Personalized Fluid Resuscitation in the Emergency Department: A Pilot Trial

Personalized Fluid Resuscitation for Improved Sepsis Resuscitation Quality in the Emergency Department

The goal of this pilot clinical trial is to learn if a fluid assessment using non-invasive cardiac output monitoring (NICOM) is helpful for patients with sepsis who have low blood pressure in the Emergency Department (ED). The study will measure whether the NICOM assessment changes fluid resuscitation practices and is feasible in the ED setting. All patients will receive standard medical care. Patients assigned to the NICOM group will receive a one-time, non-invasive bedside fluid assessment using NICOM, in addition to standard care, and the results of the fluid assessment will be provided to the treating physician.

We will conduct a single-center pilot feasibility trial comparing a dynamic fluid assessment using non-invasive cardiac output monitoring (NICOM) vs usual care in 40 patients with sepsis in the Emergency Department (ED). The trial will enroll patients with suspected sepsis and hypotension or lactate ≥4 mmol/L who have not received 30 ml/kg initial IV fluid. Patients will be randomized 3:1 to receive a NICOM fluid assessment vs standard care. The NICOM fluid assessment will involve measuring stroke volume change during a passive leg raise using NICOM. Results will be provided to the ED treating team. The primary outcome will be IV fluid received within 3 hours. Secondary outcomes include sepsis bundle compliance and feasibility and acceptability of the NICOM assessment (assessed via clinician survey).

Inclusion Criteria:

1. Adult patient being treated in the Intermountain Medical Center ED
2. Patient has suspected sepsis. Suspected sepsis can be identified by a positive sepsis screen (standard screen completed by ED triage nurse), an active sepsis alert (which is triggered based on qualifying information or active by an ED nurse), or clinician report that patient has possible sepsis
3. Patient is hypotensive OR has an initial lactate ≥4 mmol/L at the time of enrollment. Hypotension is defined as mean arterial pressure (MAP) <65 mmHg or systolic blood pressure (SBP) <90mmHg or patient is on vasopressors at time of enrollment.

Exclusion Criteria:

1. Age < 18 years

2. Known pregnant patients

3. Patients who are known to be incarcerated

4. A trained and delegated study team member is not available to perform the NICOM fluid assessment

5. Patient has been in the ED for >6 hours or was transferred from an outside ED

6. Patient has already received 30 ml/kg IV fluid or has this fluid volume ordered. Weight-based fluid dosing is calculated based on actual body weight for BMI <30kg/m2 and ideal body weight for BMI ≥30 kg/m2

7. Known clinical diagnosis of a condition potentially altering risk/benefit profile of NICOM-based fluid assessment, which may include

   1. Hemorrhagic shock (i.e.., active hemorrhage)
   2. Cardiogenic shock (i.e., hypotension suspected to be due to left or right ventricular failure)
   3. Obstructive shock (i.e., shock in the setting of known acute central pulmonary embolism, pneumothorax, or pericardial effusion)
   4. Active volume loss that requires fluid replacement per the treating clinician (i.e., injury due to burn)
   5. Acute stroke
   6. Acute myocardial infarction
   7. Status asthmaticus
   8. Status epilepticus
   9. Presence of a left ventricular assist device (LVAD)
   10. Severe aortic insufficiency

8. Known clinical contraindication to passive leg raise.

   1. Lower extremity amputation
   2. Lower extremity trauma
   3. Open abdomen
   4. Suspected or known elevated intracranial pressure, for example from intracranial hemorrhage, tumor, or traumatic brain injury
   5. Contraindication to lying flat
   6. Inability to cooperate with the maneuver (e.g., severe pain, agitation).

9. Contraindication to non-invasive cardiac output monitoring (NICOM) lead placement.

   1. Allergy to adhesive used in the NICOM lead stickers
   2. Skin breakdown precluding lead placement on the patient's chest and back

10. Treating clinician determines that NICOM assessment is either required or contraindicated for the optimal care of the patient