Impact of prehospital orientation of septic shock on 30-day mortality

Impact of prehospital orientation of septic shock on 30-day mortality | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Impact of prehospital orientation of septic shock on 30-day mortality Romain Jouffroy, Vincent Garrouste, Basile Gilbert, Stéphane Travers, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8236865/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Apr, 2026 Read the published version in Scientific Reports → Version 1 posted 14 You are reading this latest preprint version Abstract Background: In order to reduce sepsis mortality, early treatment implementation and referral to the most appropriate ward (emergency department (ED) or intensive care unit (ICU) are recommended. This multicentre retrospective study aims to study the relationship between 30-day mortality and the admission mode to ICU or ED among patients with septic shock cared for by a prehospital mobile Intensive Care Unit (MICU). Methods: From May 2016 to December 2022, septic shock patients cared for by a prehospital MICU were retrospectively analysed. To assess the relationship between 30-day mortality rate and the admission mode, a multivariate logistic regression after Inverse Probability Treatment Weighting (IPTW) propensity score matching was performed. Results: Among the 587 patients analysed, pulmonary, urinary and digestive infections were the main sepsis aetiology: 42%, 26% and 17% respectively. The overall 30-day mortality rate was 30%. Three-hundred and twenty-seven patients (58%) were admitted to ICU and 260 (42%) to the ED. On matched population, the multivariate analysis including the followings potential confounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, chronic obstructive pulmonary disease, chronic renal failure, diabetes mellitus, cancer history, hypertension, chronic heart failure, coronary artery disease, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration, an aRR=1.05 [1.00-1.09] (p=0.025) between 30-day mortality and ED admission. Conversely, the multivariate analysis with the same confounders found aRR=0.90 [0.86-0.95] between 30-day mortality and ICU admission. Conclusion: This study highlighted a positive relationship between ED admission and 30-day mortality of patients in septic shock cared for by a prehospital MICU suggesting a possible negative effect of ED admission whereas a direct ICU admission may be beneficial. Health sciences/Cardiology Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Risk factors Septic shock admission emergency department intensive care unit pre-hospital mortality INTRODUCTION Sepsis, a dysregulated host response to infection, with its most severe form, septic shock characterized by circulatory and cellular metabolism failures, are associated with a mortality ( 1 ). Prevalence and mortality of sepsis and septic shock require prompt interventions from early identification, treatments implementation, triage to the adequate facility, appropriate hospital care including rehabiltation in order to optimize outcome ( 2 , 3 ). To date, the benchmark for the management of sepsis and septic shock is summarized in international guidelines established a regularly updated by the Surviving Sepsis Campaign ( 4 ). For community acquired sepsis, nearly 50% admitted in the emergency department (ED) arrive via prehospital emergency medical service transport ( 5 ), supporting the practice of prehospital recognition and treatment instauration before hospital admission ( 6 ) thus bringing forward the screening and treatment start time, which is currently the time of hospital admission ( 1 , 4 , 6 ). Beyond this, it seems logical for the sicker one’s patients, i.e. septic shock, that a direct admission to the intensive care unit (ICU) contributes to improve outcome ( 3 ). Therefore, beyond prehospital diagnosis, severity assessment and treatment (administration of antibiotics and hemodynamic optimization), admission to an adequate facility also appears to be a cornerstone in improving the outcome of sepsis. Pre-hospital caregivers have a key role to play in deciding which facility the patient should be admitted to. This study aimed to assess the relationship between 30-day mortality and the admission mode to ICU or emergency department (ED) among patients with septic shock cared for by a prehospital mobile Intensive Care Unit (MICU). METHODS Patients French prehospital emergencies are managed by a public national organisation, the SAMU (Urgent Medical Aid Service), made of a central dispatch centre and prehospital MICU. As previously reported ( 7 ), prehospital MICU are composed by a driver, a nurse and an emergency physician with medical devices allowing respiratory, cardiovascular and neurologic deficiency ( 8 ). From May 2016 to December 2022, patients suffering from septic shock according to the 2012 sepsis-2 conference criteria ( 9 ) cared by a MICU of 10 French hospital centres (Necker-Enfants malades Hospital, Lariboisière Hospital, La Pitié Salpêtrière Hospital, Hotel Dieu Hospital, APHP, Paris – France; Paris Fire Brigade, Paris – France; Toulouse University Health Centre, Toulouse – France, La Martinique University Health Centre, Fort de France – France, Orléans University Hospital, Orléans - France and the Castres Hospital, Castres – France), were retrospectively analyzed. As previously reported ( 10 ), the operative sepsis-2 definition ( 9 ) was chosen for its applicability in the prehospital setting defining a septic shock as a refractory hypotension despite vascular filling or normotension with hypoperfusion signs because prehospital lactatemia assessment was not available in all MICU precluding Sepsis-3 conference ( 1 ) use in the prehospital setting. Patients younger than 18 years, pregnant, with serious comorbid conditions with an unknown prehospital life support, with guardianship or curatorship were not included. Patients demographic characteristics (age, weight, height, and gender) suspected prehospital sepsis origin, initial prehospital (e.g., the first MICU contact), and final prehospital (e.g., at the end of prehospital stage) vital sign values (systolic (SBP), diastolic (DBP) and mean blood pressure (MBP)) were measured with a non-invasive automated device in all centres. Heart rate (HR), pulse oximetry (SpO2), respiratory rate (RR), temperature and Glasgow coma scale (GCS)), plasma blood glucose concentration, duration of prehospital care, and prehospital treatments delivered (ABT type and dose, fluid volume expansion type and dose, as well as catecholamine type and dose) were collected from MICU prehospital medical reports. Major comorbidities, i.e., chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF), diabetes mellitus, cancer history, hypertension, chronic heart failure (CHF), coronary artery disease (CAD) and hospitalization in the previous 3 months were collected to take into account the underlying condition ( 11 ). ICU-length of stay (LOS), hospital LOS and 30-day mortality status were retrieved from medical reports in case of in-hospital death or by call when the patient was discharged from the hospital. Simplified acute physiology score (SAPS-2) ( 12 ) were calculated 24 hours after ICU admission. To minimize data abstraction bias, a standardized abstraction template established prior data collection was used ( 13 ). Ethical considerations As previously reported ( 14 ), the French Society of Anaesthesia and Intensive Care ethics committee on December 12th, 2017 (Ref number: IRB 00010254-2017-026) considered that informed consent of patients was waived for participation due to the retrospective nature of the study. Statistical Analysis Results are expressed by mean with standard deviation for quantitative parameters with a normal distribution, by median with interquartile range [1st quartile (Q1) − 3rd quartile (Q3)] for parameters with a non-gaussian distribution and with absolute value and percentage for qualitative parameters. The primary outcome was the 30-day mortality rate. A propensity analysis based on Inverse Probability Treatment Weighting (IPTW) method with the following potential cofounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, COPD, CRF, diabetes mellitus, cancer