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Cardiac Output Monitoring Managing Intravenous Therapy (COMMIT) to Treat Emergency Department Patients with Sepsis.

ABSTRACT: Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on preload dependence. The objectives of this study were to determine if a fluid responsiveness protocol would decrease progression of organ dysfunction, and a fluid responsiveness protocol would facilitate a more aggressive resuscitation.Prospective, 10-center, randomized interventional trial.suspected sepsis and lactate 2.0 to 4.0?mmol/L. Exclusion criteria (abbreviated): systolic blood pressure more than 90?mmHg, and contraindication to aggressive fluid resuscitation.fluid responsiveness protocol using Non-Invasive Cardiac Output Monitor (NICOM) to assess for fluid responsiveness (>10% increase in stroke volume in response to 5?mL/kg fluid bolus) with balance of a liter given in responsive patients.standard clinical care.primary-change in Sepsis-related Organ Failure Assessment (SOFA) score at least 1 over 72?h; secondary-fluids administered. Trial was initially powered at 600 patients, but stopped early due to a change in sponsor's funding priorities.Sixty-four patients were enrolled with 32 in the treatment arm. There were no significant differences between arms in age, comorbidities, baseline vital signs, or SOFA scores (P?>?0.05 for all). Comparing treatment versus Standard of Care-there was no difference in proportion of increase in SOFA score of at least 1 point (30% vs. 33%) (note bene underpowered, P?=?1.0) or mean preprotocol fluids 1,050?mL (95% confidence interval [CI]: 786-1,314) vs. 1,031?mL (95% CI: 741-1,325) (P?=?0.93); however, treatment patients received more fluids during the protocol (2,633?mL [95% CI: 2,264-3,001] vs. 1,002?mL [95% CI: 707-1,298]) (P?

SUBMITTER: Hou PC

PROVIDER: S-EPMC4957967 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Cardiac Output Monitoring Managing Intravenous Therapy (COMMIT) to Treat Emergency Department Patients with Sepsis.

Hou Peter C PC Filbin Michael R MR Napoli Anthony A Feldman Joseph J Pang Peter S PS Sankoff Jeffrey J Lo Bruce M BM Dickey-White Howard H Birkhahn Robert H RH Shapiro Nathan I NI

Shock (Augusta, Ga.) 20160801 2

<h4>Objective</h4>Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on preload dependence. The objectives of this study were to determine if a fluid responsiveness protocol would decrease progression of organ dysfunction, and a fluid responsiveness protocol would facilitate a more aggressive resuscitation.<h4>Methods</h4>Prospective, 10-center, randomized interventional trial.<h4>Inclusion criteria</h4>suspected sepsis and lactate 2.0 to 4.0 mmol/L. Exc ...[more]

PMID: 26925867

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Project description:BackgroundThere is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assessed six non-invasive fluid responsiveness monitoring methods which measure cardiac output directly or indirectly for their feasibility and repeatability of measurements in the ED: (1) left ventricular outflow tract echocardiography derived velocity time integral, (2) common carotid artery blood flow, (3) suprasternal aortic Doppler, (4) bioreactance, (5) plethysmography with digital vascular unloading method, and (6) inferior vena cava collapsibility index.MethodsThis is a prospective observational study of non-invasive methods of assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Feasibility of each method was determined by the proportion of clinically interpretable measurements from the number of measurement attempts. Repeatability was determined by comparing the mean difference of two paired measurements in a fluid steady state (after participants received an intravenous fluid bolus).Results76 patients were recruited in the study. A total of 207 fluid responsiveness measurement sets were analysed. Feasibility rates were 97.6% for bioreactance, 91.3% for vascular unloading method with plethysmography, 87.4% for common carotid artery blood flow, 84.1% for inferior vena cava collapsibility index, 78.7% for LVOT VTI, and 76.8% for suprasternal aortic Doppler. The feasibility rates difference between bioreactance and all other methods was statistically significant.ConclusionOur study shows that non-invasive fluid responsiveness monitoring in the emergency department may be feasible with selected methods. Higher repeatability of measurements were observed in non-ultrasound methods. These findings have implications for further studies specifically assessing the accuracy of such non-invasive cardiac output methods and their effect on patient outcome in the ED in fluid depleted states such as sepsis.

