Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—protocol for a multicenter, randomized, clinical, proof-of-concept trial

Background Intravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care. Methods This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care. The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions. Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022. Discussion Sepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis. Trial registration EudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics – Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28). Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01034-y.


Preface
The "Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients -a Multicenter, Randomized Clinical Feasibility Trial" (REFACED Sepsis) will be conducted according to this protocol. The trial will be conducted in accordance with all applicable national and international laws, regulations, and guidelines including the revised version of the • Correction of statistics in secondary outcomes (section 6.2) 1. BACKGROUND

Incidence and mortality
Sepsis is very common in emergency department (ED) patients. Sepsis and suspected infection accounts for approximately 43% of all patient admissions in a Danish medical ED 8 and sepsis accounts for more than 500,000 yearly patient visits in the United States. 9 Patients presenting to the ED with suspected infection and sepsis are at risk of disease progression to septic shock (7-26% 10-13 ) and ultimately death with mortality ranging from 10 to 23%. [14][15][16] It has been estimated that 15% of all deaths in Denmark are caused by sepsis. 17 In addition, the morbidity and effect on health-related quality of life after sepsis is significant. 18-20

Pathophysiology and definition
Sepsis is defined as life-threatening organ-dysfunction caused by a dysregulated host-response to infection. 21 Sepsis is not a specific illness but rather a syndrome encompassing a still-uncertain pathobiology. 21  Sepsis is defined in accordance with the SOFA-score. 21 SOFA-score reflects organ dysfunction in the following organs/systems: respiratory, coagulation, liver, cardiovascular, central nervous system, and renal (see appendix 2). Sepsis is present if the patient has a suspected or verified infection and an increase in SOFA-score ≥ 2 from baseline caused by or suspected to be caused by the infection.

Treatments of sepsis
The mainstay of sepsis treatment in the initial phase includes intravenous (IV) antibiotics and fluids, source control, and supportive care, if necessary. 24 The international Surviving Sepsis Campaign (SSC), which is supported by 25 medical societies, guides in treatment of septic shock, but does not give any recommendations on sepsis patients not in overt shock in general, despite the fact that sepsis is almost 60 times as common as septic shock. 8

Use of fluids
Intravenous fluid therapy is one of the most common therapeutic interventions performed in the ED. The most frequently used fluid, normal saline (0.9% NaCl), was described more than 100 years ago and the use was introduced to cholera patients. 26 Other crystalloids and colloids have been introduced, especially with the intention to balance solutions by electrolyte composition and osmolality to approximate to human plasma.
IV fluids for patients are used for different reasons; resuscitation (i.e., mostly to raise blood pressure and tissue perfusion), replacement of loss (e.g., vomit, diarrhea, perspiration, dehydration), maintenance to cover daily needs, correction of electrolytes, and as adjuvant for medications given intravenously.
The goals of fluids administration in terms of resuscitation is to increase intravascular volume. 27 The increased intravascular volume is intended to improve cardiac output and tissue oxygenation/perfusion. 24 The requirements for and response to fluid resuscitation vary greatly during the course of any critical illness.
No single physiological or biochemical measurement adequately reflects the complexity of fluid depletion nor the response to fluid resuscitation in acute illness. 27 Although the physiology of fluid treatment is not fully understood and elucidated, it probably should be regarded as a kind of medication with both intended effects and adverse reactions. 27 However, evidence to decide on this is sparse; "What is the optimal fluid treatment?" remains an unanswered question.

Fluid restriction; pros and cons
Recent fluid resuscitation and use seems to be quite liberal, in accordance with SSC, used for the abovementioned reasons (section 1.2.1). However, too liberal fluid resuscitation may potentially result in worsening of tissue edema (including lungs), challenge the heart and lengthen the duration of mechanical ventilation. Liberal fluid resuscitation may also result in increased hemodilution, which may induce use of concomitant interventions (e.g., transfusion of blood products). Intravenous fluid administration has also been suggested to cause destruction of the capillary wall, causing further tissue edema. Restrictive fluid therapy may be beneficial in reducing venous backpressure and organ edema, thereby improving function of organs such as the lungs, gut, and kidneys. 28,29 On the other hand, fluid restriction may compromise peripheral and/or organ perfusion through reduced cardiac output and thereby reduced microcirculation from the arterial side. 30

Use in sepsis
Fluid resuscitation has, as mentioned, been a corner stone of sepsis treatment for years. Liberal fluid therapy for septic patients has been recommended since the first Surviving Sepsis Campaign guideline (SSC, 2003). 31 The SSC's 2016-guidelines recommend at least 30 mL/kg of IV crystalloid fluid to be given within the first 3 hours (strong recommendation, low quality of evidence) for patients in septic shock. 24 However, as seen, fluid resuscitation is guided by low quality of evidence 24 and studies show great variation in practice. 16

