State of the evidence for emergency medical services care of adult patients with sepsis: an analysis of research from the Prehospital Evidence-based Practice
pdf

Keywords

emergency medical services
knowledge translation
evidence-based practice
paramedic
evidence appraisal
clinical recommendation

How to Cite

1.
Greene J, Goldstein J, Lane D, Jensen J, Leroux Y, Swain J, Fidgen D, Brown R, Simpson M, Carter A. State of the evidence for emergency medical services care of adult patients with sepsis: an analysis of research from the Prehospital Evidence-based Practice . Australasian Journal of Paramedicine [Internet]. 2021Jan.19 [cited 2021Dec.4];18. Available from: https://ajp.paramedics.org/index.php/ajp/article/view/851

Abstract

Introduction

The Prehospital Evidence-Based Practice (PEP) program is an online, freely accessible, continuously updated emergency medical services evidence repository. This PEP summary describes the research evidence for the identification and management of adult patients with sepsis or septic shock.

Methods

A systematic search of the literature on sepsis or septic shock was conducted. Studies were scored by trained appraisers on a three-point level of evidence scale (based on study design and quality) and a three-point direction of evidence scale (supportive, neutral or opposing findings based on the studies’ primary outcome for each intervention).

Results

One hundred forty-three studies (80 existing and 63 new) were included for 16 interventions listed in PEP for adult patients with sepsis. The evidence matrix rank for supported interventions (n=16) were supportive-high quality (n=2, 12.5%) for crystalloid infusion and vasopressors, supportive-moderate quality (n=8, 50%) for identification tools, pre-notification, point-of-care lactate, titrated oxygen, temperature monitoring and balanced crystalloids. The benefit of pre-hospital antibiotics, colloids, Trendelenburg position and early goal-directed therapy remain inconclusive with a neutral direction of evidence. There is moderate level evidence opposing the use of high flow oxygen.

Conclusion

Several standard treatments are well supported by the evidence including fluid resuscitation, using balanced crystalloids, vasopressors and titrating oxygen. Tools for identifying and guiding treatment are also supported (eg. pre-notification, temperature monitoring and lactate). The evidence for antibiotic use is inconclusive. This PEP state of the evidence analysis can be used to guide selection of appropriate pre-hospital therapies during the development of pre-hospital protocols or clinical practice guidelines.

https://doi.org/10.33151/ajp.18.851
pdf

References

Jensen JL, Petrie DA, Travers AH. The Canadian Prehospital Evidence-based Protocols Project: knowledge translation in emergency medical services care. Acad Emerg Med 2009;16:668-73.

Carter A, Jensen J, Petrie D, et al. State of the evidence for emergency medical services (EMS) care: the evolution and current methodology of the Prehospital Evidence-Based Practice (PEP) program. Healthc Policy 2018;14:57-70.

Government of Nova Scotia. Clinical policy: EHS ground ambulance clinical program documents. Available at: https://novascotia.ca/dhw/ehs/clinical-program-documents.asp [Accessed 8 March 2020].

Jensen J, Dobson T. Towards national evidence-informed practice guidelines for Canadian EMS: future directions. Healthc Policy 2011;7:22-31.

Singer M, Deutschman CS, Seymour C, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 2016;315:801-10.

Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign. Crit Care Med 2017;45:486-552.

Daniels R. Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective). J Antimicrob Chemother 201166(Suppl 2):ii11-23.

Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22:707-10.

Lane D, Ichelson RI, Drennan IR, Scales DC. Prehospital management and identification of sepsis by emergency medical services: a systematic review. Emerg Med J 2016;33:408-13.

Green RS, Djogovic D, Gray S, et al. Canadian Association of Emergency Physicians sepsis guidelines: the optimal management of severe sepsis in Canadian emergency departments. CJEM 2008;10:443-59.

Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-96.

Puskarich MA, Trzeciak S, Shapiro NI, et al. Association between timing of antibiotic administration and mortality from septic shock in patients treated with a quantitative resuscitation protocol. Crit Care Med 2011;39:2066-71.

Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010;38:1045-53.

Prehospital Evidence Based Practice Program (PEP) [Internet]. Halifax, Nova Scotia: Dalhousie University - Division of Emergency Medical Service. Available at: https://emspep.cdha.nshealth.ca/ [Accessed 13 January 2019].

Covidence systematic review software. Veritas Health Innovation, Melbourne, Australia. Available at: www.covidence.org

RefWorks web based bibliographic management software [Internet]. Available at: www.refworks.com/refworks2/default.aspx?r=references%7CMainLayout::init [Accessed 8 March 2020].

Oxford Centre for Evidence-based Medicine. Levels of evidence. 2009. [Internet.]. Available at: www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ [Accessed 8 March 2020].

Smyth MA, Brace-McDonnell SJ, Perkins GD. Identification of adults with sepsis in the prehospital environment: a systematic review. BMJ Open 2016;6:e011218.

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock. JAMA 2019;321:654.

Sepsis syndrome EHSNS CPG. Available at: https://novascotia.ca/dhw/ehs/documents/CPG/EHS6702-01-Sepsis-Syndrome.pdf

Oxman AD. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490.

Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev J 2015;4:1-9.