history, hypertension, CHF, CAD, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration was performed to assess the relationship between 30-day mortality rate and the admission mode. IPTW method was chosen to balance the relative weight between patients admitted to the ED versus patients admitted to the ICU in order to reduce bias due to non-randomized treatment allocation ( 15 ). Results were expressed as adjusted risk ratio (aRR) with [95 CI]. All tests were 2-sided with a statistically significant p-value < 0 .05. All analyses were performed using R 3.4.2 ( http://www.R-project.org ; the R Foundation for Statistical Computing, Vienna, Austria). RESULTS Patient Characteristics Five-hundred and eighty-seven patients were analysed: 370 (63%) were males and the mean age was 69 ± 15 years old. The mean prehospital duration of care was 71 ± 34 minutes without difference between patients admitted to the ED (57 ± 24 minutes) and those admitted to the ICU (83 ± 36 minutes) (p = 0.070). One-hundred and fifty-six patients (27%) received prehospital ABT: 59 patients (23%) patients admitted to the ED vs 97 patients (30%) patients admitted to the ICU, p = 0.423. Among these patients, 119 patients (76%) received a 3rd generation cephalosporin: 34% cefotaxime and 66% ceftriaxone. No patient suffered from an adverse event related to prehospital ABT administration. One-hundred and seventy-four patients (30%) received norepinephrine administration, 24 (9%) vs 150 (46%) among patients admitted to the ED vs those admitted to the ICU, p = 0.512. The median norepinephrine dose was 1.1 [0.6-2.0] mg.h − 1 : 1.0 [0.5–2.0] vs 1.0 [1.0–2.0] mg.h − 1 , p = 0.286 among patients admitted to the ED vs those admitted to the ICU (Table 1 ). Table 1 Population characteristics. Results are expressed by mean and standard deviation for quantitative parameters (normal distribution), by median and interquartile range for quantitative parameters (non-gaussian distribution) and, by absolute value and percentage for qualitative parameters. P-value corresponds to the comparison between deceased and alive patients on day-30. Overall population (n = 587) ED admission (n = 260) ICU admission (n = 327) P value Age (years) 69 ± 15 71 ± 16 67 ± 14 < 10 − 3 Male gender 370 (63%) 164 (63%) 206 (63%) 0.148 Weight (kg) 74 ± 20 73 ± 21 75 ± 20 0.007 Height (cm) 169 ± 11 169 ± 9 170 ± 13 0.288 Initial prehospital values SBP (mmHg) 96 ± 29 100 ± 29 93 ± 29 0.135 DBP (mmHg) 57 ± 19 61 ± 19 55 ± 19 0.202 MAP (mmHg) 70 ± 22 74 ± 21 67 ± 22 0.179 HR (beats.min − 1 ) 114 ± 29 112 ± 28 116 ± 29 0.408 RR (movements.min − 1 ) 30 [22–36] 28 [22–35] 32 [25–39] 0.008 Pulse oximetry (%) 92 [85–96] 93 [87–96] 90 [83–95] 0.003 Body core temperature (°C) 38.3 [36.1–39.1] 38.4 [36.8–39.3] 38.1 [36.0–39.0] 0.011 Glycemia (mmol.l − 1 ) 8.5 [6.2–12.0] 8.8 [6.5–12.2] 7.8 [5.8–11.2] 0.023 Glasgow coma scale 15 [12–15] 15 [13–15] 14 [11–15] 2.10 − 3 Lactatemia (mmol.l − 1 ) 5.6 ± 3.5 4.3 ± 3.2 6.3 ± 3.5 0.001 Pre-hospital fluid expansion (ml) 965 ± 600 815 ± 447 1064 ± 663 0.558 Norepinephrine administration 174 (30%) 24 (9%) 150 (46%) 0.512 Norepinephrine dose (mg.h − 1 ) 1.1 [0.6–2.0] 1.0 [0.5–2.0] 1.0 [1.0–2.0] 0.286 Pre-hospital AB administration 156 (27%) 59 (23%) 97 (30%) 0.423 Pre-hospital duration (min) 71 ± 34 57 ± 24 83 ± 36 0.070 Final prehospital values SBP (mmHg) 105 ± 25 104 ± 26 105 ± 24 < 10 − 3 DBP (mmHg) 62 ± 18 62 ± 18 62 ± 18 0.057 MAP (mmHg) 76 ± 19 76 ± 19 76 ± 19 0.030 HR (beats.min − 1 ) 107 ± 25 107 ± 24 107 ± 26 0.313 RR (movements.min − 1 ) 25 [19–30] 24 [18–30] 26 [20–33] 0.004 Pulse oximetry (%) 97 [94–99] 97 [95–99] 97 [93–99] 0.003 Body core temperature (°C) 38.1 [36.0–39.0] 38.2 [37.0–39.0] 37.0 [35.0–38.0] 0.002 Glycemia (mmol.l − 1 ) 8.0 [6.0–10.0] 8.0 [6.0–10.0] 8.0 [6.0–10.5] 0.491 Glasgow coma scale 15 [14–15] 15 [14–15] 14 [11–15] < 10 − 3 Lactatemia (mmol.l − 1 ) 4.2 ± 3.5 3.6 ± 3.0 4.7 ± 3.8 < 10 − 3 In-ICU length of stay (days) 4 [1–8] 4 [2–9] 2 [1–7] 0.002 In-hospital length of stay (days) 10 [5–18] 14 [8–21] 4 [2–10] < 10 − 3 SAPS-2 score 59 ± 21 56 ± 20 61 ± 22 < 10 − 3 Comorbidities Hypertension 264 (45%) 126 (48%) 138 (43%) 0.541 Coronary heart disease 117 (20%) 57 (22%) 60 (18%) 0.033 Chronic cardiac failure 144 (25%) 80 (31%) 64 (20%) < 10 − 3 Chronic renal failure 80 (14%) 43 (17%) 37 (11%) 0.076 COPD 74 (13%) 30 (12%) 44 (13%) 0.241 Diabetes Mellitus 171 (29%) 87 (33%) 84 (26%) 0.359 Cancer history 204 (35%) 94 (36%) 110 (34%) 0.022 Legend: ED = emergency department, ICU = intensive care unit, SBP = systolic blood pressure, DBP = diastolic blood pressure, MBP = mean blood pressure, HR = heart rate, RR = respiratory rate, ICU = intensive care unit, SAPS-2 = simplified acute physiology score 2nd version, COPD = chronic obstructive pulmonary disease, ABT = antibiotic therapy, min = minutes. p-value in bold corresponds to a p-value < 0.05 between patients admitted to the ED and patients admitted to the ICU. Fluid expansion was based on crystalloids infusion for all patients with no significant difference between patients admitted to the ED vs those patients admitted to the ICU: 815 ± 447 ml vs 1064 ± 663 ml respectively (p = 0.558; Table 1 ). The median ICU length of stay was 4 [1–8] days and the median length of stay in a hospital was 10 [5–18] days. The 30-day mortality was 30%. Main measurement Prehospital suspected septic shock origin was mainly pulmonary, urinary and digestive: 42% (n = 244), 26% (n = 150) and 17% (n = 101) respectively. For 34 patients (5%), the prehospital septic shock origin was unknown (Table 2 ). Table 2 Suspected prehospital septic shock origins. Origin n (percentage) Pulmonary 244 (42%) Digestive 150 (26%) Urinary 101 (17%) Cutaneous 38 (6%) Meningeal 12 (2%) Gynaecological 4 (1%) ENT 2 (0.5%) Cardiac 2 (0.5) Unknown 34 (5%) Legend: ENT: ear nose throat Main measurement Two-hundred and sixty patients (44%) were admitted to the ED and 327 patients (56%) were admitted to the ICU (p = 0.812) (Table 1 ). Among the 260 patients admitted to the ED, 180 patients (69%) were alive on day-30. Conversely, among the 327 patients admitted to the ICU, 223 patients (68%) were alive on day-30. Multivariate logistic regression on IPTW matched population On IPTW matched population including the followings confounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, chronic obstructive pulmonary disease, chronic renal failure, diabetes mellitus, cancer history, hypertension, chronic heart failure, coronary artery disease, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration, the multivariate analysis found a aRR = 1.05 [1.00-1.09] (p = 0.025) between 30-day mortality and ED admission. Conversely, the multivariate analysis with the same confounders found aRR = 0.90 [0.86–0.95] (p < 10 − 3 ) between 30-day mortality and ICU admission. DISCUSSION In the herein study, we report a relationship between hospital ward admission and 30-day mortality among septic shock patients cared for by a prehospital MICU: increase mortality associated with ED admission and decreased mortality associated with direct ICU admission. Despite studies during the last 40 years, sepsis remains a main cause of death of in-hospitalized patients ( 16 ) leading to 250 000 Americans death every year ( 17 , 18 ). Despite wide variability between countries, septic shock mortality rate is also stable, nearly 30% at one month ( 19 , 20 ). Consequently in 2017, the World Health Assembly and the World Health Organization stressed prevention, diagnosis, and sepsis management as priorities to decrease sepsis mortality ( 21 ). In this order, the Surviving Sepsis Campaign emphasizes the need for early recognition, severity assessment and early treatment to improve sepsis outcome ( 1 , 4 , 22 ). Among treatments, early ABT and early hemodynamic optimization ( 1 , 23 , 24 ) are those with the greatest impact ( 1 , 24 , 25 ), especially for septic shock patients ( 7 ) among which they must be initiated within the first hour after recognition ( 1 , 4 , 22 ) when the treatment effect is the greatest ( 1 , 24 ). More than a single treatment, a bundle of care, among which admission to an adequate facility, in other words prehospital triaging optimization, appears to be a cornerstone to improve sepsis outcome. This study results may be affected by some limitations. This