HALIFAX, N.S. — A protocol of early antibiotics and hemodynamic stabilization decreases mortality in patients with severe sepsis or septic shock, Dr. Robert Stenstrom said at the 11th International Conference on Emergency Medicine.
Initiating the program in the emergency department requires an increase in nursing and physician bedside time, but the 23% decrease in mortality makes the investment worthwhile, said Dr. Stenstrom, director of research at St. Paul's Hospital, Vancouver.
His review examined mortality and time-dependent treatment before and after emergency department implementation of a sepsis protocol. The protocol, based on that described by Dr. Emanuel Rivers in 2001 (N. Engl. J. Med. 2001;345:1368–77), calls for early IV fluids and antibiotics, followed by initiation of early goal-directed therapy aimed at hemodynamic stabilization, said Dr. Stenstrom, who is also an emergency physician at the hospital.
Included in the study were 50 patients admitted to the ICU directly from the emergency department with severe sepsis (one or more organs failing or a lactate level of 4.0 mmol/L or greater) or septic shock (systolic blood pressure less than 90 mm Hg despite fluid bolus of 25 mL/kg). There were 20 patients in the preprotocol group and 30 in the protocol group. Their mean age was 50 years; the mean Acute Physiology and Chronic Health Evaluation score was 24.
In the preprotocol group, 7 of the 20 patients received first antibiotics in less than 1 hour, and the rest received the drugs in 1–10 hours. In the protocol group, 20 of 30 patients got antibiotics in less than 1 hour and 6 got them in 1–2 hours. Three more got the drugs by 4 hours, but one patient didn't receive them until almost 8 hours had passed. Time to completion of initial fluid bolus (usually 2 L of normal saline) decreased significantly, from about 2.5 hours in the preprotocol group to just over 1 hour in the protocol group.
In the preprotocol group, 14 patients were on early goal-directed therapy by 10 hours, but it took 12–60 hours in the other 6. In the protocol group, all were on early goal-directed therapy before 10 hours.
There was no significant difference in time to ICU transfer, Dr. Stenstrom said.
At 28 days, mortality was 46% in the preprotocol group and 23% in the protocol group—a decrease of 23%.
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