Disturbed fluid responsiveness and lactate/pyruvate ratio as predictors for mortality of septic shock patients (original) (raw)
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Journal of Critical Care, 2013
Purpose: Feasibility study examining whether plethysmographic variability index (PVI) can predict fluid responsiveness in mechanically ventilated patients in the early phase of septic shock in the emergency department. Materials and Methods: Monocentric, prospective, observational study that included 31 mechanically ventilated and sedated patients with septic shock in whom volume expansion was planned. The patients were equipped with a pulse oximeter that automatically calculated and displayed PVI. The intervention consisted in infusing 8 mL/kg of hydroxylethyl starch over a 20-minute period. Before and after intervention, we recorded PVI and measured the aortic velocity-time integral (VTIao) using transthoracic echocardiography. Responders were defined as patients who increased their VTIao by 15% or higher after fluid infusion. Results: Sixteen patients were classified as responders, and 15 as nonresponders. Mean PVI values before intervention were significantly higher in responders vs nonresponders (30% ± 9% vs 8% ± 5%, P b .001). Plethysmographic variability index values before intervention were correlated with percent changes in VTIao induced by intervention (R 2 = 0.67; P b .001). A PVI threshold value of 19% discriminates responders from nonresponders with a sensitivity of 94% and a specificity of 87% (area under the curve, 0.97; P b .001). Conclusion: Our study suggests that PVI is a feasible and interesting method to predict fluid responsiveness in early phase septic shock patients in the emergency department.
Background: Fluid boluses are administered to septic shock patients with the purpose of increasing cardiac output as a means to restore tissue perfusion. Unfortunately, fluid therapy has a narrow therapeutic index, and therefore, several approaches to increase safety have been proposed. Fluid responsiveness (FR) assessment might predict which patients will effectively increase cardiac output after a fluid bolus (FR+), thus preventing potentially harmful fluid administration in non-fluid responsive (FR−) patients. However, there are scarce data on the impact of assessing FR on major outcomes. The recent ANDROMEDA-SHOCK trial included systematic per-protocol assessment of FR. We performed a post hoc analysis of the study dataset with the aim of exploring the relationship between FR status at baseline, attainment of specific targets, and clinically relevant outcomes.
Hong Kong Journal of Emergency Medicine
Objective To identify the risk factors that influence outcome for patients who are diagnosed with septic shock in the emergency department at presentation or within 24 hours after admission to intensive care unit. Methods A retrospective study of 57 adult patients with septic shock was conducted between March 1, 2006 and August 31, 2009. Results The patients were 23 males and 34 females with a median age of 67 years (20 to 92 years). Thirty-three (58%) of 57 patients died in hospital and 24 (42%) survived. Multivariate analysis identified low blood pH (OR <0.001; 95% CI <0.001-0.53) and low bicarbonate level (OR 0.81; 95% CI 0.70-0.95) at emergency department or intensive care unit admission as useful predictors of 3-day in-hospital mortality. Low blood pH (OR <0.001; 95% CI <0.001-0.05), low bicarbonate level (OR 0.75; 95% CIs 0.61-0.91), long duration of symptoms (OR 1.49; 95% CI 1.04-2.13), high MEDS score (OR 1.56; 95% CIs 1.06-2.30), and high SOFA score (OR 1.57; 95...
Fluid choices impact outcome in septic shock
Current Opinion in Critical Care, 2014
Purpose of review We discuss the goals of resuscitation, in both the early and the later phases, measures of organ perfusion, fluid responsiveness and the consequences of tissue edema. Recent findings The cost of over-aggressive fluid resuscitation is increased organ failure and mortality. In anticipation of the upcoming trials on early goal-directed therapy, we explore strategies to maximize effectiveness of resuscitation. Furthermore, we review recent data on the choice of fluid therapy. Summary Rapid diagnosis and early fluid resuscitation are crucial to patients with septic shock, initially with the primary goal to relieve the overt tissue hypoxia. Early fluid therapy is important with the caveat that patients must show an increase in their cardiac output. Beyond 6-12 h further positive fluid balance may not usefully improve tissue oxygenation and may be counterproductive.