is a retrospective study; thus, no causal conclusion can be established. A misclassification bias may result from data collection method in prehospital and in hospital medical reports. The external validity may be affected by the French prehospital emergency medical service based on SAMU and direct ICU admission by MICU. We cannot exclude that, ED overcrowding resulting on delayed medical care are not involved in the observed patient mortality increased as reported by other authors ( 26 , 27 ). CONCLUSION In this study we report a positive relationship between ED admission and 30-day mortality of patients in septic shock cared for by a prehospital MICU whereas direct ICU admission is associated with a 30-day mortality decrease. These preliminary results need to be confirmed by larger prospective multicentric studies. Abbreviations MICU: Mobile Intensive Care Unit intervention ICU: Intensive Care Unit intervention MAP: mean arterial pressure SS: septic shock SAMU: Urgent Medical Aid Service SMUR: Mobile Emergency and Resuscitation Service ED: emergency department SAP: systolic arterial pressure DAP: diastolic arterial pressure HR: heart rate SpO2: pulse oximetry RR: respiratory rate GCS: Glasgow coma scale LOS: length of stay SAPS 2: Simplified Acute Physiology Score IPTW: Inverse Probability Treatment Weighting aHR: adjusted Hazard ratio Declarations - Ethics approval and consent to participate: The study was approved by the French Society of Anaesthesia and Intensive Care ethics committee on 2017, December 12th (Ref number: IRB 00010254-2017-026). - Patients consent for publication: not applicable - All authors read, approved the manuscript and consent for publication - Availability of data and material: data and material are available on reasonable request - Competing interests: none of the author - Funding: none - Authors' contributions: (I) Conception and design: Jouffroy, Gueye, (II) Administrative support: Jouffroy, (III) Provision of study materials or patients: Jouffroy, Garrouste, Gilbert, Travers, Boularan, Bounes, Ecollan, Vivien, Gueye, Bloch-Laine, (IV) Collection and assembly of data: Jouffroy, Gueye, Garrouste, Bloch-Laine, Gilbert, (V) Data analysis and interpretation: Joufrroy, Garrouste, Gueye, (VI) Final approval of manuscript: All authors - Acknowledgements: none - All methods were carried out in accordance with the Declaration of Helsinki. - Clinical trial number: not applicable - The French Society of Anaesthesia and Intensive Care ethics committee considered that consent of patients was waived for participation in this observational study Data Availability data and material are available on reasonable request References Singer, M. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315 (8), 801–810 (2016). Lane, D., Ichelson, R. I., Drennan, I. R. & Scales, D. C. Prehospital management and identification of sepsis by emergency medical services: a systematic review. Emerg. Med. J. 33 (6), 408–413 (2016). Jouffroy, R. et al. The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization. Ann. Intensive Care . 14 (1), 58 (2024). Evans, L. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 47 (11), 1181–1247 (2021). Smyth, M. A., Brace-McDonnell, S. J. & Perkins, G. D. Impact of Prehospital Care on Outcomes in Sepsis: A Systematic Review. West. J. Emerg. Med. 17 (4), 427–437 (2016). Lazzarin, T. et al. Sepsis management in pre-hospital care - the earlier, the better? BMC Emerg. Med. 24 (1), 220 (2024). Jouffroy, R. et al. Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality. Prehosp Emerg. Care :1–8. (2020). Adnet, F. & Lapostolle, F. International EMS systems: France. Resuscitation 63 (1), 7–9 (2004). Dellinger, R. P. et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit. Care Med. 36 (1), 296–327 (2008). Jouffroy, R. et al. Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock. Crit. Care Med. 50 (10), 1440–1448 (2022). Salvatore, F. The shift of the paradigm between ageing and diseases. Clin. Chem. Lab. Med. (2020). Le Gall, J. R., Lemeshow, S. & Saulnier, F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270 (24), 2957–2963 (1993). Gearing, R. E., Mian, I. A., Barber, J. & Ickowicz, A. A methodology for conducting retrospective chart review research in child and adolescent psychiatry. J. Can. Acad. Child. Adolesc. Psychiatry . 15 (3), 126–134 (2006). Jouffroy, R. et al. Association between prehospital ROX index with 30-day mortality among septic shock. Eur. J. Med. Res. 29 (1), 304 (2024). Robins, J. M., Hernan, M. A. & Brumback, B. Marginal structural models and causal inference in epidemiology. Epidemiology 11 (5), 550–560 (2000). Martin, G. S., Mannino, D. M., Eaton, S. & Moss, M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl. J. Med. 348 (16), 1546–1554 (2003). Brun-Buisson, C. The epidemiology of the systemic inflammatory response. Intensive Care Med. 26 (Suppl 1), S64–74 (2000). Rivara, F. P. Introduction: the scientific basis for injury control. Epidemiol. Rev. 25 , 20–23 (2003). Ferrer, R. et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 299 (19), 2294–2303 (2008). Nguyen, H. B., Van Ginkel, C., Batech, M., Banta, J. & Corbett, S. W. Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. J. Crit. Care . 27 (4), 362–369 (2012). ASSEMBLY SWH. Improving the prevention, diagnosis and clinical management of sepsis. (2017). Chen, A. X., Simpson, S. Q. & Pallin, D. J. Sepsis Guidelines. N Engl. J. Med. 380 (14), 1369–1371 (2019). Leisman, D. E. et al. Survival Benefit and Cost Savings From Compliance With a Simplified 3-Hour Sepsis Bundle in a Series of Prospective, Multisite, Observational Cohorts. Crit. Care Med. 45 (3), 395–406 (2017). Evans, L. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit. Care Med. 49 (11), e1063–e143 (2021). Guirgis, F. W. et al. Managing sepsis: Electronic recognition, rapid response teams, and standardized care save lives. J. Crit. Care . 40 , 296–302 (2017). Sun, B. C. et al. Effect of emergency department crowding on outcomes of admitted patients. Ann. Emerg. Med. 61 (6), 605–611 (2013). e6. Khalifa, M. & Zabani, I. Reducing Emergency Department Crowding: Evidence Based Strategies. Stud. Health Technol. Inf. 226 , 67–70 (2016). Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table12025.docx Table22025.docx Cite Share Download PDF Status: Published Journal Publication published 28 Apr, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 11 Mar, 2026 Reviews received at journal 10 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviewers invited by journal 27 Jan, 2026 Editor assigned by journal 27 Jan, 2026 Editor invited by journal 04 Dec, 2025 Submission checks completed at journal 03 Dec, 2025 First submitted to journal 03 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8236865","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":582009292,"identity":"de33b85f-d97c-4e0e-b816-1b380827be33","order_by":0,"name":"Romain Jouffroy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYLCCBAYGZgYGxgcfgGw5kMCBB8RpYTacAWQbg7UkEGcXREtiA9QQnMC8vTvxw8MdDOz8EsmMzRUVh9Pnhx1+CLTFTk63AbsWmTNnN0sknmFglpyRzNh45szh3I230wyAWpKNzQ5g1yIhkbtBIrGNgdngRv7xh41tQC2zE0BaDiRuw61l8w+IFqAtQC3phrPTPxDSsk0CWUuCvHQOAVt4zm6zSGyTYJbseczY2HAm3XCDdE7BgQQDPH5h791882ebTTI/O9CWhgprefnZ6Zs/fKiwk8OlBaYzGcpoZjAAqzTAqxwM7KB0HYN8A2HVo2AUjIJRMLIAAHMQYclDPiC0AAAAAElFTkSuQmCC","orcid":"","institution":"University Hospital Center of Orleans - Orléans","correspondingAuthor":true,"prefix":"","firstName":"Romain","middleName":"","lastName":"Jouffroy","suffix":""},{"id":582009293,"identity":"0c59cd90-01c8-4282-807c-96d56c62c58a","order_by":1,"name":"Vincent Garrouste","email":"","orcid":"","institution":"University Hospital Center of Orleans - Orléans","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Garrouste","suffix":""},{"id":582009294,"identity":"2a343c5a-3213-430d-a9d4-02b5d6d3cedd","order_by":2,"name":"Basile Gilbert","email":"","orcid":"","institution":"University Hospital of Toulouse - Toulouse","correspondingAuthor":false,"prefix":"","firstName":"Basile","middleName":"","lastName":"Gilbert","suffix":""},{"id":582009295,"identity":"39f6b6dd-679c-495c-8795-aa0299628353","order_by":3,"name":"Stéphane Travers","email":"","orcid":"","institution":"Paris Fire Brigade - Paris","correspondingAuthor":false,"prefix":"","firstName":"Stéphane","middleName":"","lastName":"Travers","suffix":""},{"id":582009296,"identity":"67c3894f-dfc4-484b-bfc8-8d228c10225f","order_by":4,"name":"Emmanuel Bloch-Laine","email":"","orcid":"","institution":"Cochin Hospital","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Bloch-Laine","suffix":""},{"id":582009301,"identity":"995d173d-aca6-4a7e-bed7-682de9b8f555","order_by":5,"name":"Patrick Ecollan","email":"","orcid":"","institution":"SMUR, Pitié Salpêtriere Hospital","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"Ecollan","suffix":""},{"id":582009307,"identity":"a1777923-e2b1-4647-b3f1-6b667a822f6d","order_by":6,"name":"Vincent Bounes","email":"","orcid":"","institution":"University Hospital of Toulouse - Toulouse","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Bounes","suffix":""},{"id":582009309,"identity":"68ee0234-8728-409e-b566-97a82a07deea","order_by":7,"name":"Josiane Boularan","email":"","orcid":"","institution":"SAMU 31, Castres Hospital - Castres","correspondingAuthor":false,"prefix":"","firstName":"Josiane","middleName":"","lastName":"Boularan","suffix":""},{"id":582009312,"identity":"0df494a7-db15-4af6-b2e5-826c25342c56","order_by":8,"name":"Benoit Vivien","email":"","orcid":"","institution":"University Hospital Center of Orleans - Orléans","correspondingAuthor":false,"prefix":"","firstName":"Benoit","middleName":"","lastName":"Vivien","suffix":""},{"id":582009314,"identity":"2db1f357-06da-4a2c-b9fa-49a0a32ad02d","order_by":9,"name":"Papa Gueye","email":"","orcid":"","institution":"SAMU 972 CHU de Martinique Pierre Zobda - Quitman Hospital - Fort-de-France Martinique","correspondingAuthor":false,"prefix":"","firstName":"Papa","middleName":"","lastName":"Gueye","suffix":""}],"badges":[],"createdAt":"2025-11-29 12:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8236865/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8236865/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-026-49834-z","type":"published","date":"2026-04-28T15:56:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":108437549,"identity":"023cd486-a2a6-4d69-8b00-7351e8d0d4fd","added_by":"auto","created_at":"2026-05-04 15:59:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":377239,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8236865/v1/904dad5a-b2bd-4a53-bf9f-e5ad02ba76d0.pdf"},{"id":101504374,"identity":"80f75430-5ede-4885-ad23-b7037e0eb628","added_by":"auto","created_at":"2026-01-30 14:14:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20477,"visible":true,"origin":"","legend":"","description":"","filename":"Table12025.docx","url":"https://assets-eu.researchsquare.com/files/rs-8236865/v1/644078a53be8cd83bf004eb9.docx"},{"id":101504375,"identity":"3f0b705d-052d-422b-b917-07fb195db9f2","added_by":"auto","created_at":"2026-01-30 14:14:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14344,"visible":true,"origin":"","legend":"","description":"","filename":"Table22025.docx","url":"https://assets-eu.researchsquare.com/files/rs-8236865/v1/de19f197aca72ade98ec3cfa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of prehospital orientation of septic shock on 30-day mortality","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSepsis, a dysregulated host response to infection, with its most severe form, septic shock characterized by circulatory and cellular metabolism failures, are associated with a mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Prevalence and mortality of sepsis and septic shock require prompt interventions from early identification, treatments implementation, triage to the adequate facility, appropriate hospital care including rehabiltation in order to optimize outcome (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). To date, the benchmark for the management of sepsis and septic shock is summarized in international guidelines established a regularly updated by the Surviving Sepsis Campaign (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). For community acquired sepsis, nearly 50% admitted in the emergency department (ED) arrive via prehospital emergency medical service transport (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), supporting the practice of prehospital recognition and treatment instauration before hospital admission (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) thus bringing forward the screening and treatment start time, which is currently the time of hospital admission (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeyond this, it seems logical for the sicker one\u0026rsquo;s patients, i.e. septic shock, that a direct admission to the intensive care unit (ICU) contributes to improve outcome (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Therefore, beyond prehospital diagnosis, severity assessment and treatment (administration of antibiotics and hemodynamic optimization), admission to an adequate facility also appears to be a cornerstone in improving the outcome of sepsis. Pre-hospital caregivers have a key role to play in deciding which facility the patient should be admitted to.\u003c/p\u003e \u003cp\u003eThis study aimed to assess the relationship between 30-day mortality and the admission mode to ICU or emergency department (ED) among patients with septic shock cared for by a prehospital mobile Intensive Care Unit (MICU).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eFrench prehospital emergencies are managed by a public national organisation, the SAMU (Urgent Medical Aid Service), made of a central dispatch centre and prehospital MICU. As previously reported (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), prehospital MICU are composed by a driver, a nurse and an emergency physician with medical devices allowing respiratory, cardiovascular and neurologic deficiency (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom May 2016 to December 2022, patients suffering from septic shock according to the 2012 sepsis-2 conference criteria (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) cared by a MICU of 10 French hospital centres (Necker-Enfants malades Hospital, Lariboisi\u0026egrave;re Hospital, La Piti\u0026eacute; Salp\u0026ecirc;tri\u0026egrave;re Hospital, Hotel Dieu Hospital, APHP, Paris \u0026ndash; France; Paris Fire Brigade, Paris \u0026ndash; France; Toulouse University Health Centre, Toulouse \u0026ndash; France, La Martinique University Health Centre, Fort de France \u0026ndash; France, Orl\u0026eacute;ans University Hospital, Orl\u0026eacute;ans - France and the Castres Hospital, Castres \u0026ndash; France), were retrospectively analyzed. As previously reported (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), the operative sepsis-2 definition (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) was chosen for its applicability in the prehospital setting defining a septic shock as a refractory hypotension despite vascular filling or normotension with hypoperfusion signs because prehospital lactatemia assessment was not available in all MICU precluding Sepsis-3 conference (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) use in the prehospital setting.\u003c/p\u003e \u003cp\u003ePatients younger than 18 years, pregnant, with serious comorbid conditions with an unknown prehospital life support, with guardianship or curatorship were not included.