Trials in fluid and sepsis
Within the last decade, there has been an increase in observational studies and interventional trials on fluid and septic shock with a number of randomized trials ongoing. 33,35,45,46 A systematic review of predominantly observational studies found that positive fluid balance was associated with increased mortality. 35 A recent review and meta-analysis of randomized trials found no statistically significant difference between lower vs. higher fluid volumes in all-cause mortality. The study only included five trials and found low quality of evidence supporting the decision on the volumes of IV fluid therapy in adults with septic shock and sepsis. All five trials were in the intensive care units (ICU) setting. 47 A recent randomized pilot trial by Hjortrup et al. (included in the above mentioned review) was able to reduce volumes of resuscitation fluids with a restrictive fluid protocol in septic shock patients in the ICU. 45 Another pilot trial in the ED by Macdonald  Although trials are currently exploring fluid strategies in patients with hypotension and septic shock 45,50 , there are no studies on fluid administration in patients with early sepsis without shock/hypotension.
Research within this field has been requested by experts. 26,51 As fluid administration is very frequent, but not evidence-based, and carries potential risks, we consider it to be of great interest for society and patients to perform research in this area. Fluid resuscitation is a key intervention in sepsis, but the optimal amount of fluid to be given has not been established. The present trial is a feasibility trial, i.e., a trial assessing the feasibility of the proposed protocol in a clinical setting. The aim is to investigate the ability to reduce fluid volume using the given protocol. Should the trial prove feasible with separation between the two interventions, a large-scale trial assessing patient important outcomes is intended.

Overview
This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of fluid within 24 hours in 124 patients with sepsis allocated to two different IV fluid regimens enrolled at three emergency departments in Central Region Denmark. The objective is to assess the feasibility of a trial comparing two approaches to intravenous fluid resuscitation of sepsis; a restrictive approach using four criteria vs. standard care. The hypothesis is that the restrictive approach is feasible and will result in less IV fluid given. The primary outcome is total intravenous fluid volume within 24 hours and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 hours, progression to septic shock, and SAEs/SUSARs.

Allocation
Patients fulfilling all inclusion criteria and no exclusion criteria will be randomized in a 1:1 ratio in blocks of varying concealed sizes stratified by site 52 at enrollment to one of two fluid treatment arms lasting for the first 24 hours of admission or until the patient is discharged within 24 hours. Randomization will be performed via the web-based randomization system provided in REDCap ensuring allocation concealment.

Restrictive fluid administration
No IV fluids should be given unless one of the below mentioned occurs; in these cases, IV fluid may be given in measured amounts: A fluid bolus of 250 ml (half of a 500 ml fluid bag) isotonic crystalloid may be given within 15 minutes if one of the following occurs (hypoperfusion criteria): • Lactate concentration ≥ 4 mmol/l (arterial or venous blood gas/blood sample) • Hypotension (systolic BP < 90 mmHg) • Mottling beyond edge of kneecap (i.e., Mottling score >2) 53 • Severe oliguria, i.e., diuresis < 0.1 ml/kg/h, during the first 4 hours of admission Only isotonic crystalloids are to be given as resuscitation fluid; the type of isotonic crystalloid is free of choice. Crystalloid boluses are to be given via IV drip. Intravenous fluids may be given as carrier for medication, but the volume should be reduced to the lowest possible volume for the given medication.
In case of documented overt fluid losses (e.g., vomiting, large aspirates, diarrhea, drain losses, or ascites drainage or due to dehydration) IV fluid may be given to correct for the loss.
In case the oral/enteral route for water or electrolyte solutions is contraindicated or has failed as judged by the clinical team, IV fluids may be given to: • Correct significant electrolyte deficiencies • Ensure a total fluid input of 1 L per 24 h (fluids with medications and nutrition count as input).
If a patient undergoes surgery during the 24 hours inclusion period, they are temporarily out of the protocol, but we will encourage continuing restrictive fluid therapy.
The cut-off value of lactate was chosen based on SSC guidelines 24 and their one-hour bundle 54 and data indicating that the marked increase in mortality occur at lactate values above 4 mmol/l. 55,56 The mottling trigger is based on mottling score ≥ 2 (see figure below) as described by Ait-Oufella et al 53 and validated in a pre-hospital setting. 57 Severe oliguria is defined as urine output ≤ 0.1 ml/kg/hour and the criteria is only to be used within the first 4 hours of admission.