Journal of Intensive Care
Background: Fluid infusion represents one of the cornerstones of resuscitation therapies in order to increase oxygen delivery during septic shock. Fluid overload as a consequence of excessive fluid administration seems to be linked to worse long-term outcome. However, its immediate effect on patient's clinical state is poorly described. The goal of this study was to assess the impact of FO on SOFA score kinetics as a surrogate marker of organ dysfunction from day 0 to day 5. Material and methods: Retrospective, multicenter, investigator-initiated study. All adult patients (> 18 years old) admitted from January 2012 to April 2017 in one of the three ICUs for septic shock, secondary to peritonitis or pulmonary infection and mechanically ventilated, were included. Univariate analysis was performed with Student's t and chi-square test, for continuous and categorical variables, respectively. A multivariate linear regression model evaluated the impact of FO on delta SOFA score from day 0 to day 5. Secondly, a multivariate mixed-model accounting for repeated measures analyzed the impact of FO on SOFA score kinetics. Results: One hundred twenty-nine patients met the inclusion criteria and were assigned into FO and no FO groups. FO occurred in 39% of the patients. The difference between SOFA score at day 0 and day 5 was more than twofold higher in the no FO group than in the FO group with a difference of 2.37 between the two groups (4.52 vs. 2.15; p = 0.001). Cumulative fluid intake at day 5 was higher in the FO group (2738 vs. 8715 ml, p < 0.001). In multivariate analysis, FO was associated with delta SOFA score: aRR = 0.15 (95% CI 0.03-0.63; p = 0.009). In mixed model, the regression coefficient for fluid overload status (r 2 = 1.16; p = 0.014) indicated that the slope for SOFA score kinetic was less pronounced for patients with FO than for patients without FO. Conclusions: FO patients had a more prolonged multi-organ failure according to SOFA score kinetics during septic shock from resuscitation phase to day 5.
Indian Journal of Critical Care Medicine
Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ∆CAVTI and ∆LVOTVTI pre-and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods: After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18 to 65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders. " Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ∆CAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre-and post-PLR ∆CAVTI and ∆LVOTVTI were 0.530 (p = 0.016), 0.440 (p = 0.052), and 0.044 (p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ∆CAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ∆CAVTI and ∆LVOTVTI is weak in septic shock patients and only modest in sepsis patients.
Shock, 2018
Microcirculation disturbances imply poor prognosis in septic shock. Microvascular reserve can be assessed by oximetry-derived Perfusion Index (PI) after vascular occlusion test (VOT). We investigated the relationship between PI during VOT, hyperlactatemia and mortality in septic shock and the role of adrenergic stimulus in these findings. The tests were performed in 106 patients within 24h after admission. PI was evaluated before/after 03-min flow occlusion. Peaks of PI (ΔPI peak) and time-to-peak were evaluated. PI was also evaluated in hyperemic phases derived by mechanosensitive (ΔPI 0-60) and metabolic mechanisms (ΔPI 60-120). We compared nonsurvivors with survivors and patients with lowest and highest ΔPI peaks, divided by 50thpercentile. ΔPI peak was evaluated in presence/absence of hyperlactatemia. A correlation test between ΔPI peaks and noradrenaline doses and an assessment after doses increasing were also performed. The ΔPI peak values were higher in nonsurvivors [79% (47%-169%) vs 48% (25%-85%); p=0.003] although peaks were reached slower in nonsurvivors. ΔPI 0-60 was similar between groups [-12% (-42%-28) vs 01 % (-16%-23%); p=0.211]. However, ΔPI 60-120 was higher in nonsurvivors [49% (29%-84%) vs 31%(12%-65%); p=0.035]. Additionally, the group with higher ΔPI peaks had higher mortality than those with lower peaks [HR 2.25 (95%-CI=1.32-4.14); p=0.003]. Mortality was extremely high in presence of hyperlactatemia. ΔPI peaks were positively correlated with noradrenaline doses and increased after increasing doses. In conclusion, high values of PI during VOT indicates higher mortality in septic shock and are associated to adrenergic stimulus. Additionally, the assessment of PIVOT appears to improve the predictive value of arterial lactate.