\u003c/p\u003e \u003cp\u003ePatients demographic characteristics (age, weight, height, and gender) suspected prehospital sepsis origin, initial prehospital (e.g., the first MICU contact), and final prehospital (e.g., at the end of prehospital stage) vital sign values (systolic (SBP), diastolic (DBP) and mean blood pressure (MBP)) were measured with a non-invasive automated device in all centres. Heart rate (HR), pulse oximetry (SpO2), respiratory rate (RR), temperature and Glasgow coma scale (GCS)), plasma blood glucose concentration, duration of prehospital care, and prehospital treatments delivered (ABT type and dose, fluid volume expansion type and dose, as well as catecholamine type and dose) were collected from MICU prehospital medical reports. Major comorbidities, i.e., chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF), diabetes mellitus, cancer history, hypertension, chronic heart failure (CHF), coronary artery disease (CAD) and hospitalization in the previous 3 months were collected to take into account the underlying condition (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). ICU-length of stay (LOS), hospital LOS and 30-day mortality status were retrieved from medical reports in case of in-hospital death or by call when the patient was discharged from the hospital. Simplified acute physiology score (SAPS-2) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) were calculated 24 hours after ICU admission. To minimize data abstraction bias, a standardized abstraction template established prior data collection was used (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eAs previously reported (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), the French Society of Anaesthesia and Intensive Care ethics committee on December 12th, 2017 (Ref number: IRB 00010254-2017-026) considered that informed consent of patients was waived for participation due to the retrospective nature of the study.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eResults are expressed by mean with standard deviation for quantitative parameters with a normal distribution, by median with interquartile range [1st quartile (Q1) \u0026minus;\u0026thinsp;3rd quartile (Q3)] for parameters with a non-gaussian distribution and with absolute value and percentage for qualitative parameters. The primary outcome was the 30-day mortality rate.\u003c/p\u003e \u003cp\u003eA propensity analysis based on Inverse Probability Treatment Weighting (IPTW) method with the following potential cofounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, COPD, CRF, diabetes mellitus, cancer history, hypertension, CHF, CAD, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration was performed to assess the relationship between 30-day mortality rate and the admission mode. IPTW method was chosen to balance the relative weight between patients admitted to the ED versus patients admitted to the ICU in order to reduce bias due to non-randomized treatment allocation (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Results were expressed as adjusted risk ratio (aRR) with [95 CI].\u003c/p\u003e \u003cp\u003eAll tests were 2-sided with a statistically significant \u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0 .05.\u003c/p\u003e \u003cp\u003eAll analyses were performed using R 3.4.2 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.R-project.org\u003c/span\u003e\u003cspan address=\"http://www.R-project.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; the R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eFive-hundred and eighty-seven patients were analysed: 370 (63%) were males and the mean age was 69 \u0026plusmn; 15 years old.\u003c/p\u003e \u003cp\u003eThe mean prehospital duration of care was 71\u0026thinsp;\u0026plusmn;\u0026thinsp;34 minutes without difference between patients admitted to the ED (57\u0026thinsp;\u0026plusmn;\u0026thinsp;24 minutes) and those admitted to the ICU (83\u0026thinsp;\u0026plusmn;\u0026thinsp;36 minutes) (p\u0026thinsp;=\u0026thinsp;0.070).\u003c/p\u003e \u003cp\u003eOne-hundred and fifty-six patients (27%) received prehospital ABT: 59 patients (23%) patients admitted to the ED vs 97 patients (30%) patients admitted to the ICU, p\u0026thinsp;=\u0026thinsp;0.423. Among these patients, 119 patients (76%) received a 3rd generation cephalosporin: 34% cefotaxime and 66% ceftriaxone. No patient suffered from an adverse event related to prehospital ABT administration.\u003c/p\u003e \u003cp\u003eOne-hundred and seventy-four patients (30%) received norepinephrine administration, 24 (9%) vs 150 (46%) among patients admitted to the ED vs those admitted to the ICU, p\u0026thinsp;=\u0026thinsp;0.512.\u003c/p\u003e \u003cp\u003eThe median norepinephrine dose was 1.1 [0.6-2.0] mg.h\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e: 1.0 [0.5\u0026ndash;2.0] vs 1.0 [1.0\u0026ndash;2.0] mg.h\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.286 among patients admitted to the ED vs those admitted to the ICU (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePopulation characteristics. Results are expressed by mean and standard deviation for quantitative parameters (normal distribution), by median and interquartile range for quantitative parameters (non-gaussian distribution) and, by absolute value and percentage for qualitative parameters. P-value corresponds to the comparison between deceased and alive patients on day-30.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOverall population\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(n\u0026thinsp;=\u0026thinsp;587)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eED admission\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(n\u0026thinsp;=\u0026thinsp;260)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eICU admission\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(n\u0026thinsp;=\u0026thinsp;327)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u0026thinsp;\u0026plusmn;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e370 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e164 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e206 (63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u0026thinsp;\u0026plusmn;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u0026thinsp;\u0026plusmn;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u0026thinsp;\u0026plusmn;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e170\u0026thinsp;\u0026plusmn;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInitial prehospital values\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u0026thinsp;\u0026plusmn;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR (beats.min\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112\u0026thinsp;\u0026plusmn;\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116\u0026thinsp;\u0026plusmn;\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.408\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRR (movements.min\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 [22\u0026ndash;36]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 [22\u0026ndash;35]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 [25\u0026ndash;39]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse oximetry (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 [85\u0026ndash;96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93 [87\u0026ndash;96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 [83\u0026ndash;95]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody core temperature (\u0026deg;C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.3 [36.1\u0026ndash;39.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.4 [36.8\u0026ndash;39.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.1 [36.0\u0026ndash;39.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlycemia (mmol.l\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.5 [6.2\u0026ndash;12.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.8 [6.5\u0026ndash;12.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.8 [5.8\u0026ndash;11.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlasgow coma scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 [12\u0026ndash;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 [13\u0026ndash;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 [11\u0026ndash;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactatemia (mmol.l\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-hospital fluid expansion (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e965\u0026thinsp;\u0026plusmn;\u0026thinsp;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e815\u0026thinsp;\u0026plusmn;\u0026thinsp;447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1064\u0026thinsp;\u0026plusmn;\u0026thinsp;663\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorepinephrine administration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.512\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorepinephrine dose (mg.h\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 [0.6\u0026ndash;2.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0 [0.5\u0026ndash;2.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0 [1.0\u0026ndash;2.