Figure showing
Mottling score, copy with permission from Ait-Oufella et al. 53

Standard care
Fluid may be given intravenously in amounts of the clinician's choice as usual. There will be no upper limit for the use of either IV or oral/enteral fluids. In particular: • IV fluids should be given in the case of hypoperfusion or circulatory impairment and should be continued as long as hemodynamic variables improve as chosen by the clinicians. These criteria are based on the SSC guideline 24 • IV fluids should be given as maintenance if the departments have a protocol recommending maintenance fluid • IV fluids should be given to substitute expected or observed loss, dehydration or electrolyte derangements

Co-interventions
Types of fluids in both intervention groups: • Fluids used for electrolyte disturbances: Fluids should be chosen to substitute the specific deficiency • Fluids given to substitute overt loss: Isotonic crystalloids are to be used. If large amounts of ascites are tapped, then human albumin may be used.
• Blood products are only to be used on specific indications including severe bleeding, severe anaemia and prophylactic in case of severe coagulopathy.

Concomitant interventions
Patients should, besides the above-mentioned randomized treatments, be cared for as usual in terms of their infection. Treatment of sepsis is complex with multiple interventions and, as blinding of treating personnel is not feasible, use of several concomitant interventions may be influenced by allocated intervention arm. In order to minimize these potential differences, the use of concomitant interventions for sepsis should be based on the Danish Society of Infectious Disease guidelines and the one-hour bundle from SSC.

Criteria for modification of interventions for a given trial participant and protocol violations
The clinical team may at any time violate the protocol if they find it to be in the interest of the participant.
We will have a 24-hour per day trial hotline to enable discussion between the clinicians caring for trial participants and the REFACED Sepsis trial team regarding protocol related issues.
REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 23 of 62 Protocol violations are defined as follows:

Intervention group Major protocol violation Documentation
Restrictive fluid administration IV fluids given if none of the bellow is true: •

Assessment of participant compliance
We will monitor protocol compliance at the trial site through the electronic case report form (eCRF) in REDCap and alert sites in the case of clear violation (central monitoring). In addition, the trial will be monitored according to the Good Clinical Practice (GCP) directive and a monitoring plan conducted in collaboration with the GCP-unit at Aarhus and Aalborg Universities.

Blinding
Fluid restriction vs. standard care fluid therapy cannot be blinded for investigators, clinical staff, or participants.

Patients
The trial procedures will be limited to the interventions given in the first 24 hours of admission. Data will be obtained from the study specific case report form and the electronic medical records.

Clinical personnel
Prior to the beginning of patient enrollment and continuously throughout the enrollment period, the clinical teams involved in the treatment of sepsis patients at the participating hospitals will be informed about the REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 24 of 62 trial. Clinical personnel will be informed about the background and objectives of the trial, the inclusion/exclusion criteria, the interventions, and the trial procedures they are involved in. We anticipate formal, in-person didactics continuously with informal sessions and emails as applicable in between as well as an educational video, especially due to the current COVID-19-pandemic.

Setting
The trial will be conducted at three EDs at Aarhus University Hospital and Regional Hospital Randers and Viborg, Denmark. All three participating sites have clinical experience and expertise in treating sepsis patients.

Inclusion criteria
The research team, clinically working nurses and ED physicians will screen ED patients for the following inclusion criteria: broad sepsis population and increase the likelihood of describing the entire 24 hours inclusion period. We will strive to enroll participants as soon as they fulfill the criteria in the ED. There is no exact maximum time frame for patient inclusion, however with the exclusion criteria of > 500 ml. IV fluids administered, the inclusion is expected and intended to happen within the first couple of hours.

Exclusion criteria
We will exclude patients fulfilling any of following exclusion criteria:

Co-enrollment
There will be no general restrictions on entry into other clinical trials although this will be evaluated on a case-by-case basis. 58 However, patients enrolled in REFACED Sepsis will not be able to be enrolled in the CLASSIC trial (ClinicalTrials.gov identifier NCT03668236) if transferred to the ICU, since it would be contradictory to receive restrictive care in one of the studies and standard care in the other at the same time.

Definition
The primary outcome will be the total amount of all administered intravenous, crystalloid fluids within 24 hours of randomization.

Feasibility aim
The primary result is to see, if patients in the restrictive arm have significantly less intravenous fluid administered within 24 hours than the standard-care group. This study is a feasibility study, and a future large-scale study is planned.

Definitions
The secondary outcomes will be

Elaboration on secondary outcomes
The study is a feasibility trial only powered to answer the primary aim. However, we regard the above mentioned as important feasibility measures. The trial will include additional outcomes focused on hemodynamics, organ failure, and long-term outcomes in order to be able to power calculate for the planned large-scale trial.
Both 30-day and 90-day survival will be obtained from electronic medical records or the Danish Civil Personal Register which allows for accurate and virtually complete follow-up. 60 We will include 90-day survival as a measure of long-term survival. 90 days were chosen since it is unlikely that mortality later than that will be directly linked to the sepsis event or the trial interventions.
A vasopressor will be defined as any continuous infusion of noradrenaline, dopamine, dobutamine, terlipressin, vasopressin, phenylephrine, and/or adrenaline. Receiving vasopressors for a total of at least 3 hours on a given day is defined as receiving vasopressors for that day. Invasive ventilation is defined as mechanical ventilation through an endotracheal or tracheostomy tube, not only used for surgery for a total of at least 3 hours on a given day.

