Usefulness of Prehospital Care for Patients with Septic Shock: Experience and Evidence-Based Medicine Are Mounting

Every year, sepsis affects more than 50 million people worldwide and leads to more than 10 million deaths (1, 2). The overall sepsis mortality rate ranges from 10–20%, but reaches 50–60% for septic shock, making sepsis a health issue of the utmost importance (3). Consequently, early recognition and diagnosis, severity assessment, and treatment are essential to improve sepsis survival (4). This journal frequently publishes on the prehospital detection and management of sepsis, with two articles in the current issue. Although defining and detecting sepsis severity in adults are easier since the 2016 Sepsis-3 conference, managing children with sepsis can be challenging, especially in the prehospital setting (5). In the current issue of this journal, Kadish et al. report that pediatric sepsis guidelines are positive factors pertaining to recognition and management of pediatric sepsis, but may be counterproductive when complicated or non-existent (6). From video conferences conducted with 38 EMS professionals in six focus groups, the authors identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. Six of the positive factors, mainly concerning education, were identified that could improve prognosis: awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information. Undoubtedly, future studies should focus on these factors likely to improve prognosis through earlier recognition of sepsis, though not only in pediatrics. After sepsis recognition, diagnosis, and severity assessment, international guidelines recommend earlier treatment, which should be initiated within the first hour for the most severe form, septic shock (4). From in-hospital studies, evidence-based medicine concludes that both early antibiotic therapy and hemodynamic optimization allow sepsis-related mortality to decrease (5, 7–11). Considering the prehospital setting, care begins before hospital admission, by as much as 15 to 170min (12), and 70% of sepsis signs are already present before hospital admission (13). Consequently, the question of implementing hospital-like care in the prehospital setting is legitimate and opens a new window within the first hour of care for saving lives to the most at-risk patients, suffering from the most severe forms of sepsis. In-hospital hemodynamic optimization relies on fluid volume expansion and early norepinephrine infusion (4, 7, 11, 14), with a target mean arterial pressure of at least 65mmHg (14), and a shortened delay to correct hypotension is associated with improved outcomes (15, 16). Conversely, in the prehospital setting, such care is not always systematically performed by EMS, perhaps because inadvertent prehospital initiation of hemodynamic optimization and antibiotic therapy may induce unintended harms for patients with noninfectious shock (17). In the current issue, Miller et al. report that fewer than 50% of prehospital sepsis patients cared for by their EMS system had intravenous therapy attempted, among which nearly half met the fluid volume goal (18). Female sex and congestive heart failure were negatively associated, whereas systolic blood pressure lower than 90mmHg and abnormal temperature were positively associated, with receiving at least 500ml intravenous fluid in the field. These results are in line with a previous study involving a different EMS system, which had reported that prehospital fluid resuscitation is mainly performed using crystalloids with quantitative fluid expansion lower than recommended, that was finally associated with increased mortality (19). Beyond these considerations, we must keep in mind that a single treatment cannot be alone responsible for outcome improvement, and the greater impact on septic shock outcome remains more from global implemented treatments and strategies, rather than from the prehospital EMS organization itself (16, 20). Further prospective studies are needed to clarify the usefulness and the effectiveness of optimized prehospital care for septic shock patients.