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-hospital AB administration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-hospital duration (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u0026thinsp;\u0026plusmn;\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57\u0026thinsp;\u0026plusmn;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83\u0026thinsp;\u0026plusmn;\u0026thinsp;36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFinal prehospital values\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105\u0026thinsp;\u0026plusmn;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104\u0026thinsp;\u0026plusmn;\u0026thinsp;26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105\u0026thinsp;\u0026plusmn;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62\u0026thinsp;\u0026plusmn;\u0026thinsp;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76\u0026thinsp;\u0026plusmn;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR (beats.min\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u0026thinsp;\u0026plusmn;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107\u0026thinsp;\u0026plusmn;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107\u0026thinsp;\u0026plusmn;\u0026thinsp;26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRR (movements.min\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 [19\u0026ndash;30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 [18\u0026ndash;30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 [20\u0026ndash;33]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulse oximetry (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 [94\u0026ndash;99]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 [95\u0026ndash;99]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97 [93\u0026ndash;99]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody core temperature (\u0026deg;C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.1 [36.0\u0026ndash;39.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.2 [37.0\u0026ndash;39.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.0 [35.0\u0026ndash;38.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlycemia (mmol.l\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.0 [6.0\u0026ndash;10.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0 [6.0\u0026ndash;10.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0 [6.0\u0026ndash;10.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlasgow coma scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 [14\u0026ndash;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 [14\u0026ndash;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 [11\u0026ndash;15]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactatemia (mmol.l\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-ICU length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 [1\u0026ndash;8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 [2\u0026ndash;9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [1\u0026ndash;7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital length of stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 [5\u0026ndash;18]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 [8\u0026ndash;21]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 [2\u0026ndash;10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSAPS-2 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u0026thinsp;\u0026plusmn;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61\u0026thinsp;\u0026plusmn;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eComorbidities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e264 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e138 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.541\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic cardiac failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic renal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e110 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eLegend: ED\u0026thinsp;=\u0026thinsp;emergency department, ICU\u0026thinsp;=\u0026thinsp;intensive care unit, SBP\u0026thinsp;=\u0026thinsp;systolic blood pressure, DBP\u0026thinsp;=\u0026thinsp;diastolic blood pressure, MBP\u0026thinsp;=\u0026thinsp;mean blood pressure, HR\u0026thinsp;=\u0026thinsp;heart rate, RR\u0026thinsp;=\u0026thinsp;respiratory rate, ICU\u0026thinsp;=\u0026thinsp;intensive care unit, SAPS-2\u0026thinsp;=\u0026thinsp;simplified acute physiology score 2nd version, COPD\u0026thinsp;=\u0026thinsp;chronic obstructive pulmonary disease, ABT\u0026thinsp;=\u0026thinsp;antibiotic therapy, min\u0026thinsp;=\u0026thinsp;minutes.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003ep-value in bold corresponds to a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 between patients admitted to the ED and patients admitted to the ICU.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFluid expansion was based on crystalloids infusion for all patients with no significant difference between patients admitted to the ED vs those patients admitted to the ICU: 815\u0026thinsp;\u0026plusmn;\u0026thinsp;447 ml vs 1064\u0026thinsp;\u0026plusmn;\u0026thinsp;663 ml respectively (p\u0026thinsp;=\u0026thinsp;0.558; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe median ICU length of stay was 4 [1\u0026ndash;8] days and the median length of stay in a hospital was 10 [5\u0026ndash;18] days.\u003c/p\u003e \u003cp\u003eThe 30-day mortality was 30%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMain measurement\u003c/h2\u003e \u003cp\u003ePrehospital suspected septic shock origin was mainly pulmonary, urinary and digestive: 42% (n\u0026thinsp;=\u0026thinsp;244), 26% (n\u0026thinsp;=\u0026thinsp;150) and 17% (n\u0026thinsp;=\u0026thinsp;101) respectively. For 34 patients (5%), the prehospital septic shock origin was unknown (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSuspected prehospital septic shock origins.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOrigin\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en (percentage)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e244 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDigestive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCutaneous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeningeal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynaecological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eENT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eLegend: ENT: ear nose throat\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMain measurement\u003c/h3\u003e\n\u003cp\u003eTwo-hundred and sixty patients (44%) were admitted to the ED and 327 patients (56%) were admitted to the ICU (p\u0026thinsp;=\u0026thinsp;0.812) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the 260 patients admitted to the ED, 180 patients (69%) were alive on day-30. Conversely, among the 327 patients admitted to the ICU, 223 patients (68%) were alive on day-30.\u003c/p\u003e\n\u003ch3\u003eMultivariate logistic regression on IPTW matched population\u003c/h3\u003e\n\u003cp\u003eOn IPTW matched population including the followings confounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, chronic obstructive pulmonary disease, chronic renal failure, diabetes mellitus, cancer history, hypertension, chronic heart failure, coronary artery disease, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration, the multivariate analysis found a aRR\u0026thinsp;=\u0026thinsp;1.05 [1.00-1.09] (p\u0026thinsp;=\u0026thinsp;0.025) between 30-day mortality and ED admission. Conversely, the multivariate analysis with the same confounders found aRR\u0026thinsp;=\u0026thinsp;0.90 [0.86\u0026ndash;0.95] (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e) between 30-day mortality and ICU admission.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn the herein study, we report a relationship between hospital ward admission and 30-day mortality among septic shock patients cared for by a prehospital MICU: increase mortality associated with ED admission and decreased mortality associated with direct ICU admission.