General consideration
The trial will only be conducted in departments that are used to care for and treat sepsis patients. We therefore in general believe it is safe for individual patients to be enrolled into the REFACED Sepsis trial.
REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 27 of 62 As described above, randomized trial data and data from observational and physiological studies do not provide firm evidence, that one of the interventions in the REFACED Sepsis trial is superior to the other. We therefore believe, that the REFACED Sepsis trial is safe for the patients also at the group level.
Generally, fluid administration is considered safe and is very commonly used in clinical practice. The overall benefit and potential harm will be captured in our secondary outcomes, and the clinical team will document any specific adverse events suspected to be related to the intervention.
The registration of the batch numbers and the expiry dates of the IV fluids and the identity of the clinician administering the fluid will be registered as per standard practice at the sites. These data will not be registered in the trial documents, but can be obtained by the Sponsor or the authorities if needed. We

Definitions for adverse events and reactions
The following definitions will be used 2 : Adverse event (AE): any untoward medical occurrence in a subject to whom a medicinal product is Suspected unexpected serious adverse reaction (SUSAR): a serious adverse reaction, the nature, severity or outcome of which is not consistent with the reference safety information (SmPC).

Assessment of adverse events
Timing In all participants, we will assess the occurrence of SARs in the 7 days following randomization (the intervention period is 24 hours; 7 days allow for another 6 days of assessment after the intervention, which is clinically relevant in critically ill patients.

Classification of an event
We will make no inferences about a causal relationship between the intervention and the SARs but register the occurrence in the two groups and report them in the final report according to the definition given above.
The investigators will classify SAEs (as per the definition above occurring within 7 days from randomization) and report them to the sponsor. If such a SAE is deemed both unexpected and related to the intervention by the investigator, it will be considered a SUSAR and reported as such. If the sponsor does not adjudicate the SAE as related to the intervention, this will also be noted in the final report to the Medicines Authorities.

Definitions of serious adverse reactions in REFACED Sepsis
Defined serious adverse reactions (SARs) are: • General tonic-clonic seizures: Stiffening and/or jerking movements of all 4 extremities in a patient who becomes or is unconscious after randomization • Anafylactic reactions defined as urticarial skin reaction AND at least one of the following observed after randomization: • Worsened circulation (>20% decrease in systolic blood pressure or >20% increase in vasopressor dose) • Increased airway resistance (>20% increase in peak pressure on the ventilator) if

Definitions of Suspected Unexpected Serious Adverse Reaction (SUSAR) in REFACED Sepsis
SUSARs will be defined as serious reactions not described in the Summaries of Product Characteristics for the used crystalloids happening within 7 days of admission if not otherwise stated. Suspected Unexpected Serious Adverse Reactions (SUSAR) will be reported to the regulatory authorities as applicable.

Reporting
Any SAE adjudicated to be unexpected or related to the trial intervention by the investigator, will be reported within 24 hours to the sponsor or his delegate. If deemed a SUSAR by the sponsor, he will report it Once a year, the sponsor will submit a list of all SARs that have occurred at all sites during the trial period and a report on safety of the trial subjects to the Danish Medicines Agency and National Ethics Committee.
The sponsor will notify and upload the results from the clinical trial including important adverse events on EudraCT using the "Declaration of the End of Trial Form" when the trial has been completed (no later than 90 days thereafter) and if earlier than planned, the reasons for stopping the trial.

Sample size calculation
The trial will be powered to the primary outcome of 24-hour total intravenous fluids. Sample size calculation is based on unpublished data from an observational study conducted in three of the hospitals in Central Denmark Region. The study found that sepsis patients received a mean of 3762 ml (SD 1839) intravenous and oral fluid in 24 hours. Looking at only patients with sepsis, blood cultures drawn and intravenous antibiotics, patients received 2670 ml intravenous fluids (SD 1695). We conservatively estimate that the total amount of IV fluid in the control group will be approximately 2650 ml (standard deviation 1.7 L). We consider a mean difference of 1 L to be clinical meaningful and therefore estimate 1650 ml (standard deviation 1.7 L) in the intervention group. Based on these estimates, an alpha of 5%, a power of 90%, and a two-sample t-test, a sample size of 124 patients is required; 62 in each treatment arm. Using the same standard deviation of 1.7 L, which is even higher than the mean in the restrictive arm, is or most conservative estimate being able to segregate the two groups.

