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Abstract 20160: Early Fluid Resuscitation of Undifferentiated Hypovolemic Hypotensive Patients in the Emergency Department: The Shock Access for Emergent Resuscitation (SAFER) Study

Study Objective: To describe initial emergency department (ED) efforts in obtaining adequate vascular access (AVA) and initiating appropriate fluid resuscitation for hypovolemic patients with undifferentiated hypotension within the first 3 hours following ED arrival.
 
 Background:
 Hypotensive hypovolemic patients require immediate AVA, to facilitate the administration of medications and fluids to restore homeostasis. Patients with septic shock must receive appropriate intravenous antibiotics within 60 minutes of sepsis diagnosis, and 30 mL/kg fluid challenge within 3 hours.
 
 
 Methods:
 Unplanned interim analysis was performed on data from the first 87 consented patients enrolled in the Shock Access For Emergent Resuscitation (SAFER) study. SAFER is an observational, prospective, multicenter study focused on the early ED management of undifferentiated hypovolemic, hypotensive adult patients triaged to the medical resuscitation bay for suspected shock. AVA was defined as any two of the following vascular access devices (VADs): 20-gauge or larger peripheral intravenous (PIV) or intraosseous (IO) catheter, or central venous catheter (CVC).
 
 
 Results:
 87 patients were enrolled, with a mean age of 60.3 years (SD 13.7 years). Fifty patients (57.5%) were females. The median time required for successful VAD placement was 125 seconds for PIV (IQR 206-75, n=103), 371 seconds for ultrasound-PIV (IQR 409-287, n=12), 129 seconds for IO (IQR 177-107, n=7), and 876 seconds for CVC lines (IQR 1241-660, n=18). AVA was achieved within 3 hours in 57 patients (65.5%). Thirty-three patients (37.9%) were found to have severe sepsis or septic shock, with 20 patients (23.0%) requiring vasopressors. Among septic patients, the mean volume of crystalloid infused was 1361 mL (SD 1028) or 18.6 mL/kg at 1 hour, and 2461 mL (SD 1652 mL) or 34.6 mL/kg at 3 hours. Among 98 vascular access attempts in septic patients, first-attempt success rates were higher for IO (100%, n=6) and CVC (70%, n=20) than for PIV (57.4%, n=61) or US-PIV (36.4%, n=11) lines. Nineteen (57.6%) septic patients received less than the requisite 30 mL/kg fluid challenge.
 
 
 Conclusion:
 Difficulties in obtaining AVA may prevent compliance with current guidelines for the management of septic shock. Further study is needed.
