Variation in Initial Fluid Resuscitation Volume and Type in Patients With Sepsis Across Michigan Hospitals

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Rationale: The Surviving Sepsis Campaign guidelines suggest a 30ml/kg initial intravenous (IV) fluid bolus for patients with sepsis-induced hypoperfusion and suggest using balanced crystalloids over normal saline. Studies have raised concerns about compliance with these fluid guidelines, but it has been difficult to determine the scope of the problem given challenges inherent to accurately identifying eligible patients retrospectively in electronic health records. In this study, we evaluated variation in IV fluid volume and type in patients with sepsis across Michigan hospitals, where we have detailed, chart-abstracted data that allows us to assess fluid practices in eligible patients. Methods: This is a retrospective cohort study of patients hospitalized with communityacquired sepsis at 65 hospitals in the Michigan Hospital Medicine Safety Consortium (HMS), a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. Data from a random sample of adult sepsis hospitalizations (11/2020-7/2023) were entered into the HMS-Sepsis registry by trained abstractors. Sepsis (infection and ≥1 organ dysfunction) was determined using both diagnosis codes and chart review. We sought to determine how commonly eligible patients with sepsis met fluid guideline measures. Patients were eligible for the 30ml/kg measure if they had hypoperfusion (lactate ≥4 mmol/L, systolic blood pressure <90mmHg, or treatment with vasopressors) within 3 hours of hospital arrival and none of the following contraindications to fluid: end-stage renal disease, moderate-severe aortic stenosis, or heart failure with ejection fraction ≤39%. Patients were eligible for the balanced fluid measure if they received > 3 liters IV fluid within 48 hours and passed if ≥75% of fluid delivered was balanced. Results: Of 18,204 patients in the HMS-Sepsis registry, 5,439 (29.9%) were eligible for a 30ml/kg fluid bolus. Of these, 3,221 (59.2%) received 30ml/kg of fluid by ideal body weight within 6 hours of hospital arrival (range across hospitals with ≥10 observations each: 24.2% - 81.9%). (Figure 1A). Among the sub-set of patients treated with vasopressors, 364/579 (62.9%) received 30ml/kg IV fluids within 2 hours of vasopressor initiation (range across hospitals with ≥10 observations each: 16.7% - 100%). For fluid type, 10,070/18,204 (55.3%) patients were eligible for the balanced fluid measure. Of these, 1,395/10,070 (13.9%) received ≥75% balanced fluids (range across hospitals with ≥10 observations each: 0% - 75.5%) (Figure 1B). Conclusion: Rates of compliance with an initial 30ml/kg bolus and use of balanced fluids in eligible patients is low and widely variable across hospitals, presenting an opportunity for quality improvement.

Volume

209

Issue

Suppl

First Page

A4990

Comments

International Conference of the American Thoracic Society, May 17-22, 2024, San Diego, CA

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A4990

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