General considerations
The statistical reporting will adhere to the CONSORT guidelines. 61,62 All tests will be two-sided, a p-value < 0.05 will be considered significant, and all confidence intervals will have 95% coverage.
Patient inclusion and exclusion will be illustrated in a CONSORT flow diagram (see Appendix 7 for a draft).
We will include measures related to feasibility including the enrolled to screened ratio, time to randomization, and protocol adherence/major protocol violations. All analyses will be conducted in the intention-to-treat (ITT) population defined as all randomized participants for whom consent was obtained.
We will perform the primary analyses adjusted for the stratification variable site.
REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 31 of 62 The two groups will be compared in relation to baseline patient and sepsis characteristics using descriptive statistics.

Primary and secondary outcomes
To estimate the mean difference in fluid volume between groups, we will use linear regression with adjustment for the stratification variable. If the data is severely non-normally distributed, we will consider other appropriate options (e.g., "robust standard errors" or transformation). Other continuous variables will be analyzed similarly. For binary outcomes, we will use logistic regression adjusted for site and results will be presented as odds ratios.

Missing data
Missing data will be reported in the relevant publications. We do not expect any missing data for the primary outcome (except for those discharged within the 24 hours) or the key secondary outcomes. Patients discharged within 24 hours or who died within 24 hours, will be included in the ITT analysis with the amounts they received until discharge/death. We do not expect missing data on mortality or adverse events.
Multiple imputation using known risk factors for outcomes in sepsis will be used to impute values for patients with missing data if missing data is substantial (> 10%).

Statistical stopping criteria
Since the primary outcome is not mortality, there will be no formal stopping criteria for efficacy. There will be no predefined stopping criteria for futility since enrollment of the full cohort might allow for detection of differences in other outcomes even if the primary outcome is negative.

Data collection process
Enrollment and randomization will be performed by the treating team directly in the trial specific REDCapsite. The treating team will register limited data in REDCap including patient identifier (i.e., Danish Central Personal Register number), site and inclusion/exclusion criteria, and limited trial specific data in the electronical medical record to notify the enrollment of the patient in the trial. This will include study ID, timing of enrollment and allocation. Ringers) and volume and time to re-evaluation and protocol violations and reasons for these. Further data will be obtained from the electronic medical journal by the research team as described below including for example vital signs, blood tests etc.; all data will be based on measurements and assessments made by the clinical team. A trained member of the research team (either the sponsor, site investigators or employed research nurses and medical students) will be responsible for data collection and entry into the eCRF from the electronic medical journal and from the paper-CRF. Data will be entered directly into the database software from the electronic medical journal (see section 7.4). The paper-CRF and e-CRF in REDCap will both be developed and tested and validated before initiation of the trial at all sites to optimize the use and be able to uniform the data abstraction.

Variables
All sepsis patients at the participating sites will be entered into a screening log by daily going through all adult, admitted patients who had a blood culture perfomed (screening criteria) and check if these patients fulfilled inclusion criteria and exclusion criteria. The screening log will be carried out by a trained member of the research team (either the sponsor, site investigators or employed research nurses and medical students). For those not randomized, a specific reason for non-inclusion/exclusion will be documented. The screening log will for all screened patients include variables for inclusion, exclusion and for some patients the logistical reasons for not including the patients. This data will be collected either before informed consent by the "legal guardian" or for patients screened and excluded without informed consent. Data collected from the electronic patient journal before consent will be passed on to the primary investigator for use in the trial, as well as legal authorities by request. Screening for patients will be performed "real-time" by the trained research team and the treating teams, but the screening log will be filled out once daily by the trained research team going through all patients admitted since the last screening log was performed. All randomized patients will be entered into the main REDCap database.
A detailed data dictionary that clearly defines all included variables in the eCRF (elaboration of 7.1.3-7.1.8) will be created prior to patient enrollment. The data dictionary will provide the name of the variable (including the code used in the database), a detailed definition of the variable, categories for categorical variables, and units and ranges for continuous variables.
The number of collected variables will be kept relatively small to limit resource use and data entry mistakes. Below is provided a brief overview of the included variables but details are reserved for the data dictionary. The following variables will be obtained on all included patients and collected from the electronic patient journal or the paper-CRF (7. • Previously admitted for: • Heart failure + ejection fraction and/or diastolic dysfunction Other/unknown

Variables obtained at randomization (the closest measured around time for randomization):
Values for SOFA-score at admission 21

Vital parameters
• Highest heart rate, respiratory rate, • Lowest values of mean arterial blood pressure • Highest values of arterial or venous lactate concentration or from a blood sample Antibiotics: Type, timing and dosage and administration form Volume of resuscitation fluids (crystalloids, colloids and blood products in ml) until randomization Other fluids including blood products, nutrition, fluid with medication

