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Hammond DA, Ficek OA, Painter JT, McCain K, Cullen J, Brotherton AL, Kakkera K, Chopra D, Meena N. Prospective Open-label Trial of Early Concomitant Vasopressin and Norepinephrine Therapy versus Initial Norepinephrine Monotherapy in Septic Shock. Pharmacotherapy 2018; 38:531-538. [PMID: 29600824 DOI: 10.1002/phar.2105] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Delays in achieving target mean arterial pressure (MAP) are associated with increased morbidity and mortality in patients with septic shock. This trial was conducted to test the hypothesis that early concomitant treatment with vasopressin and norepinephrine reduces the time to achieve and maintain target MAP compared with initial norepinephrine monotherapy. METHODS A single-center prospective open-label trial was conducted in patients with septic shock between November 2015 and June 2016 at a medical intensive care unit in an academic medical center. Initial norepinephrine monotherapy was initiated between November 2015 and February 2016. Between March and June 2016, vasopressin was initiated within 4 hours of norepinephrine. The primary outcome was time to achieving and maintaining MAP of 65 mm Hg for at least 4 hours that was compared between groups using the Student t test and examined using the Kaplan-Meier curve (Clinical Trials registration: NCT02454348). RESULTS Eighty-two patients were included (41 in each group). Patients treated with early concomitant vasopressin and norepinephrine more frequently had a positive culture (59% vs 37%, p=0.05) and grew nonlactose fermenting gram-negative bacilli (34% vs 10%, p=0.01) compared with patients treated with norepinephrine monotherapy, respectively. The median time to achieve and maintain MAP occurred faster in the early concomitant vasopressin and norepinephrine group, at 5.7 hours (interquartile range [IQR] 1.7-10.3 hrs), compared with 7.6 hours (IQR 3.6-16.7 hrs, p=0.058) in the norepinephrine group. Durations of therapy for norepinephrine or vasopressin, amount of norepinephrine received in the first 24 hours, norepinephrine dosage when MAP was achieved and maintained, maximum norepinephrine dosage, and mortality were similar between groups. CONCLUSION Patients treated with early concomitant vasopressin and norepinephrine achieved and maintained MAP of 65 mm Hg faster than those receiving initial norepinephrine monotherapy, suggesting that overcoming vasopressin deficiency sooner may reduce the time patients spend in the early phase of septic shock.
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Affiliation(s)
| | - Oktawia A Ficek
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas
| | - Jacob T Painter
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas
| | - Kelsey McCain
- University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas
| | | | | | - Krishna Kakkera
- University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas
| | - Divyan Chopra
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, Arkansas
| | - Nikhil Meena
- University of Arkansas for Medical Sciences Medical Center, Little Rock, Arkansas.,University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas
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Cambiaghi A, Díaz R, Martinez JB, Odena A, Brunelli L, Caironi P, Masson S, Baselli G, Ristagno G, Gattinoni L, de Oliveira E, Pastorelli R, Ferrario M. An Innovative Approach for The Integration of Proteomics and Metabolomics Data In Severe Septic Shock Patients Stratified for Mortality. Sci Rep 2018; 8:6681. [PMID: 29703925 PMCID: PMC5923340 DOI: 10.1038/s41598-018-25035-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 04/09/2018] [Indexed: 12/29/2022] Open
Abstract
In this work, we examined plasma metabolome, proteome and clinical features in patients with severe septic shock enrolled in the multicenter ALBIOS study. The objective was to identify changes in the levels of metabolites involved in septic shock progression and to integrate this information with the variation occurring in proteins and clinical data. Mass spectrometry-based targeted metabolomics and untargeted proteomics allowed us to quantify absolute metabolites concentration and relative proteins abundance. We computed the ratio D7/D1 to take into account their variation from day 1 (D1) to day 7 (D7) after shock diagnosis. Patients were divided into two groups according to 28-day mortality. Three different elastic net logistic regression models were built: one on metabolites only, one on metabolites and proteins and one to integrate metabolomics and proteomics data with clinical parameters. Linear discriminant analysis and Partial least squares Discriminant Analysis were also implemented. All the obtained models correctly classified the observations in the testing set. By looking at the variable importance (VIP) and the selected features, the integration of metabolomics with proteomics data showed the importance of circulating lipids and coagulation cascade in septic shock progression, thus capturing a further layer of biological information complementary to metabolomics information.
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Affiliation(s)
| | - Ramón Díaz
- Proteomics Platform - Parc Científic de Barcelona, Barcelona, Spain
| | | | - Antonia Odena
- Proteomics Platform - Parc Científic de Barcelona, Barcelona, Spain
| | - Laura Brunelli
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Pietro Caironi
- Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria S. Luigi Gonzaga, Orbassano, Italy.,Dipartimento di Oncologia, Università degli Studi di Torino, Turin, Italy
| | - Serge Masson
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | | | | | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
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Abstract
Sepsis is a leading cause of maternal morbidity and mortality in developed and developing nations. Obstetric practitioners should be familiar with guidelines that promote the safe and expeditious recovery of those affected. This article will provide the reader with rational steps to aid in the recovery of such a patient.
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Affiliation(s)
- Arthur Jason Vaught
- John Hopkins School of Medicine, 600 N. Wolfe St, Phipps 228, Baltimore, MD 21287.
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Abstract
BACKGROUND Sepsis accounts for 10% of intensive care unit admissions and significant healthcare costs. Although the mortality rate from sepsis has been decreasing with better critical care, early identification of septic patients, and prompt interventions, the mortality rate remains 20%-30%. METHOD Review of the English-language literature. RESULTS Norepinephrine is the first-line vasopressor in shock and is associated with a lower mortality rate as well as fewer adverse effects. Dopamine has similar actions but is associated with significantly more tachydysrhythmias and should be reserved for patients with bradycardia. Epinephrine and vasopressin are appropriate second-line vasopressors and may enable use of lower doses of norepinephrine while improving hemodynamics. Inotropes may be added in patients with cardiac dysfunction. CONCLUSION Appropriate treatment of sepsis includes prompt identification, early antimicrobial drug therapy, appropriate fluid resuscitation, and initiation of vasopressors in the presence of continued septic shock. Further research needs to be done to better understand the ideal timing of the addition of a second agent and the optimal combinations of vasopressors for individual patients.
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Affiliation(s)
- Kristin P Colling
- Department of Surgery, Division of Critical Care and Acute Care Surgery, University of Minnesota , Minneapolis Minnesota
| | - Kaysie L Banton
- Department of Surgery, Division of Critical Care and Acute Care Surgery, University of Minnesota , Minneapolis Minnesota
| | - Greg J Beilman
- Department of Surgery, Division of Critical Care and Acute Care Surgery, University of Minnesota , Minneapolis Minnesota
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Abstract
Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.