Project description:PURPOSE:Sepsis is a common acute life-threatening condition that emergency physicians routinely face. Diagnostic options within the Emergency Department (ED) are limited due to lack of infrastructure, consequently limiting the use of invasive hemodynamic monitoring or imaging tests. The mortality rate due to sepsis can be assessed via multiple scoring systems, for example, mortality in emergency department sepsis (MEDS) score and sepsis patient evaluation in the emergency department (SPEED) score, both of which quantify the variation of mortality rates according to clinical findings, laboratory data, or therapeutic interventions. This study aims to improve the management processes of sepsis patients by comparing SPEED score and MEDS score for predicting the 28-day mortality in cases of emergency sepsis. METHODS:The study is a cross-sectional, prospective study including 61 sepsis patients in ED in Suez Canal University Hospital, Egypt, from August 2017 to June 2018. Patients were selected by two steps: (1) suspected septic patients presenting with at least one of the following abnormal clinical findings: (a) body temperature higher than 38 °C or lower than 36 °C, (b) heart rate higher than 90 beats/min, (c) hyperventilation evidenced by respiratory rate higher than 20 breaths/min or PaCO2 lower than 32 mmHg, and (d) white blood cell count higher than 12,000/?L or lower than 4000/?L; (2) confirmed septic patients with at least a 2-point increase from the baseline total sequential organ failure assessment (SOFA) score following infection. Other inclusion criteria included adult patients with an age ?18 years regardless of gender and those who had either systemic inflammatory response syndrome or suspected/confirmed infection. Patients were shortly follow-up for the 28-day mortality. Each patient was subject to SPEED score and MEDS score and then the results were compared to detect which of them was more effective in predicting outcome. The receiver operating characteristic curves were also done for MEDS and SPEED scores. RESULTS:Among the 61 patients, 41 died with the mortality rate of 67.2%. The mortality rate increased with a higher SPEED and MEDS scores. Both SPEED and MEDS scores revealed significant difference between the survivors and nonsurvivors (p = 0.004 and p < 0.001, respectively), indicating that both the two systems are effective in predicting the 28-day mortality of sepsis patients. Thereafter, the receiver operating characteristic curves were plotted, which showed that SPEED was better than the MEDS score when applied to the complete study population with an area under the curve being 0.87 (0.788-0.963) as compared with 0.75 (0.634-0.876) for MEDS. Logistic regression analysis revealed that the best fitting predictor of 28-day mortality for sepsis patients was the SPEED scoring system. For every one unit increase in SPEED score, the odds of 28-day mortality increased by 37%. CONCLUSION:SPEED score is more useful and accurate than MEDS score in predicting the 28-day mortality among sepsis patients. Therefore SPEED rather than MEDS should be more widely used in the ED for sepsis patients.

Project description:Background. While often first treated in the emergency department (ED), identification of sepsis is difficult. Electronic medical record (EMR) clinical decision tools offer a novel strategy for identifying patients with sepsis. The objective of this study was to test the accuracy of an EMR-based, automated sepsis identification system. Methods. We tested an EMR-based sepsis identification tool at a major academic, urban ED with 64,000 annual visits. The EMR system collected vital sign and laboratory test information on all ED patients, triggering a "sepsis alert" for those with ?2 SIRS (systemic inflammatory response syndrome) criteria (fever, tachycardia, tachypnea, leukocytosis) plus ?1 major organ dysfunction (SBP ? 90 mm Hg, lactic acid ?2.0 mg/dL). We confirmed the presence of sepsis through manual review of physician, nursing, and laboratory records. We also reviewed a random selection of ED cases that did not trigger a sepsis alert. We evaluated the diagnostic accuracy of the sepsis identification tool. Results. From January 1 through March 31, 2012, there were 795 automated sepsis alerts. We randomly selected 300 cases without a sepsis alert from the same period. The true prevalence of sepsis was 355/795 (44.7%) among alerts and 0/300 (0%) among non-alerts. The positive predictive value of the sepsis alert was 44.7% (95% CI [41.2-48.2%]). Pneumonia and respiratory infections (38%) and urinary tract infection (32.7%) were the most common infections among the 355 patients with true sepsis (true positives). Among false-positive sepsis alerts, the most common medical conditions were gastrointestinal (26.1%), traumatic (25.7%), and cardiovascular (20.0%) conditions. Rates of hospital admission were: true-positive sepsis alert 91.0%, false-positive alert 83.0%, no sepsis alert 5.7%. Conclusions. This ED EMR-based automated sepsis identification system was able to detect cases with sepsis. Automated EMR-based detection may provide a viable strategy for identifying sepsis in the ED.

Dataset Information

Cardiac Output Monitoring Managing Intravenous Therapy (COMMIT) to Treat Emergency Department Patients with Sepsis.

Publications

Cardiac Output Monitoring Managing Intravenous Therapy (COMMIT) to Treat Emergency Department Patients with Sepsis.

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