Variables obtained at 6-, 12-and 24 hours after randomization:
Hourly volumes of resuscitation fluid with specification of indication for each fluid bolus Other fluids including blood products, nutrition, fluid with medication Highest creatinine within 24 hours to evaluate KDIGO-criteria

Data quality and validity
We will train all clinically working nurses and physicians involved in the treatment of enrolled patients to optimize data quality and validity. This will further be optimized by having trained trial personnel entering all data from the paper-CRF and electronic medical journal according to a detailed data dictionary. Research Electronic Data Capture (REDCap) (see section 7.4) is designed such that data forms contain field-specific validation checks ensuring that mandatory fields are filled out and that continuous variables are within predefined ranges. The eCRF will be validated thoroughly before enrollment of the first patient.

Data storage and security
The database application we will use is REDCap. 63 REDCap is a professional database that provides a userfriendly interface. The REDCap data management system is secure, fully compliant with all regulatory guidelines, and includes a complete audit-trail for data entry validation. Through these mechanisms, as well as relevant training for all involved parties, patient confidentiality will be safeguarded. REDCap is available for free at participating sites.
The case report form and the consent form for each patient will initially be stored in a secure, locked place at the individual sites and will also be uploaded to REDCap. Every half-year the paper-CRFs will be transported to the Research Center for Emergency Medicine in Aarhus while a copy will remain at the sites.
Here they will be securely stored in locked cabinets, where only the principal investigator and the research nurse will have access. The files will be stored for 15 years after the end of the trial, where after they will be destroyed, or else they will be stored according to new regulations if implemented prior to enrollment of the first patient.

Data will be handled according to all relevant Danish laws including the General Data Protection
Regulation ("Databeskyttelsesforordningen") and the Data Protection Act ("Databeskyttelsesloven"). The project will be registered with the Central Denmark Region's internal list of research projects. De-identified data will be made publicly available 9 months after the publication of the outcome data according to the recent ICMJE recommendations. All trial-related documents will be public available at a trial-website REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 37 of 62 including those of the trial master file, the eCRF template, instructions, educational material etc. Patient related data will not be accessible through this website.

Data access
Each patient will receive a unique trial identification number. During the trial, the sponsor investigator and will have access to the entire database, while primary site investigators, research nurses and employed study personnel will have access to data from their own sites. All employes at enrolling sites with involvement in patient inclusion, enrollment and treatment, will be granted access to the REDCap database for their own site with a personal user name and a personal access code. The Good Clinical Practice unit, regulatory agencies, and other relevant entities will have direct access to patients' records and to all relevant trial data including the case report form as applicable.

Screening and enrollment
Patients will be screened and randomized followed by enrollment by the treating clinical team or the trained study personnel. Screening for patients will be performed "real-time" by the trained research team and the treating teams looking through lists of patients arriving or admitted to the EDs with clinical symptoms of sepsis and fulfilling inclusion criteria. As soon as fulfillment of inclusion criteria are proven, the "first legal guardian" will be approached to get informed consent. This trial guardian has received required information (written and oral) about the trial to be able to make an informed decision about the patient's study participation and enrollment. The oral consent will be followed by a written consent within a few hours when the critical situation has calmed down (see 9.3.2).
The clinical management of included patients, other than fluid strategy according to randomization, will be at the complete discretion of the treating clinical team in order to test the interventions in a real-life clinical scenario. As described in 3.3.4 "Concomitant interventions" clinicians will be encouraged to follow national standards by the Danish Society of Infectious Disease.

Variables
All sepsis patients at the participating sites will be entered into a screening log by daily going through all those not randomized, a specific reason for non-inclusion/exclusion will be documented. The screening log will for all screened patients include variables for identification (CPR-number), hospitalization date, inclusion (blood culture obtained yes/no, intravenous antibiotics administered yes/no, suspected infection in charts yes/no, ≥2 SOFA score (requiring results from laboratory values), exclusion (invasively ventilated yes/no, vasopressors given yes/no, severe bleeding yes/no, pregnancy yes/no, prior enrollment yes/no, not suspected to survive 24 hours yes/no) and for some patients the logistical reasons for not including the patients. This data will be collected either before informed consent by the "first trial guardian" or for patients screened and excluded without informed consent. Data will be used in the study to describe patient flow in the CONSORT diagram. Screening for patients will be performed "real-time" by the trained research team and the treating teams, but the screening log will be filled out once daily by the trained research team going through all patients admitted since the last screening log was performed. All randomized patients will be entered into the main REDCap database.
A detailed data dictionary that clearly defines all included variables in the eCRF (elaboration of 7.1.3-7.1.8) will be created prior to patient enrollment. The data dictionary will provide the name of the variable (including the code used in the database), a detailed definition of the variable, categories for categorical variables, and units and ranges for continuous variables.
The number of collected variables will be kept relatively small to limit resource use and data entry mistakes. Below is provided a brief overview of the included variables but details are reserved for the data dictionary. The following variables will be obtained on all included patients and collected from the electronic patient journal or the paper-CRF (7.1.3-7.1.8):