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Affiliation(s)
- Bracken A Armstrong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA.
| | - Richard D Betzold
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
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Macdonald SPJ, Taylor DM, Keijzers G, Arendts G, Fatovich DM, Kinnear FB, Brown SGA, Bellomo R, Burrows S, Fraser JF, Litton E, Ascencio-Lane JC, Anstey M, McCutcheon D, Smart L, Vlad I, Winearls J, Wibrow B. REstricted Fluid REsuscitation in Sepsis-associated Hypotension (REFRESH): study protocol for a pilot randomised controlled trial. Trials 2017; 18:399. [PMID: 28851407 PMCID: PMC5576288 DOI: 10.1186/s13063-017-2137-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 08/03/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Guidelines recommend an initial intravenous (IV) fluid bolus of 30 ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this. Accumulating observational data suggest harm associated with the injudicious use of fluids in sepsis. There is currently equipoise regarding liberal or restricted fluid-volume resuscitation as first-line treatment for sepsis-related hypotension. A randomised trial comparing these two approaches is, therefore, justified. METHODS/DESIGN The REstricted Fluid REsuscitation in Sepsis-associated Hypotension trial (REFRESH) is a multicentre, open-label, randomised, phase II clinical feasibility trial. Participants will be patients presenting to the emergency departments of Australian metropolitan hospitals with suspected sepsis and a systolic blood pressure of < 100 mmHg, persisting after a 1000-ml fluid bolus with isotonic crystalloid. Participants will be randomised to either a second 1000-ml fluid bolus (standard care) or maintenance rate fluid only, with the early commencement of a vasopressor infusion to maintain a mean arterial pressure of > 65 mmHg, if required (restricted fluid). All will receive further protocolised fluid boluses (500 ml or 250 ml, respectively), if required during the 6-h study period. The primary outcome measure is total volume administered in the first 6 h. Secondary outcomes include fluid volume at 24 h, organ support 'free days' to day 28, 90-day mortality, and a range of feasibility and process-of-care measures. Participants will also undergo serial measurement, over the first 24 h, of biomarkers of inflammation, endothelial cell activation and glycocalyx degradation for comparison between the groups. DISCUSSION This is the first randomised trial examining fluid volume for initial resuscitation in septic shock in an industrialised country. A pragmatic, open-label design will establish the feasibility of undertaking a large, international, multicentre trial with sufficient power to assess clinical outcomes. The embedded biomarker study aims to provide mechanistic plausibility for a larger trial by defining the effects of fluid volume on markers of systemic inflammation and the vascular endothelium. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry, ID: ACTRN12616000006448. Registered on 12 January 2016.
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Affiliation(s)
- Stephen P. J. Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Royal Perth Hospital, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, VIC Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, QLD Australia
- School of Medicine, Bond University, Gold Coast, QLD Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Fiona Stanley Hospital, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Daniel M. Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Royal Perth Hospital, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Frances B. Kinnear
- Emergency and Children’s Services, The Prince Charles Hospital, Brisbane, QLD Australia
| | - Simon G. A. Brown
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Royal Hobart Hospital, Hobart, TAS Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC Australia
- School of Medicine, University of Melbourne, Melbourne, VIC Australia
| | - Sally Burrows
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA Australia
| | - John F. Fraser
- School of Medicine, Bond University, Gold Coast, QLD Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD Australia
- School of Medicine, University of Queensland, Brisbane, QLD Australia
| | - Edward Litton
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA Australia
| | | | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, WA Australia
| | - David McCutcheon
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
- Emergency Department, Armadale Health Service, Perth, WA Australia
| | - Lisa Smart
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Ioana Vlad
- Emergency Department, Sir Charles Gairdner Hospital, Perth, WA Australia
| | - James Winearls
- School of Medical Sciences, Griffith University, Gold Coast, QLD Australia
- School of Medicine, University of Queensland, Brisbane, QLD Australia
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD Australia
| | - Bradley Wibrow
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, WA Australia
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Hammond DA, Cullen J, Painter JT, McCain K, Clem OA, Brotherton AL, Chopra D, Meena N. Efficacy and Safety of the Early Addition of Vasopressin to Norepinephrine in Septic Shock. J Intensive Care Med 2017; 34:910-916. [PMID: 28820036 DOI: 10.1177/0885066617725255] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delays in achievement of target mean arterial pressure (MAP) have been associated with increased mortality in patients with septic shock. Vasopressin may be added to norepinephrine to raise MAP or decrease norepinephrine dosage. The purpose of this study was to determine whether early initiation of vasopressin to norepinephrine resulted in a reduced time to target MAP compared to norepinephrine monotherapy. METHODS This retrospective cohort study compared early addition of vasopressin within 4 hours of septic shock onset to norepinephrine versus initial norepinephrine monotherapy in medically, critically ill patients with septic shock admitted from May 2014 to October 2015. Time to goal MAP was compared using Student t test and examined with Kaplan-Meier curves. Changes in Sequential Organ Failure Assessment (SOFA) scores were evaluated with Wilcoxon rank sum test. RESULTS Each group contained 48 patients. Mean arterial pressure (61.5 vs 58.6 mm Hg) and intravenous fluid volume received at vasopressor initiation (14.3 vs 25.2 hours, P = .014) were similar. Patients started on early vasopressin achieved and maintained goal MAP sooner (6.2 vs 9.9 hours, P = .023), experienced greater reductions in SOFA scores at 72 hours (-4 vs -1, P = .012), and had shorter hospital durations (343 vs 604 hours, P = .014). Not initiating early vasopressin trended toward an association with increased time to goal MAP (P = .067). CONCLUSION Early initiation of vasopressin in patients with septic shock may achieve and maintain goal MAP sooner and resolve organ dysfunction at 72 hours more effectively than later or no initiation.
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Affiliation(s)
- Drayton A Hammond
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA.,University of Arkansas for Medical Sciences Medical Center, Little Rock, AR, USA
| | - Julia Cullen
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Jacob T Painter
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Kelsey McCain
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Oktawia A Clem
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | | | - Divyan Chopra
- University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Nikhil Meena
- University of Arkansas for Medical Sciences Medical Center, Little Rock, AR, USA.,University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, USA
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The Absence of Fever Is Associated With Higher Mortality and Decreased Antibiotic and IV Fluid Administration in Emergency Department Patients With Suspected Septic Shock. Crit Care Med 2017; 45:e575-e582. [PMID: 28333759 DOI: 10.1097/ccm.0000000000002311] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study evaluates whether emergency department septic shock patients without a fever (reported or measured) receive less IV fluids, have decreased antibiotic administration, and suffer increased in-hospital mortality. DESIGN This was a secondary analysis of a prospective, observational study of patients with shock. SETTING The study was conducted in an urban, academic emergency department. PATIENTS The original study enrolled consecutive adult (aged 18 yr or older) emergency department patients from November 11, 2012, to September 23, 2013, who met one of the following shock criteria: 1) systolic blood pressure less than 90 mm Hg after at least 1L IV fluids, 2) new vasopressor requirement, or 3) systolic blood pressure less than 90 mm Hg and IV fluids held for concern of fluid overload. The current study is limited to patients with septic shock. Patients were grouped as febrile if they had a subjective fever or a measured temperature >100.4°F documented in the emergency department; afebrile patients lacked both. MEASUREMENTS AND MAIN RESULTS Among 378 patients with septic shock, 207 of 378 (55%; 50-60%) were febrile by history or measurement. Afebrile patients had lower rates of antibiotic administration in the emergency department (81% vs 94%; p < 0.01), lower mean volumes of IV fluids (2,607 vs 3,013 mL; p < 0.01), and higher in-hospital mortality rates (33% vs 11%; p < 0.01). After adjusting for bicarbonate less than 20 mEq/L, lactate concentration, respiratory rate greater than or equal to 24 breaths/min, emergency department antibiotics, and emergency department IV fluids volume, being afebrile remained a significant predictor of in-hospital mortality (odds ratio, 4.3; 95% CI, 2.2-8.2; area under the curve = 0.83). CONCLUSIONS In emergency department patients with septic shock, afebrile patients received lower rates of emergency department antibiotic administration, lower mean IV fluids volume, and suffered higher in-hospital mortality.
