Introduction: The Surviving Sepsis Campaign (SSC) suggests that hypovolemic patients, in the setting of hypoperfusion, be administered 30 mL/kg crystalloid fluid within the first 3 hours of presentation to hospital. More recent evidence suggests that fluid resuscitation within 30 min of sepsis identification is associated with reduced mortality, hospital length of stay and ICU days. This study describes Emergency Department (ED) fluid resuscitation of patients with septic shock and/or sepsis-related in-hospital mortality, prior to implementation of a sepsis medical directive. Methods: Retrospective chart review of adult patients (18+ years), presenting to two tertiary care EDs between 01 Nov 2014 and 31 Oct 2015, with >=2 SIRS criteria and/or ED suspicion of infection and/or ED or hospital discharge sepsis diagnosis. Data were abstracted from electronic health records. Patients with septic shock, or who expired in the ED/hospital, were selected for manual chart review of clinical variables including: time, type and volume of ED IV fluid administration. Results: 13,506 patient encounters met inclusion criteria. In-hospital mortality rates were 2% (sepsis), 11.5% (severe sepsis), and 24.1% (septic shock). Of patients hypotensive at triage, fluids were administered to 33/50 (66.00%) septic shock patients, and 22/43 (51.16 %) patients who eventually expired. For all septic shock and expired patients (943), median time to IV fluid initiation was 60.50 minutes [29.75 to 101.25] for septic shock and 77.00 minutes [36.00 to 127.00] for expired patients. Median volume of fluid administered was 1.50L [1.0 to 2.00] for septic shock and 1.00L [1.00 to 2.00] for expired patients. Of septic shock and expired patients, IV fluid administration and body weight data was available for 148 encounters (15.6%). Within this group, 19 (12.8%) received no IV fluid. 90 (60.8%) received 0.1-75% of their recommended IV fluid volume. 25 (16.9%) received 75.1-125%, and 14 (9.4%) received >125.1% of their recommended fluid volume. Conclusion: In this study, severe forms of sepsis were often treated with <30 mL/kg crystalloid fluid. Fluids were administered outside of the recommended 30 min, but within the 3 h, time windows. In-hospital mortality was consistent with published data. Future research will examine a broader data set for IV fluid resuscitation in sepsis, and will measure the impact of a fluid resuscitation in sepsis medical directive.

The terminology used for describing intervention groups in randomised controlled trials (RCT) on the effect of intravenous fluid on outcome in abdominal surgery has been imprecise, and the lack of standardised definitions of the terms ‘standard’, ‘restricted’ and ‘liberal’ has led to some confusion and difficulty in interpreting the literature. The aims of this paper were to clarify these definitions and to use them to perform a meta-analysis of nine RCT on primarily crystalloid-based peri-operative intravenous fluid therapy in 801 patients undergoing elective open abdominal surgery. Patients who received more or less fluids than those who received a ‘balanced’ amount were considered to be in a state of ‘fluid imbalance’. When ‘restricted’ fluid regimens were compared with ‘standard or liberal’ fluid regimens, there was no difference in post-operative complication rates (risk ratio 0·96 (95% CI 0·56, 1·65), P=0·89) or length of hospital stay (weighted mean difference (WMD) −1·77 (95% CI −4·36, 0·81) d, P=0·18). However, when the fluid regimens were reclassified and patients were grouped into those who were managed in a state of fluid ‘balance’ or ‘imbalance’, the former group had significantly fewer complications (risk ratio 0·59 (95% CI 0·44, 0·81), P=0·0008) and a shorter length of stay (WMD −3·44 (95% CI −6·33, −0·54) d, P=0·02) than the latter. Using imprecise terminology, there was no apparent difference between the effects of fluid-restricted and standard or liberal fluid regimens on outcome in patients undergoing elective open abdominal surgery. However, patients managed in a state of fluid balance fared better than those managed in a state of fluid imbalance.