\u003c/p\u003e \u003cp\u003eDespite studies during the last 40 years, sepsis remains a main cause of death of in-hospitalized patients (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) leading to 250 000 Americans death every year (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Despite wide variability between countries, septic shock mortality rate is also stable, nearly 30% at one month (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsequently in 2017, the World Health Assembly and the World Health Organization stressed prevention, diagnosis, and sepsis management as priorities to decrease sepsis mortality (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In this order, the Surviving Sepsis Campaign emphasizes the need for early recognition, severity assessment and early treatment to improve sepsis outcome (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Among treatments, early ABT and early hemodynamic optimization (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) are those with the greatest impact (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), especially for septic shock patients (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) among which they must be initiated within the first hour after recognition (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) when the treatment effect is the greatest (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). More than a single treatment, a bundle of care, among which admission to an adequate facility, in other words prehospital triaging optimization, appears to be a cornerstone to improve sepsis outcome.\u003c/p\u003e \u003cp\u003eThis study results may be affected by some limitations. This is a retrospective study; thus, no causal conclusion can be established. A misclassification bias may result from data collection method in prehospital and in hospital medical reports. The external validity may be affected by the French prehospital emergency medical service based on SAMU and direct ICU admission by MICU. We cannot exclude that, ED overcrowding resulting on delayed medical care are not involved in the observed patient mortality increased as reported by other authors (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn this study we report a positive relationship between ED admission and 30-day mortality of patients in septic shock cared for by a prehospital MICU whereas direct ICU admission is associated with a 30-day mortality decrease.\u003c/p\u003e \u003cp\u003eThese preliminary results need to be confirmed by larger prospective multicentric studies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMICU: Mobile Intensive Care Unit intervention\u003c/p\u003e\n\u003cp\u003eICU: Intensive Care Unit intervention\u003c/p\u003e\n\u003cp\u003eMAP: mean arterial pressure\u003c/p\u003e\n\u003cp\u003eSS: septic shock\u003c/p\u003e\n\u003cp\u003eSAMU: Urgent Medical Aid Service\u003c/p\u003e\n\u003cp\u003eSMUR: Mobile Emergency and Resuscitation Service\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eED: emergency department\u003c/p\u003e\n\u003cp\u003eSAP: systolic arterial pressure\u003c/p\u003e\n\u003cp\u003eDAP: diastolic arterial pressure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHR: heart rate \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpO2: pulse oximetry\u003c/p\u003e\n\u003cp\u003eRR: respiratory rate\u003c/p\u003e\n\u003cp\u003eGCS: Glasgow coma scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLOS: length of stay\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSAPS 2: Simplified Acute Physiology Score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIPTW: Inverse Probability Treatment Weighting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eaHR: adjusted Hazard ratio\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e - Ethics approval and consent to participate: The study was approved by the French Society of Anaesthesia and Intensive Care ethics committee on 2017, December 12th (Ref number: IRB 00010254-2017-026).\u003c/p\u003e \u003cp\u003e- Patients consent for publication: not applicable\u003c/p\u003e \u003cp\u003e - All authors read, approved the manuscript and consent for publication\u003c/p\u003e \u003cp\u003e- Availability of data and material: data and material are available on reasonable request\u003c/p\u003e \u003cp\u003e- Competing interests: none of the author\u003c/p\u003e \u003cp\u003e- Funding: none\u003c/p\u003e \u003cp\u003e - Authors' contributions: (I) Conception and design: Jouffroy, Gueye, (II) Administrative support: Jouffroy, (III) Provision of study materials or patients: Jouffroy, Garrouste, Gilbert, Travers, Boularan, Bounes, Ecollan, Vivien, Gueye, Bloch-Laine, (IV) Collection and assembly of data: Jouffroy, Gueye, Garrouste, Bloch-Laine, Gilbert, (V) Data analysis and interpretation: Joufrroy, Garrouste, Gueye, (VI) Final approval of manuscript: All authors\u003c/p\u003e \u003cp\u003e- Acknowledgements: none\u003c/p\u003e \u003cp\u003e - All methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003e- Clinical trial number: not applicable\u003c/p\u003e \u003cp\u003e- The French Society of Anaesthesia and Intensive Care ethics committee considered that consent of patients was waived for participation in this observational study\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003edata and material are available on reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSinger, M. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). \u003cem\u003eJAMA\u003c/em\u003e \u003cb\u003e315\u003c/b\u003e (8), 801\u0026ndash;810 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLane, D., Ichelson, R. I., Drennan, I. R. \u0026amp; Scales, D. C. Prehospital management and identification of sepsis by emergency medical services: a systematic review. \u003cem\u003eEmerg. Med. J.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e (6), 408\u0026ndash;413 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJouffroy, R. et al. The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization. \u003cem\u003eAnn. Intensive Care\u003c/em\u003e. \u003cb\u003e14\u003c/b\u003e (1), 58 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans, L. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. \u003cem\u003eIntensive Care Med.\u003c/em\u003e \u003cb\u003e47\u003c/b\u003e (11), 1181\u0026ndash;1247 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmyth, M. A., Brace-McDonnell, S. J. \u0026amp; Perkins, G. D. Impact of Prehospital Care on Outcomes in Sepsis: A Systematic Review. \u003cem\u003eWest. J. Emerg. Med.\u003c/em\u003e \u003cb\u003e17\u003c/b\u003e (4), 427\u0026ndash;437 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLazzarin, T. et al. Sepsis management in pre-hospital care - the earlier, the better? \u003cem\u003eBMC Emerg. Med.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (1), 220 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJouffroy, R. et al. Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality. \u003cem\u003ePrehosp Emerg. Care\u003c/em\u003e :1\u0026ndash;8. (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdnet, F. \u0026amp; Lapostolle, F. International EMS systems: France. \u003cem\u003eResuscitation\u003c/em\u003e \u003cb\u003e63\u003c/b\u003e (1), 7\u0026ndash;9 (2004).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDellinger, R. P. et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. \u003cem\u003eCrit. Care Med.\u003c/em\u003e \u003cb\u003e36\u003c/b\u003e (1), 296\u0026ndash;327 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJouffroy, R. et al. Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock. \u003cem\u003eCrit. Care Med.\u003c/em\u003e \u003cb\u003e50\u003c/b\u003e (10), 1440\u0026ndash;1448 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalvatore, F. The shift of the paradigm between ageing and diseases. \u003cem\u003eClin. Chem. Lab. Med.\u003c/em\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe Gall, J. R., Lemeshow, S. \u0026amp; Saulnier, F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. \u003cem\u003eJAMA\u003c/em\u003e \u003cb\u003e270\u003c/b\u003e (24), 2957\u0026ndash;2963 (1993).