12-2019 | Septicemia | Original Research

The association between intravenous fluid resuscitation and mortality in older emergency department patients with suspected infection

Authors: Sin Y. Ko, Laura M. Esteve Cuevas, Merel Willeboer, Annemieke Ansems, Laura C. Blomaard, Jacinta A. Lucke, Simon P. Mooijaart, Bas de Groot

Published in: International Journal of Emergency Medicine | Issue 1/2019

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Abstract

Objective

Recent studies suggest that hypotension thresholds in current guidelines might be too low for older patients due to arterial stiffening, possibly leading to insufficient fluid resuscitation. We compared intravenous (IV) fluid volumes that older (≥ 70 years) and younger (< 70 years) patients with suspected infection with similar initial systolic blood pressure (SBP) received in the emergency department (ED) and investigated whether this was associated with in-hospital mortality in older patients.

Methods

This was an observational multicenter study using an existing database in which consecutive ED patients hospitalized with suspected infection were prospectively included. We first compared the fluid volumes older and younger ED patients received per initial SBP category. Patients were then stratified into two SBP categories (≤ or > 120 mmHg; 120 has been suggested to be a better threshold) and thereafter into three fluid volume categories: 0–1 L, 1–2 L, or > 2 L. In each SBP and fluid category, case-mix-adjusted in-hospital mortality was compared between older and younger patients, using multivariable logistic regression analysis.

Results

The included 981 (37%) older and 1678 (63%) younger ED patients received similar IV fluid volumes per initial SBP category. Older patients with an initial SBP > 120 mmHg had a higher adjusted OR of 2.06 (95% CI 1.02–4.16), in the 0–1 L category, while this association was not found in the higher fluid categories of 1–2 L or > 2 L. In the SBP ≤ 120 mmHg category, this association was also absent.

Conclusion

This hypothesis-generating study suggests that older patients with suspected infection may need higher fluid volumes than younger patients, when having a seemingly normal initial SBP.
Appendix
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Literature
1.
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Crit Care Med. 2017;45(3):486–552.CrossRef
2.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.CrossRef
3.
The ARISE investigators and the ANZICS trials group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506.CrossRef
4.
Mouncey PR, Osborn TM, Power SG, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301–11.CrossRef
5.
Harris T, Coats TJ, Elwan MH. Fluid therapy in the emergency department: an expert practice review. Emerg Med J. 2018;35:511–5.CrossRef
6.
Strait JB, Lakatta EG. Aging-associated cardiovascular changes and their relationship to heart failure. Heart Fail Clin. 2012;8(1):143–64.CrossRef
7.
Nasa P, Juneja D, Singh O, et al. Severe sepsis and septic shock in the elderly: an overview. World J Crit Care Med. 2012;1(1):23–30.CrossRef
8.
Girard TD, Opal SM, Ely EW. Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clin Infect Dis. 2005;40(5):719–27.CrossRef
9.
Liu VX, Morehouse JW, Marelich GP, et al. Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values. Am J Respir Crit Care Med. 2016;193(11):1264–70.CrossRef
10.
Yoshikawa TT, Norman DC. Acute emergencies and critical care of the geriatric patient. 1st ed. New York: Marcel Dekker; 2000.
11.
de Groot B, Stolwijk F, Warmerdam M, et al. The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study. Scand J Trauma Resusc Emerg Med. 2017;25:91.CrossRef
12.
Glickman SW, Cairns CB, Otero RM, et al. Disease progression in hemodynamically stable patients presenting to the emergency department with sepsis. Acad Emerg Med. 2010;17(4):383–90.CrossRef
13.
Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):801–10.CrossRef
14.
Warmerdam M, Baris L, van Liebergen, et al. The association between systolic blood pressure and in-hospital mortality in older emergency department patients who are hospitalised with a suspected infection. Emerg Med J. 2018;35(10):619–22.
15.
Clarke DL, Chipps JA, Sartorius B, et al. Mortality rates increase dramatically below a systolic blood pressure of 105-mm Hg in septic surgical patients. Am J Surg. 2016;212(5):941–5.CrossRef
16.
Oyetunji TA, Chang DC, Crompton JG, et al. Redefining hypotension in the elderly: normotension is not reassuring. Arch Surg. 2011;146(7):865–9.CrossRef
17.
De Groot B, Struyk B, Najafi R, et al. Inclusion of emergency department patients in early stages of sepsis in a quality improvement programme has the potential to improve survival: a prospective dual-centre study. Emerg Med J. 2017;34(9):578–85.CrossRef
18.
de Groot B, Ansems A, Gerling DH, et al. The association between time to antibiotics and relevant clinical outcomes in emergency department patients with various stages of sepsis: a prospective multi-center study. Crit Care. 2015;19(1):194.CrossRef
19.
20.
de Groot B, Lameijer J, de Deckere ER, et al. The prognostic performance of the predisposition, infection, response and organ failure (PIRO) classification in high-risk and low-risk emergency department sepsis populations: comparison with clinical judgement and sepsis category. Emerg Med J. 2014;31(4):292.CrossRef
21.
Howell MD, Talmor D, Schuetz P, et al. Proof of principle: the predisposition, infection, response, organ failure sepsis staging system. Crit Care Med. 2011;39:322–7.CrossRef
22.
Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and cox regression. Am J Epidemiol. 2007;165(6):710–7.CrossRef
23.
Twisk J. Applied multilevel analysis. 1st ed. New York: Cambridge University Press; 2006.CrossRef
24.
Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med. 2003;29:530–8.CrossRef
25.
Lederer DJ, Bell SC, Branson RD, et al. Control of confounding and reporting of results in causal inference studies: guidance for authors from editors of respiratory, sleep, and critical care journals. Ann Thorac Med. 2009;4(3):128–32.CrossRef
26.
van der Veen D, Remeijer C, Fogteloo AJ, et al. Independent determinants of prolonged emergency department length of stay in a tertiary care centre: a prospective cohort study. Scand J Trauma Resusc Emerg Med. 2018;26:81.CrossRef
27.
El Solh AA, Akinussi ME, Alsawalha LN, et al. Outcome of septic shock in older adults after implementation of the sepsis “bundle”. J Am Geriatr Soc. 2008;56(2):272–8.CrossRef
28.
Heppner HJ, Singler K, Kwetkat A, et al. Do clinical guidelines improve management of sepsis in critically ill elderly patients? A before-and-after study of the implementation of a sepsis protocol. Wien Klin Wochenschr. 2012;124(19):692–8.CrossRef
29.
Metadata
Title
The association between intravenous fluid resuscitation and mortality in older emergency department patients with suspected infection
Authors
Sin Y. Ko
Laura M. Esteve Cuevas
Merel Willeboer
Annemieke Ansems
Laura C. Blomaard
Jacinta A. Lucke
Simon P. Mooijaart
Bas de Groot
Publication date
01-12-2019
Publisher
Springer Berlin Heidelberg
Published in
International Journal of Emergency Medicine / Issue 1/2019
Print ISSN: 1865-1372
Electronic ISSN: 1865-1380
DOI
https://doi.org/10.1186/s12245-018-0219-2

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