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Morgan RW, Fitzgerald JC, Weiss SL, Nadkarni VM, Sutton RM, Berg RA. Sepsis-associated in-hospital cardiac arrest: Epidemiology, pathophysiology, and potential therapies. J Crit Care 2017; 40:128-135. [DOI: 10.1016/j.jcrc.2017.03.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/19/2017] [Accepted: 03/29/2017] [Indexed: 12/20/2022]
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Prasad V, Lynch JC, Pasakarnis CL, Thorsen JE, Filbin MR, Reisner AT, Heldt T. Classification models to predict vasopressor administration for septic shock in the emergency department. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:2650-2653. [PMID: 29060444 DOI: 10.1109/embc.2017.8037402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Optimal management of sepsis and septic shock in the emergency department (ED) involves timely decisions related to intravenous fluid resuscitation and initiation of vasoactive medication support. A decision-support tool trained on electronic health record data, can help improve this complex decision. We retrospectively extracted vital signs, lab measurements, and fluid administration information from 807 patient visits over a two-year period to a major ED. Patients selected for inclusion had a high likelihood of septic shock. We trained binary classifiers to discriminate between patients administered vasopressors in the ED and those not administered vasopressors at any point. Using features extracted from the entire ED visit record yielded a maximum area under the receiver-operating characteristic curve (AUC) of 0.798 (95% CI 0.725-0.849) in a hold-out test set. In a separate task, we used individual vital signs observations with lab results to predict vasopressor administration, yielding a maximum AUC of 0.762 (95% CI 0.748-0.777). Lastly, we trained separate classifiers for different subgroups of vital signs observations. These subgroups were defined by the cumulative number of fluid boluses delivered at the time of the observation. The maximum AUC achieved by any of these classifiers was 0.815 (95% CI 0.784-0.853), occurring for vital signs observations made after 2 bolus administrations. Classifiers in all tasks significantly outperformed existing clinical tools for assessing prognosis in ED sepsis. This work shows how relatively few features can provide instantaneous and accurate prediction of need for an intervention that is typically a complex clinical decision.
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Xu JY, Chen QH, Liu SQ, Pan C, Xu XP, Han JB, Xie JF, Huang YZ, Guo FM, Yang Y, Qiu HB. The Effect of Early Goal-Directed Therapy on Outcome in Adult Severe Sepsis and Septic Shock Patients: A Meta-Analysis of Randomized Clinical Trials. Anesth Analg 2017; 123:371-81. [PMID: 27049857 PMCID: PMC4956677 DOI: 10.1213/ane.0000000000001278] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Supplemental Digital Content is available in the text. Published ahead of print April 5, 2016 BACKGROUND: Whether early goal-directed therapy (EGDT) improves outcome in severe sepsis and septic shock remains unclear. We performed a meta-analysis of existing clinical trials to examine whether EGDT improved outcome in the resuscitation of adult sepsis patients compared with control care. METHODS: We searched for eligible studies using MEDLINE, Elsevier, Cochrane Central Register of Controlled Trials, and Web of Science databases. Studies were eligible if they compared the effects of EGDT versus control care on mortality in adult patients with severe sepsis and septic shock. Two reviewers extracted data independently. Data including mortality, sample size of the patients with severe sepsis and septic shock, and resuscitation end points were extracted. Data were analyzed using methods recommended by the Cochrane Collaboration Review Manager 4.2 software. Random errors were evaluated by trial sequential analysis (TSA). RESULTS: Nine studies compared EGDT with control care, and 5202 severe sepsis and septic shock patients were included. A nonsignificant trend toward reduction in the longest all-cause mortality was observed in the EGDT group compared with control care (relative risk, 0.89; 99% confidence interval, 0.74–1.07; P = 0.10). However, EGDT significantly reduced intensive care unit mortality in severe sepsis and septic shock patients (relative risk, 0.72; 99% confidence interval, 0.57–0.90; P = 0.0002). TSA indicated lack of firm evidence for a beneficial effect. CONCLUSIONS: In this meta-analysis, a nonsignificant trend toward reduction in the longest all-cause mortality in patients resuscitated with EGDT was noted. However, EGDT significantly reduced intensive care unit mortality in severe sepsis and septic shock patients. TSA indicated a lack of firm evidence for the results. More powered, randomized controlled trials are needed to determine the effects.
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Affiliation(s)
- Jing-Yuan Xu
- From the Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, Nanjing, P.R. China
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Impact of duration of hypotension prior to norepinephrine initiation in medical intensive care unit patients with septic shock: A prospective observational study. J Crit Care 2017; 40:178-183. [PMID: 28412642 DOI: 10.1016/j.jcrc.2017.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/13/2017] [Accepted: 04/07/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE To determine the impact of duration of hypotension prior to norepinephrine initiation on outcomes in MICU patients with septic shock. We hypothesized increased duration of hypotension prior to norepinephrine initiation would be associated with an increased risk for ICU mortality. MATERIALS AND METHODS We conducted a prospective-observational study in the MICU of a single-center tertiary academic medical center. We enrolled 160 adults ≥18years old with septic shock. Descriptive statistics were computed for demographic and outcome variables. Primary logistic regression analysis was adjusted for severity of illness. RESULTS The mean age of our patients was 59years (±17); 42% were female; the mean APACHE II score was 24.1 (±8.0), and the mean SOFA score was 9.6 (±4.0). Median duration of hypotension prior to norepinephrine initiation was 3.6h (IQR 1.6-9.9). Duration of hypotension prior to norepinephrine did not increase the risk for ICU mortality (OR 1.03 per hour after hypotension, 95% CI: 0.98-1.09, p=0.20). CONCLUSION Duration of hypotension less than one hour and greater than one hour prior to norepinephrine initiation in MICU patients with septic shock is not associated with an increased risk for ICU mortality.
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Early fluid resuscitation and volume therapy in venoarterial extracorporeal membrane oxygenation. J Crit Care 2017; 37:130-135. [DOI: 10.1016/j.jcrc.2016.09.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/26/2016] [Accepted: 09/16/2016] [Indexed: 02/06/2023]
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Belletti A, Benedetto U, Biondi-Zoccai G, Leggieri C, Silvani P, Angelini GD, Zangrillo A, Landoni G. The effect of vasoactive drugs on mortality in patients with severe sepsis and septic shock. A network meta-analysis of randomized trials. J Crit Care 2017; 37:91-98. [PMID: 27660923 DOI: 10.1016/j.jcrc.2016.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/04/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Umberto Benedetto
- University of Bristol, School of Clinical Sciences, Bristol Heart Institute, Bristol, United Kingdom.
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy.
| | - Carlo Leggieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Paolo Silvani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gianni D Angelini
- University of Bristol, School of Clinical Sciences, Bristol Heart Institute, Bristol, United Kingdom.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Sartelli M, Chichom-Mefire A, Labricciosa FM, Hardcastle T, Abu-Zidan FM, Adesunkanmi AK, Ansaloni L, Bala M, Balogh ZJ, Beltrán MA, Ben-Ishay O, Biffl WL, Birindelli A, Cainzos MA, Catalini G, Ceresoli M, Che Jusoh A, Chiara O, Coccolini F, Coimbra R, Cortese F, Demetrashvili Z, Di Saverio S, Diaz JJ, Egiev VN, Ferrada P, Fraga GP, Ghnnam WM, Lee JG, Gomes CA, Hecker A, Herzog T, Kim JI, Inaba K, Isik A, Karamarkovic A, Kashuk J, Khokha V, Kirkpatrick AW, Kluger Y, Koike K, Kong VY, Leppaniemi A, Machain GM, Maier RV, Marwah S, McFarlane ME, Montori G, Moore EE, Negoi I, Olaoye I, Omari AH, Ordonez CA, Pereira BM, Pereira Júnior GA, Pupelis G, Reis T, Sakakhushev B, Sato N, Segovia Lohse HA, Shelat VG, Søreide K, Uhl W, Ulrych J, Van Goor H, Velmahos GC, Yuan KC, Wani I, Weber DG, Zachariah SK, Catena F. The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2017; 12:29. [PMID: 28702076 PMCID: PMC5504840 DOI: 10.1186/s13017-017-0141-6] [Citation(s) in RCA: 223] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 06/20/2017] [Indexed: 02/06/2023] Open
Abstract
Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.