Clinical equipoise
Fluid resuscitation is a key intervention in sepsis and septic shock, but the optimal amount of fluid to be interventions, a large-scale trial assessing patient important outcomes is intended. Thus, it is the opinion of the steering committee that this study is of great interest and ethically justified.

General considerations
Research in sepsis is ethically challenging for three reasons: 1) patients have impaired cognition due to the sepsis event and can therefore not provide informed consent, 2) patients are in distress when admitted with sepsis, and 3) treatment must be administered quickly (Max. 1 hour as stated by SSC 25 ) limiting the possibility of obtaining informed consent from the patient or relatives prior to inclusion. 24 Despite these challenges, there is an ongoing need to conduct research in this specific patient population to improve their outcome, because no other patient groups, who may consent, can be used as a substitute.
Patients with sepsis are temporarily incompetent because of the severe infection with systemic involvement. Taken together, this is an 'acute drug trial' and the patients will be enrolled after proxy consent (from a physician, first trial guardian) according to national law.
International guidelines, such as the revised The current trial will adhere to the revised Declaration of Helsinki as well as all applicable laws and regulatory guidelines.

Regulations in relation to the current trial for patients physically or mentally incapable of giving consent
#1. The research can only be conducted in the given acute situation Given the high morbidity and mortality of sepsis (see section 1.1.1), clinical trials are highly needed to improve patient outcomes. Sepsis requires ≥2 points in SOFA-score meaning the patient has at least two present organ dysfunctions. There is no other clinical condition that reflects the broad sepsis group and any study aimed to improve outcomes for sepsis patients can therefore only be conducted in this population.

#2. The patient is incapable of providing informed consent
Sepsis is an unpredictable and sudden event; patients have some times been ill for a while, but are, due to rapid disease progression, admitted acutely sick in distress. Sepsis requires ≥2 points in SOFA-score meaning the patient has at least two present organ dysfunctions leaving the patient in a position and mental state, REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 41 of 62 where they will not be able to provide an informed consent after written and oral information 67,68 . It is therefore impossible to obtain consent prior to or during the acute event for these patients. If the patient is awake, fully conscious and able to understand oral and read written information about the study and therefore capable of providing an informed consent, the patient will not be included in the study.
#3. Consent cannot be obtained from a surrogate given the urgency of the intervention Sepsis is an acute event that needs administration of antibiotics and fluids within approximately 60 minutes. 25 Given these time frames, it would be impossible to inform the surrogate thoroughly in writing and verbally, allowing for a relative to arrive to support the surrogate as required, provide the required reflection time and obtain consent from a surrogate.

#4. The research specifically involves the patient's current condition
The interventions in this trial are specifically targeted for sepsis patients and if proven effective, will benefit the patient's current condition as well as the sepsis population.

Ethical review committee
The trial will be approved by the regional ethics committee (case number: X).

Trial-specific procedures
The "legal guardian" will be either a physician member of the treating team or a physician on call and available 24/7. The physician might be involved in the clinical care of the patient but will not be involved in trial procedures related to the specific patient. The legal guardian can be involved in trial procedures for other unrelated patients. Through ongoing training and information (see section 3.5.2), the "first trial guardian" will be aware of the trial including the background and significance, inclusion/exclusion criteria, and potential risks and benefits as well as ensuring that the patient can be enrolled in an acute medical trial.
This way, the "legal guardian" will be able to make an informed and prompt decision about patient enrollment. The specific details related to the "legal guardian" (i.e., who will be the designated "legal guardian") will be site-specific.
As soon as possible after enrolment (though due to the current COVID-19, see below, this is regarded to be within 10 days of enrollment) consent will be obtained from the participant's next of kin and a second trial guardian. The second trial guardian is also a doctor who is independent of the trial, who has knowledge REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 42 of 62 of the clinical condition and who is familiar with the trial protocol to such extent that he/she can judge for each patient, if it will be reasonable to enroll the patient in the trial.
When approached, the patient or a surrogate will be informed, verbally and in writing, about the background and significance of the study, inclusion criteria, potential risks and benefits, as well as a brief description of the study protocol. They will be informed that no additional interventions or procedures will be performed after the 24-hour enrollment period. The patient or the surrogate will then provide written informed consent utilizing the informed consent form approved by the ethical review committee. When consent is obtained from participants or a surrogate, information about potential de-identified data sharing will also be included. See Appendix 5 for versions of all consent forms. Consent will be obtained by a physician/other study personnel educated to do so and informed about the study, who has signed for receiving delegated tasks and the procedure requires using and following instructions as described in If SARS-CoV-2 is still a determining factor in the Danish ED at the time of trial enrollment, the following will apply: To minimize the risk of transmission of SARS-CoV-2 between trial staff and the surrogate/next of kin, we will inform and obtain informed consent from the next of kin by telephone. We will contact the next of kin by telephone and arrange a time and date for a telephone conversation with a member of the trial staff (e.g. doctor, research nurse, medical student etc.) who is certified in obtaining informed consent.
During this conversation, we will arrange how to send the written information to the next of kin (i.e. e-mail, post). We will encourage the next of kin to read the written information before the next conversation. We will also encourage the next of kin to bring a companion; in this case, the telephone conversation will be held with the telephone on speaker. After we have informed the next of kin about the trial, we will ask the next of kin to return the signed consent form by post.
Participants will be asked for informed consent as soon as possible after they regain the ability to provide consent. For participants, both oral and written information will be given preferably in person. The participant has the right to bring a companion.

