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Association Between Intravenous Fluid Bolus and Biomarker Trajectory During Prehospital Care.

ABSTRACT: Background: Patients with acute illness who receive intravenous (IV) fluids prior to hospital arrival may have a lower in-hospital mortality. To better understand whether this is a direct treatment effect or epiphenomenon of downstream care, we tested the association between a prehospital fluid bolus and the change in inflammatory cytokines measured at prehospital and emergency department timepoints in a sample of non-trauma, non-cardiac arrest patients at risk for critical illness. Methods: In a prospective cohort study, we screened 4,013 non-trauma, non-cardiac arrest encounters transported by City of Pittsburgh Emergency Medical Services (EMS) to 2 hospitals from August 2013 to February 2014. In 345 patients, we measured prehospital biomarkers (IL-6, IL-10, and TNF) at 2 time points: the time of prehospital IV access placement by EMS and at ED arrival. We determined the relative change for marker X as: ([X_ED - X_EMS]/X_EMS). We determined the risk-adjusted association between prehospital IV fluid bolus and relative change for each marker using multivariable linear regression. Results: Among 345 patients, 88 (26%) received a prehospital IV fluid bolus and 257 (74%) did not. Compared to patients who did not receive prehospital fluids, median prehospital IL-6 was greater initially in subjects receiving a prehospital IV fluid bolus (22.3 [IQR 6.4-113] vs. 11.5 [IQR 5.5-47.6]). Prehospital IL-10 and TNF were similar in both groups (IL-10: 3.5 [IQR 2.2-25.6] vs. 3.0 [IQR 1.9-9.0]; TNF: 7.5 [IQR 6.4-10.4] vs. 6.9 [IQR 6.0-8.3]). After adjustment for demographics, illness severity, and prehospital transport time, we observed a relative decrease in IL-6 at hospital arrival in those receiving a prehospital fluid bolus (adjusted ? = -10.0, 95% CI: -19.4, -0.6, p?=?0.04), but we did not detect a significant change in IL-10 (p?=?0.34) or TNF (p?=?0.53). Conclusions: Among non-trauma, non-cardiac arrest patients at risk for critical illness, a prehospital IV fluid bolus was associated with a relative decrease in IL-6, but not IL-10 or TNF.

SUBMITTER: Brant EB

PROVIDER: S-EPMC6938563 | biostudies-literature | 2020 Mar-Apr

REPOSITORIES: biostudies-literature

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Association Between Intravenous Fluid Bolus and Biomarker Trajectory During Prehospital Care.

Brant Emily B EB Kennedy Jason J Martin-Gill Christian C Jackson Vanessa V Peck Palmer Octavia M OM Callaway Clifton W CW Kahn Jeremy M JM Yealy Donald M DM Angus Derek C DC Seymour Christopher W CW

Prehospital emergency care 20190701 2

<b>Background:</b> Patients with acute illness who receive intravenous (IV) fluids prior to hospital arrival may have a lower in-hospital mortality. To better understand whether this is a direct treatment effect or epiphenomenon of downstream care, we tested the association between a prehospital fluid bolus and the change in inflammatory cytokines measured at prehospital and emergency department timepoints in a sample of non-trauma, non-cardiac arrest patients at risk for critical illness. <b>Me ...[more]

PMID: 31180262

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Project description:ObjectivesThe goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams.DesignObservational study.SettingEmergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders.ParticipantsForty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations.Primary and secondary outcome measuresTeams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team.ResultsAcross 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88).ConclusionsThis study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

Project description:ImportanceSlower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality.ObjectiveTo determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU).Design, setting, and participantsUnblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately).InterventionsPatients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design.Main outcomes and measuresThe primary end point was 90-day survival.ResultsOf all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98).Conclusions and relevanceAmong patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate.Trial registrationClinicalTrials.gov Identifier: NCT02875873.

Dataset Information

Association Between Intravenous Fluid Bolus and Biomarker Trajectory During Prehospital Care.

Publications

Association Between Intravenous Fluid Bolus and Biomarker Trajectory During Prehospital Care.

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