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Affiliation(s)
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Francesco M. Labricciosa
- 0000 0001 1017 3210grid.7010.6Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Timothy Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Fikri M. Abu-Zidan
- 0000 0001 2193 6666grid.43519.3aDepartment of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Abdulrashid K. Adesunkanmi
- 0000 0001 2183 9444grid.10824.3fDepartment of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Luca Ansaloni
- 0000 0004 1757 8431grid.460094.fGeneral Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Miklosh Bala
- 0000 0001 2221 2926grid.17788.31Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J. Balogh
- 0000 0004 0577 6676grid.414724.0Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales Australia
| | - Marcelo A. Beltrán
- Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | - Offir Ben-Ishay
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter L. Biffl
- 0000 0001 1482 1895grid.162346.4Acute Care Surgery at The Queen’s Medical Center, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, USA
| | - Arianna Birindelli
- 0000 0004 1759 7093grid.416290.8Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Miguel A. Cainzos
- 0000 0000 8816 6945grid.411048.8Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | | | - Marco Ceresoli
- 0000 0004 1757 8431grid.460094.fGeneral Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Asri Che Jusoh
- Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | - Osvaldo Chiara
- grid.416200.1Emergency Department, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Federico Coccolini
- 0000 0004 1757 8431grid.460094.fGeneral Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Raul Coimbra
- 0000 0001 2107 4242grid.266100.3Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | | | - Zaza Demetrashvili
- 0000 0004 0428 8304grid.412274.6Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, T’bilisi, Georgia
| | - Salomone Di Saverio
- 0000 0004 1759 7093grid.416290.8Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Jose J. Diaz
- 0000 0001 2175 4264grid.411024.2Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | - Valery N. Egiev
- 0000 0000 9559 0613grid.78028.35Department of Surgery, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Paula Ferrada
- 0000 0004 0458 8737grid.224260.0Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Gustavo P. Fraga
- 0000 0001 0723 2494grid.411087.bDivision of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Wagih M. Ghnnam
- 0000000103426662grid.10251.37Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Jae Gil Lee
- 0000 0004 0470 5454grid.15444.30Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Carlos A. Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Andreas Hecker
- 0000 0000 8584 9230grid.411067.5Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Torsten Herzog
- 0000 0004 0490 981Xgrid.5570.7Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jae Il Kim
- 0000 0004 0470 5112grid.411612.1Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Kenji Inaba
- 0000 0001 2156 6853grid.42505.36Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- 0000 0001 1498 7262grid.412176.7Department of General Surgery, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | - Aleksandar Karamarkovic
- 0000 0001 2166 9385grid.7149.bClinic for Emergency Surgery, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Jeffry Kashuk
- 0000 0004 1937 0546grid.12136.37Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Andrew W. Kirkpatrick
- 0000 0004 0469 2139grid.414959.4Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, Alberta Canada
| | - Yoram Kluger
- 0000 0000 9950 8111grid.413731.3Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Kaoru Koike
- 0000 0004 0372 2033grid.258799.8Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Victor Y. Kong
- 0000 0004 0576 7753grid.414386.cDepartment of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Gustavo M. Machain
- 0000 0001 2289 5077grid.412213.7II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - Ronald V. Maier
- 0000000122986657grid.34477.33Department of Surgery, University of Washington, Seattle, WA USA
| | - Sanjay Marwah
- 0000 0004 1771 1642grid.412572.7Department of Surgery, Pt BDS Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Michael E. McFarlane
- 0000 0004 0500 5353grid.412963.bDepartment of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Giulia Montori
- 0000 0004 1757 8431grid.460094.fGeneral Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Iyiade Olaoye
- 0000 0000 8878 5287grid.412975.cDepartment of Surgery, University of Ilorin, Teaching Hospital, Ilorin, Nigeria
| | - Abdelkarim H. Omari
- 0000 0004 0411 3985grid.460946.9Department of Surgery, King Abdullah University Hospital, Irbid, Jordan
| | - Carlos A. Ordonez
- 0000 0001 2295 7397grid.8271.cDepartment of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Bruno M. Pereira
- 0000 0001 0723 2494grid.411087.bDivision of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | | | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Tarcisio Reis
- Emergency Post-operative Department, Otavio de Freitas Hospital and Hosvaldo Cruz Hospital, Recife, Brazil
| | - Boris Sakakhushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Norio Sato
- 0000 0001 1011 3808grid.255464.4Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Helmut A. Segovia Lohse
- 0000 0001 2289 5077grid.412213.7II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - Vishal G. Shelat
- grid.240988.fDepartment of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Kjetil Søreide
- 0000 0004 0627 2891grid.412835.9Department of Gastrointestinal Surgery, Stavanger University Hospital, Stravenger, Norway
- 0000 0004 1936 7443grid.7914.bDepartment of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Waldemar Uhl
- 0000 0004 0490 981Xgrid.5570.7Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jan Ulrych
- 0000 0000 9100 9940grid.411798.2First Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Harry Van Goor
- 0000 0004 0444 9382grid.10417.33Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - George C. Velmahos
- 0000 0004 0386 9924grid.32224.35Trauma, Emergency Surgery, and Surgical Critical Care Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | - Kuo-Ching Yuan
- 0000 0004 1756 1461grid.454210.6Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Imtiaz Wani
- 0000 0001 0174 2901grid.414739.cDepartment of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Dieter G. Weber
- 0000 0004 0453 3875grid.416195.eDepartment of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Sanoop K. Zachariah
- 0000 0004 1766 361Xgrid.464618.9Department of Surgery, Mosc Medical College, Kolenchery, Cochin, India
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
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Schwartz MB, Ferreira JA, Aaronson PM. The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. Am J Emerg Med 2016; 34:2419-2422. [DOI: 10.1016/j.ajem.2016.09.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/29/2016] [Accepted: 09/18/2016] [Indexed: 10/21/2022] Open
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Glassford NJ, Bellomo R. The Complexities of Intravenous Fluid Research: Questions of Scale, Volume, and Accumulation. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.00934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Vincent JL, Leone M. Optimum treatment of vasopressor-dependent distributive shock. Expert Rev Anti Infect Ther 2016; 15:5-10. [DOI: 10.1080/14787210.2017.1252673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Long B, Koyfman A, Modisett KL, Woods CJ. Practical Considerations in Sepsis Resuscitation. J Emerg Med 2016; 52:472-483. [PMID: 27823892 DOI: 10.1016/j.jemermed.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment. OBJECTIVE This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment. DISCUSSION Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario. CONCLUSIONS The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian J Woods
- Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
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Treatment of Pediatric Septic Shock With the Surviving Sepsis Campaign Guidelines and PICU Patient Outcomes. Pediatr Crit Care Med 2016; 17:e451-e458. [PMID: 27500722 DOI: 10.1097/pcc.0000000000000906] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Surviving Sepsis Campaign recommends rapid recognition and treatment of severe sepsis and septic shock. Few reports have evaluated the impact of these recommendations in pediatrics. We sought to determine if outcomes in patients who received initial care compliant with the Surviving Sepsis Campaign time goals differed from those treated more slowly. DESIGN Single center retrospective cohort study. SETTING Emergency department and PICU at an academic children's hospital. PATIENTS Three hundred twenty-one patients treated for septic shock in the emergency department and admitted directly to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The exposure was receipt of emergency department care compliant with the Surviving Sepsis Campaign recommendations (delivery of IV fluids, IV antibiotics, and vasoactive infusions within 1 hr of shock recognition). The primary outcome was development of new or progressive multiple organ dysfunction syndrome. Secondary outcomes included mortality, need for mechanical ventilation or vasoactive medications, and hospital and PICU length of stay. Of the 321 children studied, 117 received Surviving Sepsis Campaign compliant care in the emergency department and 204 did not. New or progressive multiple organ dysfunction syndrome developed in nine of the patients (7.7%) who received Surviving Sepsis Campaign compliant care and 25 (12.3%) who did not (p = 0.26). There were 17 deaths; overall mortality rate was 5%. There were no significant differences between groups in any of the secondary outcomes. Although only 36% of patients met the Surviving Sepsis Campaign guideline recommendation of bundled care within 1 hour of shock recognition, 75% of patients received the recommended interventions in less than 3 hours. CONCLUSIONS Treatment for pediatric septic shock in compliance with the Surviving Sepsis Campaign recommendations was not associated with better outcomes compared with children whose initial therapies in the emergency department were administered more slowly. However, all patients were treated rapidly and we report low morbidity and mortality. This underscores the importance of rapid recognition and treatment of septic shock.