Feasibility
Data from 2020 from two of the participating hospitals are provided in Table 1. As illustrated, we expect approximately 64 patients to be eligible for enrollment each week from the two included sites. Given the acuity of sepsis and the busy environment in the emergency departments, we expect inclusion to last 2-3 months, with an enrollment rate as low as 35% and only day-time-enrollment if necessary. The number of sepsis patients at Regional Hospital Viborg is unknown, but excepted to be equal to or larger than Regional Hospital Randers due to its larger total number of hospital admissions.

Enrollment
Enrollment at each site will be continuously monitored by the sponsor, principal site investigators, and the research nurse. Formal reports outlining the number of sepsis patients and the proportion of those enrolled at each site will be shared with the steering committee monthly.

PUBLICATION PLAN
Two manuscripts are planned from the current trial. Results will be published regardless of outcome; positive, negative and inconclusive results will be published. Prior to enrollment of the last patient, a methodology article will be published including a detailed description of the trial and the statistical analysis plan. The second and primary manuscript will include the main results including pre-defined primary and secondary outcomes. The manuscript will adhere to the CONSORT guidelines. 61,62 The principal investigator (sponsor investigator) will be the first and corresponding author. Additional authorship will follow REFACED Sepsis Protocol -version 2.2 -Dec 5th 2021 Page 46 of 62 authorship guidelines from the International Committee of Medical Journal Editors 72 and will include members of the steering committee and one investigator per sites that have recruited at least one participant. In addition, as a guideline, sites enrolling > 20 patients will be entitled one additional author and sites enrolling > 40 patients two additional authors in addition to the site investigator and members of the steering committee. This will only apply to the main manuscript of the study. The main results will be presented at an international conference. The trial results will be shared with participating sites and via press releases but not directly with the participating patients but linked to via the study web-site. Study findings will be published irrespective of the results. Trial results will be uploaded in EudraCT as soon as possible and at the latest within a year after trial completion. Data will be publicly available at clinicaltrialsregister.eu after this upload.

DATA SHARING
Six months after the publication of the last results, all de-identified individual patient data will be made available for data sharing. 73 Procedures, including re-coding of key variables, will be put in place to allow for complete de-identification of the data. Data will be completely anonymized according to Danish law.
All relevant trial-related documents, including the protocol, data dictionary, and the main statistical code, will be shared along with the data. There will be no predetermined end date for the data sharing. Data will be available for any research purpose to all interested parties who have approval from an independent review committee and who have a methodological sound proposal as determined by the steering committee of the current trial. Only the methodological qualities and not the purpose or objective of the proposal will be considered. Interested parties will be able to request the data by contacting the sponsor investigator.
Authorship of potentially additional publications emerging from the shared data will follow standard authorship guidelines from the International Committee of Medical Journal Editors 72 and might or might not include authors from the steering committee depending on the nature of their involvement. operational expenses. Additional funding will be applied for at various private and public foundations. The funding agencies or any pharmaceutical companies will have no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. None of the members of the steering committee have any financial disclosures or financial connections to any of the foundations.

TASKS AND RESPONSIBILITIES
Sponsor investigator, sponsor, and coordinating investigator: Overall responsibility for protocol development, funding, budget overview, data dictionary development, ethical approval, trial registration, daily management, trial oversight, contact to the pharmacy, contact to Good Clinical Practice monitoring unit and the data and safety monitoring board, assessment of overall recruitments and education, potential recruitment of additional sites, data analysis, and dissemination and presentation of results