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGearing, R. E., Mian, I. A., Barber, J. \u0026amp; Ickowicz, A. A methodology for conducting retrospective chart review research in child and adolescent psychiatry. \u003cem\u003eJ. Can. Acad. Child. Adolesc. Psychiatry\u003c/em\u003e. \u003cb\u003e15\u003c/b\u003e (3), 126\u0026ndash;134 (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJouffroy, R. et al. Association between prehospital ROX index with 30-day mortality among septic shock. \u003cem\u003eEur. J. Med. Res.\u003c/em\u003e \u003cb\u003e29\u003c/b\u003e (1), 304 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobins, J. M., Hernan, M. A. \u0026amp; Brumback, B. Marginal structural models and causal inference in epidemiology. \u003cem\u003eEpidemiology\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e (5), 550\u0026ndash;560 (2000).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin, G. S., Mannino, D. M., Eaton, S. \u0026amp; Moss, M. The epidemiology of sepsis in the United States from 1979 through 2000. \u003cem\u003eN Engl. J. Med.\u003c/em\u003e \u003cb\u003e348\u003c/b\u003e (16), 1546\u0026ndash;1554 (2003).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrun-Buisson, C. The epidemiology of the systemic inflammatory response. \u003cem\u003eIntensive Care Med.\u003c/em\u003e \u003cb\u003e26\u003c/b\u003e (Suppl 1), S64\u0026ndash;74 (2000).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRivara, F. P. Introduction: the scientific basis for injury control. \u003cem\u003eEpidemiol. Rev.\u003c/em\u003e \u003cb\u003e25\u003c/b\u003e, 20\u0026ndash;23 (2003).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrer, R. et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. \u003cem\u003eJAMA\u003c/em\u003e \u003cb\u003e299\u003c/b\u003e (19), 2294\u0026ndash;2303 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen, H. B., Van Ginkel, C., Batech, M., Banta, J. \u0026amp; Corbett, S. W. Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. \u003cem\u003eJ. Crit. Care\u003c/em\u003e. \u003cb\u003e27\u003c/b\u003e (4), 362\u0026ndash;369 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eASSEMBLY SWH. Improving the prevention, diagnosis and clinical management of sepsis. (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen, A. X., Simpson, S. Q. \u0026amp; Pallin, D. J. Sepsis Guidelines. \u003cem\u003eN Engl. J. Med.\u003c/em\u003e \u003cb\u003e380\u003c/b\u003e (14), 1369\u0026ndash;1371 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeisman, D. E. et al. Survival Benefit and Cost Savings From Compliance With a Simplified 3-Hour Sepsis Bundle in a Series of Prospective, Multisite, Observational Cohorts. \u003cem\u003eCrit. Care Med.\u003c/em\u003e \u003cb\u003e45\u003c/b\u003e (3), 395\u0026ndash;406 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans, L. et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. \u003cem\u003eCrit. Care Med.\u003c/em\u003e \u003cb\u003e49\u003c/b\u003e (11), e1063\u0026ndash;e143 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuirgis, F. W. et al. Managing sepsis: Electronic recognition, rapid response teams, and standardized care save lives. \u003cem\u003eJ. Crit. Care\u003c/em\u003e. \u003cb\u003e40\u003c/b\u003e, 296\u0026ndash;302 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun, B. C. et al. Effect of emergency department crowding on outcomes of admitted patients. \u003cem\u003eAnn. Emerg. Med.\u003c/em\u003e \u003cb\u003e61\u003c/b\u003e (6), 605\u0026ndash;611 (2013). e6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalifa, M. \u0026amp; Zabani, I. Reducing Emergency Department Crowding: Evidence Based Strategies. \u003cem\u003eStud. Health Technol. Inf.\u003c/em\u003e \u003cb\u003e226\u003c/b\u003e, 67\u0026ndash;70 (2016).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Septic shock, admission, emergency department, intensive care unit, pre-hospital, mortality","lastPublishedDoi":"10.21203/rs.3.rs-8236865/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8236865/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn order to reduce sepsis mortality, early treatment implementation and referral to the most appropriate ward (emergency department (ED) or intensive care unit (ICU) are recommended.\u003c/p\u003e\n\u003cp\u003eThis multicentre retrospective study aims to study the relationship between 30-day mortality and the admission mode to ICU or ED among patients with septic shock cared for by a prehospital mobile Intensive Care Unit (MICU).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom May 2016 to December 2022, septic shock patients cared for by a prehospital MICU were retrospectively analysed. To assess the relationship between 30-day mortality rate and the admission mode, a multivariate logistic regression after Inverse Probability Treatment Weighting (IPTW) propensity score matching was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 587 patients analysed, pulmonary, urinary and digestive infections were the main sepsis aetiology: 42%, 26% and 17% respectively. The overall 30-day mortality rate was 30%. Three-hundred and twenty-seven patients (58%) were admitted to ICU and 260 (42%) to the ED. On matched population, the multivariate analysis including the followings potential confounders: prehospital fluid expansion, norepinephrine administration, antibiotic therapy, age, chronic obstructive pulmonary disease, chronic renal failure, diabetes mellitus, cancer history, hypertension, chronic heart failure, coronary artery disease, hospitalization in the previous 3 months, SAPS-2, management in rural area and prehospital duration, an aRR=1.05 [1.00-1.09] (p=0.025) between 30-day mortality and ED admission. Conversely, the multivariate analysis with the same confounders found aRR=0.90 [0.86-0.95] between 30-day mortality and ICU admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlighted a positive relationship between ED admission and 30-day mortality of patients in septic shock cared for by a prehospital MICU suggesting a possible negative effect of ED admission whereas a direct ICU admission may be beneficial.\u003c/p\u003e","manuscriptTitle":"Impact of prehospital orientation of septic shock on 30-day mortality","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 14:14:28","doi":"10.21203/rs.3.rs-8236865/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-11T04:52:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-10T10:40:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302918167115247178498291384733529118226","date":"2026-03-10T09:19:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277206614601251727027447162670713567770","date":"2026-03-04T18:51:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49624363774730478505661752379577691907","date":"2026-03-03T19:10:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146355339106340152483893495099791871632","date":"2026-03-03T18:13:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T08:48:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"236622156335706796212023736318430177003","date":"2026-01-28T19:04:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143380572482634053689425669301049005283","date":"2026-01-27T19:13:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T18:45:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T18:43:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-05T04:32:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-04T01:54:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-12-04T01:47:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0dc85463-995a-40bd-a0d5-3cb537e39743","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":61922170,"name":"Health sciences/Cardiology"},{"id":61922171,"name":"Health sciences/Diseases"},{"id":61922172,"name":"Health sciences/Health care"},{"id":61922173,"name":"Health sciences/Medical research"},{"id":61922174,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-05-04T15:58:50+00:00","versionOfRecord":{"articleIdentity":"rs-8236865","link":"https://doi.org/10.1038/s41598-026-49834-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-04-28 15:56:58","publishedOnDateReadable":"April 28th, 2026"},"versionCreatedAt":"2026-01-30 14:14:28","video":"","vorDoi":"10.1038/s41598-026-49834-z","vorDoiUrl":"https://doi.org/10.1038/s41598-026-49834-z","workflowStages":[]},"version":"v1","identity":"rs-8236865","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8236865","identity":"rs-8236865","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}