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Dhooria S, Sehgal IS, Agarwal R. The quest for the optimal blood pressure in septic shock. J Thorac Dis 2016; 8:E1019-E1022. [PMID: 27747051 DOI: 10.21037/jtd.2016.08.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Balk RA, Kadri SS, Cao Z, Robinson SB, Lipkin C, Bozzette SA. Effect of Procalcitonin Testing on Health-care Utilization and Costs in Critically Ill Patients in the United States. Chest 2016; 151:23-33. [PMID: 27568580 DOI: 10.1016/j.chest.2016.06.046] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 06/14/2016] [Accepted: 06/16/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There is a growing use of procalcitonin (PCT) to facilitate the diagnosis and management of severe sepsis. We investigated the impact of one to two PCT determinations on ICU day 1 on health-care utilization and cost in a large research database. METHODS A retrospective, propensity score-matched multivariable analysis was performed on the Premier Healthcare Database for patients admitted to the ICU with one to two PCT evaluations on day 1 of ICU admission vs patients who did not have PCT testing. RESULTS A total of 33,569 PCT-managed patients were compared with 98,543 propensity score-matched non-PCT patients. In multivariable regression analysis, PCT utilization was associated with significantly decreased total length of stay (11.6 days [95% CI, 11.4 to 11.7] vs 12.7 days [95% CI, 12.6 to 12.8]; 95% CI for difference, 1 to 1.3; P < .001) and ICU length of stay (5.1 days [95% CI, 5.1 to 5.2] vs 5.3 days [95% CI, 5.3 to 5.4]; 95% CI for difference, 0.1 to 0.3; P < .03), and lower hospital costs ($30,454 [95% CI, 29,968 to 31,033] vs $33,213 [95% CI, 32,964 to 33,556); 95% CI for difference, 2,159 to 3,321; P < .001). There was significantly less total antibiotic exposure (16.2 days [95% CI, 16.1 to 16.5] vs 16.9 days [95% CI, 16.8 to 17.1]; 95% CI for difference, -0.9 to 0.4; P = .006) in PCT-managed patients. Patients in the PCT group were more likely to be discharged to home (44.1% [95% CI, 43.7 to 44.6] vs 41.3% [95% CI, 41 to 41.6]; 95% CI for difference, 2.3 to 3.3; P = .006). Mortality was not different in an analysis including the 96% of patients who had an independent measure of mortality risk available (19.1% [95% CI, 18.7 to 19.4] vs 19.1% [95% CI, 18.9 to 19.3]; 95% CI for difference, -0.5 to 0.4; P = .93). CONCLUSIONS Use of PCT testing on the first day of ICU admission was associated with significantly lower hospital and ICU lengths of stay, as well as decreased total, ICU, and pharmacy cost of care. Further elucidation of clinical outcomes requires additional data.
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Affiliation(s)
- Robert A Balk
- Division of Pulmonary and Critical Care Medicine, Rush Medical College and Rush University Medical Center, Chicago, IL.
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Zhun Cao
- Premier Research Services, Inc, Charlotte, NC
| | | | | | - Samuel A Bozzette
- Medical Affairs-Americas/East Asia and Global Health Economics and Outcomes, bioMérieux USA, Durham, NC; Medicine and International Relations, University of California San Diego, San Diego, CA; Health Policy and Management, University of North Carolina, Raleigh, NC
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Association of Fluid Accumulation with Clinical Outcomes in Critically Ill Children with Severe Sepsis. PLoS One 2016; 11:e0160093. [PMID: 27467522 PMCID: PMC4965086 DOI: 10.1371/journal.pone.0160093] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/13/2016] [Indexed: 01/01/2023] Open
Abstract
Objective To evaluate whether early and acquired daily fluid overload (FO), as well as fluctuations in fluid accumulation, were associated with adverse outcomes in critically ill children with severe sepsis. Methods This study enrolled 202 children in a pediatric intensive care unit (PICU) with severe sepsis. Early fluid overload was defined as ≥5% fluid accumulation occurring in the first 24 hours of PICU admission. The maximum daily fluid accumulation ≥5% occurring during the next 6 days in patients with at least 48 hours of PICU stay was defined as PICU-acquired daily fluid overload. The fluctuation in fluid accumulation was calculated as the difference between the maximum and the minimum daily fluid accumulation obtained during the first 7 days after admission. Results Of the 202 patients, 61 (30.2%) died during PICU stay. Among all patients, 41 (20.3%) experienced early fluid overload, including 9 with a FO ≥10%. Among patients with at least 48 hours of PICU stay (n = 154), 36 (23.4%) developed PICU-acquired daily fluid overload, including 2 with a FO ≥10%. Both early fluid overload (AOR = 1.20; 95% CI 1.08–1.33; P = 0.001; n = 202) and PICU-acquired daily fluid overload (AOR = 5.47 per log increase; 95% CI 1.15–25.96; P = 0.032; n = 154) were independent risk factors associated with mortality after adjusting for age, illness severity, etc. However, fluctuations in fluid accumulation were not associated with mortality after adjustment. Length of PICU stay increased with greater fluctuations in fluid accumulation in all patients with at least 48 hours of PICU stay (FO <5%, 5%-10% vs. ≥10%: 4 [3–8], 7 [4–11] vs. 10 [6–16] days; P <0.001; n = 154) and in survivors (4 [3–8], 7 [5–11] vs. 10 [5–15] days; P <0.001; n = 121). Early fluid overload achieved an area under-the-receiver-operating-characteristic curve of 0.74 (95% CI 0.65–0.82; P <0.001; n = 202) for predicting mortality in patients with severe sepsis, with a sensitivity of 67.2% and a specificity of 80.1% at the optimal cut-off value of 2.65%. Conclusions Both early and acquired daily fluid overload were independently associated with PICU mortality in children with severe sepsis.
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Assessing The Predictive Value of Clinical Factors Used to Determine The Presence of Sepsis Causing Shock in the Emergency Department. Shock 2016; 46:27-32. [DOI: 10.1097/shk.0000000000000558] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care 2016; 20:160. [PMID: 27364620 PMCID: PMC4929762 DOI: 10.1186/s13054-016-1288-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.
