Date: February 22nd, 2019

Reference: Lane et al. Association Between Early Intravenous Fluids Provided by Paramedics and Subsequent In-Hospital Mortality Among Patients With Sepsis. JAMA 2018

Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.

Case: A 77-year-old man’s partner calls 911 because he has a fever, cough, shortness of breath and lethargy. The patient is known to have hypertension and dyslipidemia. Paramedics arrive quickly and find a man in bed with a temperature of 39.5C, heart rate of 111 beats per minute, respiratory rate of 24 breaths per minute, oxygen saturation of 91% and a blood pressure of 98/56. They suspect a respiratory infection, provided supplemental oxygen with a target of 94-96% (SGEM#243), establish IV access and begin a 500cc normal saline bolus.

Background: Sepsis is a serious condition with high morbidity and mortality. It has been covered on the SGEM many times over the last seven seasons (SGEM# 69, 90, 92, 113, and 168).

Recently we covered a paper looking at whether or not pre-hospital antibiotics could provide a benefit to patients with varying degrees of sepsis (SGEM #207).  The study by Alam et al took adult patients with a diagnosis of suspected infection and randomized them to ceftriaxone 2g IV started pre-hospital or usual care with a primary outcome of all-cause mortality at 28 days.

The bottom line from that episode pre-hospital antibiotics in the ambulance do not appear to have a mortality benefit in patients with varying degrees of sepsis in an optimized EMS system.

The Surviving Sepsis Campaign makes a number of recommendations in their 2016 guideline. One recommendation that they make is the rapid administration of 30ml/kg of crystalloid for hypotension. This is a strong recommendation from SSC based on low quality evidence. This was updated in 2018 with the 3-hour and 6-hour bundles combined into a single 1-hour bundle. This led to a petition requesting the SSC retract their 2018 guidelines (SGEM Xtra). For more information see PulmCrit recent post.

Clinical Question: Is IV fluid administration by Paramedics for patients with suspected sepsis associated with reduced in hospital mortality rates?

Reference: Lane et al. Association Between Early Intravenous Fluids Provided by Paramedics and Subsequent In-Hospital Mortality Among Patients With Sepsis. JAMA 2018

* Population: Patients with sepsis identified using the international Statistical Classification of Disease and Related Health Problems, Tenth Revision (ICD-10CA) coding that was modified to be consisten...