American Journal of Emergency Medicine, 2019
according to the data provided from the alive group and deceased group in Table 1, the mean value of mean blood pressure, systolic blood pressure, diastolic blood pressure, heart rate, pulse oximetry in the overall population should be 66, 79, 56, 116 and 88 respectively, rather than 72, 99, 60, 121 and 83 respectively, so we suggest the authors check their data again. Secondly, Jouffroy [1] et al. claimed they defined optimal fluid expansion as N20 ml/kg ideal body weight (IBW) according to 2012 version [2] of Surviving Sepsis Campaign (SSC) guidelines, however, we do not agree with this viewpoint. As a matter of fact, the 2012 version [2] of SSC guidelines recommended a minimum of 30 ml/kg of crystalloids should be administrated as an initial fluid challenge in patients with septic shock, while, the 2012 SSC guideline [2] recommended to deliver a bolus of 20 ml/kg of crystalloids over 5-10 min for pediatric septic shock patients not for the adults! The inadequate initial fluid resuscitation in adults may contribute mostly to the conclusion in the study [1] that fluid volume expansion indexed on IBW N20 ml/kg was associated with decreased mortality. Thus, we suggest the authors divide the 3 resuscitation groups according to the cutoffs of "b30 ml/kg IBW", "30 ml/kg-40 ml/kg" and "N40 ml/kg", which would be more scientific than the cutoffs of "b10 ml/kg IBW", "10 ml/kg-20 ml/kg" and "N20 ml/kg". Thirdly, fluid resuscitation is essential and necessary for septic shock patients, but overzealous fluid administration can do harm too. One size does not fit all for fluid resuscitation in pre-hospital patients with septic shock. For patients with acute lung injury [3], acute respiratory distress syndrome or congestive heart failure second to septic shock, conservative fluid strategy should be applied, as sometimes positive fluid balance is associated with an increased risk of mortality in septic shock [4]. Multiple methods can be combined to assess the volume status and fluid responsiveness of the septic shock patients, including physical examination (mottled, clammy or dry skin, oliguria, altered mental state), laboratory parameters (blood lactate, blood urea nitrogen/creatinine ratio, urinary sodium), bedside ultrasound, chest X-ray, central venous pressure (CVP), passive leg-raising test, fluid challenge and etc. [5], though some are unavailable in the pre-hospital environment, the importance of assessing the volume status and fluid responsiveness should not be forgotten or ignored. Fourthly, as the 2012 SSC guideline [2] stressed, not only fluid resuscitation was vital for reducing the mortality of septic shock patients, but also obtaining blood cultures, administration of antibiotics, measuring lactate levels, applying vasopressors if needed and achieving the resuscitation goals (CVP 8-12 mm Hg, mean arterial pressure (MAP) ≧ 65 mmHg, urine output ≧ 0.5 ml/kg/h, Superior vena cava oxygenation saturation (ScvO 2) ≧ 70% or mixed venous oxygen saturation (SvO 2) ≧ 65%) correlated closely with the mortality of the patients, and these vital elements had been integrated as 3 h/6 h bundles and got worldwide spreaded through the dissemination of SSC guidelines. Nevertheless, in the multivariate analysis of factors associated with mortality at Day 28 of septic shock patients in the commented paper [1], only age, immunosuppression, pre-hospital duration and volume of fluid were adjusted as covariables, disease severity and the aforementioned vital elements of bundles had not been included into the analysis, thus, we are afraid that the results may not be quite accurate. At last, we appreciate Jouffroy et al. for their innovative and meaningful study, but the interpretation of their work should be cautious and further rigorous studies are warranted.
Septic shock in ICU: update in hemodynamic monitoring
The objective of this review is to summarize the present status of basic and functional hemodynamic monitoring, emphasizing in the latter the new indices called dynamic indices of fl uid response, which have been progressively incorporated into clinical practice. HEMODYNAMIC PARAMETERS FOR GUIDING FLUID THERAPY One of the cornerstones of treatment of the patient in shock is the use of intravenous fl uids. 4 However, its use and dosage is still carried out empirically. Fundamen-tally, the only reason for providing fl uids to a critically ill patient is to increase the systolic volume (SV) and, in this manner, the cardiac output (CO). 5 However, taking into consideration that only 50% of critical patients re-spond to fl uid expansion, due to myocardial dysfunction and altered adrenergic sensibility, 6 the hemodynamic parameters for deciding on administration of these fl u-ids should identify those patients (responsive patients) who would benefi t and at the same time avoid useless and...