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Affiliation(s)
- H. Bryant Nguyen
- />Department of Medicine, Pulmonary and Critical Care Medicine, Loma Linda University, Loma Linda, CA USA
- />Department of Emergency Medicine, Loma Linda University, Loma Linda, CA USA
| | - Anja Kathrin Jaehne
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Quality Assurance, Aspirus Hospital, Iron River, MI USA
| | - Namita Jayaprakash
- />Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, MN USA
| | - Matthew W. Semler
- />Department of Medicine, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN USA
| | - Sara Hegab
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Angel Coz Yataco
- />Department of Medicine, Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY USA
| | - Geneva Tatem
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Dhafer Salem
- />Department of Internal Medicine, Mercy Hospital Medical Center, Chicago, IL USA
| | - Steven Moore
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Kamran Boka
- />Department of Internal Medicine, Division of Critical Care Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jasreen Kaur Gill
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jayna Gardner-Gray
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Jacqueline Pflaum
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Juan Pablo Domecq
- />Department of Internal Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />CONEVID, Conocimiento y Evidencia Research Unit, Universidad Peruana Cayetano Heredia, Lima, PERU
| | - Gina Hurst
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Medicine, Pulmonary and Critical Care Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Justin B. Belsky
- />Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Raymond Fowkes
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
| | - Ronald B. Elkin
- />Pulmonary and Critical Care Medicine, California Pacific Medical Center, San Francisco, CA USA
| | - Steven Q. Simpson
- />Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, Kansas USA
| | - Jay L. Falk
- />Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA
- />University of Central Florida College of Medicine, Orlando, Florida USA
- />University of Florida College of Medicine, Orlando, Florida USA
- />University of South Florida College of Medicine, Orlando, Florida USA
- />Florida State University College of Medicine, Orlando, Florida USA
| | - Daniel J. Singer
- />Department of Surgery, Division of Surgical Critical Care, Icahn School of Medicine, Mount Sinai Hospital,, New York, NY USA
| | - Emanuel P. Rivers
- />Department of Emergency Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI USA
- />Department of Surgery, Henry Ford Hospital, Wayne State University, Detroit, MI USA
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Leone M. Septic shock: A global response. Presse Med 2016; 45:e91-2. [DOI: 10.1016/j.lpm.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Tatara T. Context-sensitive fluid therapy in critical illness. J Intensive Care 2016; 4:20. [PMID: 26985394 PMCID: PMC4793702 DOI: 10.1186/s40560-016-0150-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/11/2016] [Indexed: 12/19/2022] Open
Abstract
Microcirculatory alterations are frequently observed in critically ill patients undergoing major surgery and those who suffer from trauma or sepsis. Despite the need for adequate fluid administration to restore microcirculation, there is no consensus regarding optimal fluid therapy for these patients. The recent recognition of the importance of the endothelial glycocalyx layer in capillary fluid and solute exchange has largely changed our views on fluid therapy in critical illness. Given that disease status largely differs among critically ill patients, fluid therapy must not be considered generally, but rather tailored to the clinical condition of each patient. This review outlines the current understanding of context-sensitive volume expansion by fluid solutions and considers its clinical implications for critically ill patients. The modulation of capillary hydrostatic pressure through the appropriate use of vasopressors may increase the effectiveness of fluid infusion and thereby reduce detrimental effects resulting from excessive fluid administration.
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Affiliation(s)
- Tsuneo Tatara
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501 Japan
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Abstract
The Early Goal-Directed Therapy versus Standard Care for Sepsis trial by Rivers and colleagues in 2001 suggested that a significant mortality reduction may be realized through goal-directed interventions early in the care of patients with septic shock. However, the recent publication of the Protocol-Based Care for Early Septic Shock (ProCESS), Australasian Resuscitation in Sepsis Evaluation (ARISE), and Protocolised Management in Sepsis (ProMISE) trials did not demonstrate the superiority of early goal-directed therapy over usual care. If usual care includes timely and meticulous care, a protocol may not be needed to realize the continued lowering mortality rates.
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On the Threshold of a Dream. Crit Care Med 2016; 43:2504-6. [PMID: 26468701 DOI: 10.1097/ccm.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW This review highlights the recent evidence describing the outcomes associated with fluid overload in critically ill patients and provides an overview of fluid management strategies aimed at preventing fluid overload during the resuscitation of patients with shock. RECENT FINDINGS Fluid overload is a common complication of fluid resuscitation and is associated with increased hospital costs, morbidity and mortality. SUMMARY Fluid management goals differ during the resuscitation, optimization, stabilization and evacuation phases of fluid resuscitation. To prevent fluid overload, strategies that reduce excessive fluid infusions and emphasize the removal of accumulated fluids should be implemented.
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Belletti A, Musu M, Silvetti S, Saleh O, Pasin L, Monaco F, Hajjar LA, Fominskiy E, Finco G, Zangrillo A, Landoni G. Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials. PLoS One 2015; 10:e0142605. [PMID: 26558621 PMCID: PMC4641698 DOI: 10.1371/journal.pone.0142605] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 10/23/2015] [Indexed: 11/20/2022] Open
Abstract
Introduction Hypotensive state is frequently observed in several critical conditions. If an adequate mean arterial pressure is not promptly restored, insufficient tissue perfusion and organ dysfunction may develop. Fluids and catecholamines are the cornerstone of critical hypotensive states management. Catecholamines side effects such as increased myocardial oxygen consumption and development of arrhythmias are well known. Thus, in recent years, interest in catecholamine-sparing agents such as vasopressin, terlipressin and methylene blue has increased; however, few randomized trials, mostly with small sample sizes, have been performed. We therefore conducted a meta-analysis of randomized trials to investigate the effect of non-catecholaminergic vasopressors on mortality. Methods PubMed, BioMed Central and Embase were searched (update December 31st, 2014) by two independent investigators. Inclusion criteria were: random allocation to treatment, at least one group receiving a non-catecholaminergic vasopressor, patients with or at risk for vasodilatory shock. Exclusion criteria were: crossover studies, pediatric population, non-human studies, studies published as abstract only, lack of data on mortality. Studied drugs were vasopressin, terlipressin and methylene blue. Primary endpoint was mortality at the longest follow-up available. Results A total of 1,608 patients from 20 studies were included in our analysis. The studied settings were sepsis (10/20 studies [50%]), cardiac surgery (7/20 [35%]), vasodilatory shock due to any cause (2/20 [19%]), and acute traumatic injury (1/20 [5%]). Overall, pooled estimates showed that treatment with non-catecholaminergic agents improves survival (278/810 [34.3%] versus 309/798 [38.7%], risk ratio = 0.88, 95% confidence interval = 0.79 to 0.98, p = 0.02). None of the drugs was associated with significant reduction in mortality when analyzed independently. Results were not confirmed when analyzing studies with a low risk of bias. Conclusions Catecholamine-sparing agents in patients with or at risk for vasodilatory shock may improve survival. Further researches on this topic are needed to confirm the finding.
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Affiliation(s)
- Alessandro Belletti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Musu
- Department of Medical Sciences “M. Aresu”, Cagliari University, Cagliari, Italy
| | - Simona Silvetti
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Omar Saleh
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pasin
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila A. Hajjar
- Surgical Intensive Care Unit, Department of Cardiopneumology, University of São Paulo, São Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anaesthesiology and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Gabriele Finco
- Department of Medical Sciences “M. Aresu”, Cagliari University, Cagliari, Italy
| | - Alberto Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- * E-mail:
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Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GML. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:286. [PMID: 26316210 PMCID: PMC4552276 DOI: 10.1186/s13054-015-1011-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Severe sepsis and septic shock are among the leading causes of mortality in the intensive care unit. Over a decade ago, early goal-directed therapy (EGDT) emerged as a novel approach for reducing sepsis mortality and was incorporated into guidelines published by the international Surviving Sepsis Campaign. In addition to requiring early detection of sepsis and prompt initiation of antibiotics, the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids, vasopressors, red cell transfusions, and inotropes. The effect of these measures on patient outcomes, however, remains controversial. Recently, three large randomized trials were undertaken to re-examine the effect of EGDT on morbidity and mortality: the ProCESS trial in the United States, the ARISE trial in Australia and New Zealand, and the ProMISe trial in England. These trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care. In particular, whereas early administration of antibiotics appeared to increase survival, tailoring resuscitation to static measurements of central venous pressure and central venous oxygen saturation did not confer survival benefit to most patients. In the following review, we examine these findings as well as other evidence from recent randomized trials of goal-directed resuscitation. We also discuss future areas of research and emerging paradigms in sepsis trials.
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Affiliation(s)
- Ravi G Gupta
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA.
| | - Sarah M Hartigan
- Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980070, Richmond, VA, 23298, USA
| | - Markos G Kashiouris
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA
| | - Curtis N Sessler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA
| | - Gonzalo M L Bearman
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980019, Richmond, VA, 23298, USA
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van Paridon BM, Sheppard C, G GG, Joffe AR. Timing of antibiotics, volume, and vasoactive infusions in children with sepsis admitted to intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:293. [PMID: 26283545 PMCID: PMC4539944 DOI: 10.1186/s13054-015-1010-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/23/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Early administration of antibiotics for sepsis, and of fluid boluses and vasoactive agents for septic shock, is recommended. Evidence for this in children is limited. METHODS The Alberta Sepsis Network prospectively enrolled eligible children admitted to the Pediatric Intensive Care Unit (PICU) with sepsis from 04/2012-10/2014. Demographics, severity of illness, and outcomes variables were prospectively entered into the ASN database after deferred consent. Timing of interventions were determined by retrospective chart review using a study manual and case-report-form. We aimed to determine the association of intervention timing and outcome in children with sepsis. Univariate (t-test and Fisher's Exact) and multiple linear regression statistics evaluated predictors of outcomes of PICU length of stay (LOS) and ventilation days. RESULTS Seventy-nine children, age median 60 (IQR 22-133) months, 40 (51%) female, 39 (49%) with severe underlying co-morbidity, 44 (56%) with septic shock, and median PRISM-III 10.5 [IQR 6.0-17.0] were enrolled. Most patients presented in an ED: 36 (46%) at an outlying hospital ED, and 21 (27%) at the Children's Hospital ED. Most infections were pneumonia with/without empyema (42, 53%), meningitis (11, 14%), or bacteremia (10, 13%). The time from presentation to acceptable antibiotic administration was a median of 115.0 [IQR 59.0-323.0] minutes; 20 (25%) of patients received their antibiotics in the first hour from presentation. Independent predictors of PICU LOS were PRISM-III, and severe underlying co-morbidity, but not time to antibiotics. In the septic shock subgroup, the volume of fluid boluses given in the first 2 hours was independently associated with longer PICU LOS (effect size 0.22 days; 95% CI 0.5, 0.38; per ml/kg). Independent predictors of ventilator days were PRISM-III score and severe underlying co-morbidity. In the septic shock subgroup, volume of fluid boluses in the first 2 hours was independently associated with more ventilator days (effect size 0.09 days; 95% CI 0.02, 0.15; per ml/kg). CONCLUSION Higher volume of early fluid boluses in children with sepsis and septic shock was independently associated with longer PICU LOS and ventilator days. More study on the benefits and harms of fluid bolus therapy in children are needed.
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Affiliation(s)
- Bregje M van Paridon
- Department of Pediatrics, Sophia Childrens Hospital Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - Cathy Sheppard
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
| | - Garcia Guerra G
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta, Edmonton, AB, Canada.
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Alberta, Edmonton, AB, Canada. .,4-546 Edmonton Clinic Health Academy, 11405 87 Ave, Edmonton, AB, T6G 1C9, Canada.
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Feissel M, Aho LS, Georgiev S, Tapponnier R, Badie J, Bruyère R, Quenot JP. Pulse Wave Transit Time Measurements of Cardiac Output in Septic Shock Patients: A Comparison of the Estimated Continuous Cardiac Output System with Transthoracic Echocardiography. PLoS One 2015; 10:e0130489. [PMID: 26126112 PMCID: PMC4488420 DOI: 10.1371/journal.pone.0130489] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/19/2015] [Indexed: 12/29/2022] Open
Abstract
Background We determined reliability of cardiac output (CO) measured by pulse wave transit time cardiac output system (esCCO system; COesCCO) vs transthoracic echocardiography (COTTE) in mechanically ventilated patients in the early phase of septic shock. A secondary objective was to assess ability of esCCO to detect change in CO after fluid infusion. Methods Mechanically ventilated patients admitted to the ICU, aged >18 years, in sinus rhythm, in the early phase of septic shock were prospectively included. We performed fluid infusion of 500ml of crystalloid solution over 20 minutes and recorded CO by EsCCO and TTE immediately before (T0) and 5 minutes after (T1) fluid administration. Patients were divided into 2 groups (responders and non-responders) according to a threshold of 15% increase in COTTE in response to volume expansion. Results In total, 25 patients were included, average 64±15 years, 15 (60%) were men. Average SAPSII and SOFA scores were 55±21.3 and 13±2, respectively. ICU mortality was 36%. Mean cardiac output at T0 was 5.8±1.35 L/min by esCCO and 5.27±1.17 L/min by COTTE. At T1, respective values were 6.63 ± 1.57 L/min for esCCO and 6.10±1.29 L/min for COTTE. Overall, 12 patients were classified as responders, 13 as non-responders by the reference method. A threshold of 11% increase in COesCCO was found to discriminate responders from non-responders with a sensitivity of 83% (95% CI, 0.52-0.98) and a specificity of 77% (95% CI, 0.46-0.95). Conclusion We show strong correlation esCCO and echocardiography for measuring CO, and change in CO after fluid infusion in ICU patients.
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Affiliation(s)
- Marc Feissel
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Ludwig Serge Aho
- Service d’Epidémiologie et d’Hygiène Hospitalière, Centre Hospitalier Universitaire de Dijon, Bocage Central, Dijon, France
| | - Stefan Georgiev
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Romain Tapponnier
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Julio Badie
- Service de Réanimation, Maladies Infectieuses, Centre Hospitalier de Belfort-Montbéliard, Belfort, France
| | - Rémi Bruyère
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Dijon, Bocage Central, Dijon, France
- INSERM Centre de Recherche UMR866, Université de Bourgogne, Dijon, France
| | - Jean-Pierre Quenot
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Dijon, Bocage Central, Dijon, France
- INSERM Centre de Recherche UMR1347, Université de Bourgogne, Dijon, France
- * E-mail:
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Perner A, Vieillard-Baron A, Bakker J. Fluid resuscitation in ICU patients: quo vadis? Intensive Care Med 2015; 41:1667-9. [PMID: 26072659 DOI: 10.1007/s00134-015-3900-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 05/27/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark,
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Early fluid accumulation in children with shock and ICU mortality: a matched case-control study. Intensive Care Med 2015; 41:1445-53. [PMID: 26077052 DOI: 10.1007/s00134-015-3851-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/27/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the association between early fluid accumulation and mortality in children with shock states. METHODS We retrospectively reviewed children admitted in shock states to the pediatric intensive care unit (ICU) at a tertiary level children's hospital over a 7-month period. The study was designed as a matched case-control study. Children with early fluid overload, defined as fluid accumulation of ≥10% of admission body weight during the initial 3 days, were designated as the cases. They were compared with matched controls without early fluid accumulation. Cases and controls were matched for age, severity of illness at ICU admission and need for organ support. They were compared with respect to all-cause ICU mortality and other secondary outcomes. RESULTS A total of 114 children (age range 0-17.4 years; N = 42 cases and 72 matched controls) met the study criteria. Mortality rate was 13% (15/114) in this cohort. Multivariable logistic regression analysis identified the presence of early fluid overload [adjusted odds ratio (OR) 9.17, 95% confidence interval (CI) 2.22-55.57], its severity (adjusted OR 1.11, 95% CI 1.05-1.19) and its duration (adjusted OR 1.61, 95% CI 1.21-2.28) as independent predictors of mortality. Cases had higher mortality than the controls (26 vs. 6 %; p 0.003), and this difference remained significant in the matched analysis (37 vs. 3%; p 0.002). CONCLUSION The presence, severity and duration of early fluid are associated with increased ICU mortality in children admitted to the pediatric ICU in shock states.
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Karvellas CJ, Abraldes JG, Arabi YM, Kumar A. Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study. Aliment Pharmacol Ther 2015; 41:747-57. [PMID: 25703246 DOI: 10.1111/apt.13135] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 12/19/2014] [Accepted: 02/02/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP)-associated septic shock carries significant mortality in cirrhosis. AIM To determine whether practice-related aspects of antimicrobial therapy contribute to high mortality. METHODS Retrospective cohort study of all (n = 126) cirrhotics with spontaneous bacterial peritonitis (neutrophil count >250 or positive ascitic culture)-associated septic shock (1996-2011) from an international, multicenter database. Appropriate antimicrobial therapy implied either in vitro activity against a subsequently isolated pathogen (culture positive) or empiric management consistent with broadly accepted norms (culture negative). RESULTS Overall hospital mortality was 81.8%. Comparing survivors (n = 23) with non-survivors (n = 103), survivors had lower Acute Physiology and Chronic Health Evaluation (APACHEII) (mean ± s.d.; 22 ± 7 vs. 32 ± 8) and model for end-stage liver disease (MELD) (24 ± 9 vs. 34 ± 11) scores and serum lactate on admission (4.9 ± 3.1 vs. 8.9 ± 5.3), P < 0.001 for all. Survivors were less likely to receive inappropriate initial antimicrobial therapy (0% vs. 25%, P = 0.013) and received appropriate antimicrobial therapy earlier [median 1.8 (1.1-5.2) vs. 9.5 (3.9-14.3) h, P < 0.001]. After adjusting for covariates, APACHEII [OR, odds ratio 1.45 (1.04-2.02) per 1 unit increment, P = 0.03], lactate [OR 2.34 (1.04-5.29) per unit increment, P = 0.04] and time delay to appropriate antimicrobials [OR 1.86 (1.10-3.14) per hour increment, P = 0.02] were significantly associated with increased mortality. CONCLUSIONS Cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis have high mortality (>80%). Each hour of delay in appropriate antimicrobial therapy was associated with a 1.86 times increased hospital mortality. Admission APACHEII and serum lactate also significantly impacted hospital mortality. Earlier initiation of appropriate antimicrobial therapy could substantially improve outcome.
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Affiliation(s)
- C J Karvellas
- Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada; Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
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Leone M, Asfar P, Radermacher P, Vincent JL, Martin C. Optimizing mean arterial pressure in septic shock: a critical reappraisal of the literature. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:101. [PMID: 25888071 PMCID: PMC4355573 DOI: 10.1186/s13054-015-0794-z] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Guidelines recommend that a mean arterial pressure (MAP) value greater than 65 mm Hg should be the initial blood pressure target in septic shock, but what evidence is there to support this statement? We searched Pubmed and Google Scholar by using the key words 'arterial pressure', 'septic shock', and 'norepinephrine' and retrieved human studies published between 1 January 2000 and 31 July 2014. We identified seven comparative studies: two randomized clinical trials and five observational studies. The results of the literature review suggest that a MAP target of 65 mm Hg is usually sufficient in patients with septic shock. However, a MAP of around 75 to 85 mm Hg may reduce the development of acute kidney injury in patients with chronic arterial hypertension. Because of the high prevalence of chronic arterial hypertension in patients who develop septic shock, this finding is of considerable importance. Future studies should assess interactions between time, fluid volumes administered, and doses of vasopressors.
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Affiliation(s)
- Marc Leone
- Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, 13015, Marseille, France.
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare Centre Hospitalier Universitaire Angers; and Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, PRES L'UNAM, 4 Rue Larrey, 49100, Angers, France.
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, route de Lennik 808, 1070, Brussels, Belgium.
| | - Claude Martin
- Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, 13015, Marseille, France.
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Guidet B, Ait-Oufella H. Fluid resuscitation should respect the endothelial glycocalyx layer. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:707. [PMID: 25629597 PMCID: PMC4331386 DOI: 10.1186/s13054-014-0707-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Endothelial glycocalyx degradation induced by fluid overload adds to the concern of a detrimental effect of uncontrolled fluid resuscitation and the risk of unnecessary fluid infusion. As a consequence, the use of new tools for monitoring response to fluids appears promising. From that perspective, the monitoring of plasma concentration of glycocalyx degradation markers could be useful.
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Brunauer A, Koköfer A, Bataar O, Gradwohl-Matis I, Dankl D, Dünser MW. The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:719. [PMID: 25524592 PMCID: PMC4299308 DOI: 10.1186/s13054-014-0719-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/11/2014] [Indexed: 01/22/2023]
Abstract
Introduction Liberal and overaggressive use of vasopressors during the initial period of shock resuscitation may compromise organ perfusion and worsen outcome. When transiently applying the concept of permissive hypotension, it would be helpful to know at which arterial blood pressure terminal cardiovascular collapse occurs. Methods In this retrospective cohort study, we aimed to identify the arterial blood pressure associated with terminal cardiovascular collapse in 140 patients who died in the intensive care unit while being invasively monitored. Demographic data, co-morbid conditions and clinical data at admission and during the 24 hours before and at the time of terminal cardiovascular collapse were collected. The systolic, mean and diastolic arterial blood pressures immediately before terminal cardiovascular collapse were documented. Terminal cardiovascular collapse was defined as an abrupt (<5 minutes) and exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest. Results The mean ± standard deviation (SD) values of the systolic, mean and diastolic arterial blood pressures associated with terminal cardiovascular collapse were 47 ± 12 mmHg, 35 ± 11 mmHg and 29 ± 9 mmHg, respectively. Patients with congestive heart failure (39 ± 13 mmHg versus 34 ± 10 mmHg; P = 0.04), left main stem stenosis (39 ± 11 mmHg versus 34 ± 11 mmHg; P = 0.03) or acute right heart failure (39 ± 13 mmHg versus 34 ± 10 mmHg; P = 0.03) had higher arterial blood pressures than patients without these risk factors. Patients with severe valvular aortic stenosis had the highest arterial blood pressures associated with terminal cardiovascular collapse (systolic, 60 ± 20 mmHg; mean, 46 ± 12 mmHg; diastolic, 36 ± 10 mmHg), but this difference was not significant. Patients with sepsis and patients exposed to sedatives or opioids during the terminal phase exhibited lower arterial blood pressures than patients without sepsis or administration of such drugs. Conclusions The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients was very low and varied with individual co-morbid conditions (for example, congestive heart failure, left main stem stenosis, severe valvular aortic stenosis, acute right heart failure), drug exposure (for example, sedatives or opioids) and the type of acute illness (for example, sepsis). Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0719-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andreas Brunauer
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Andreas Koköfer
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Otgon Bataar
- Department of Emergency and Critical Care Medicine, Central State University Hospital, Marx Street, Ulaanbaatar, Mongolia.
| | - Ilse Gradwohl-Matis
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Daniel Dankl
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
| | - Martin W Dünser
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, University Hospital Salzburg and Paracelsus Private Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria.
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Lira A, Pinsky MR. Choices in fluid type and volume during resuscitation: impact on patient outcomes. Ann Intensive Care 2014; 4:38. [PMID: 25625012 PMCID: PMC4298675 DOI: 10.1186/s13613-014-0038-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/14/2014] [Indexed: 01/19/2023] Open
Abstract
We summarize the emerging new literature regarding the pathophysiological principles underlying the beneficial and deleterious effects of fluid administration during resuscitation, as well as current recommendations and recent clinical evidence regarding specific colloids and crystalloids. This systematic review allows us to conclude that there is no clear benefit associated with the use of colloids compared to crystalloids and no evidence to support the unique benefit of albumin as a resuscitation fluid. Hydroxyethyl starch use has been associated with increased acute kidney injury (AKI) and use of renal replacement therapy. Other synthetic colloids (dextran and gelatins) though not well studied do not appear superior to crystalloids. Normal saline (NS) use is associated with hyperchloremic metabolic acidosis and increased risk of AKI. This risk is decreased when balanced salt solutions are used. Balanced crystalloid solutions have shown no harmful effects, and there is evidence for benefit over NS. Finally, fluid resuscitation should be applied in a goal-directed manner and targeted to physiologic needs of individual patients. The evidence supports use of fluids in volume-responsive patients whose end-organ perfusion parameters have not been met.
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Affiliation(s)
- Alena Lira
- Department of Critical Care Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh 15261, PA, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh 15261, PA, USA
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Beck V, Chateau D, Bryson GL, Pisipati A, Zanotti S, Parrillo JE, Kumar A. Timing of vasopressor initiation and mortality in septic shock: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R97. [PMID: 24887489 PMCID: PMC4075345 DOI: 10.1186/cc13868] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 05/01/2014] [Indexed: 12/25/2022]
Abstract
Introduction Despite recent advances in the management of septic shock, mortality remains unacceptably high. Earlier initiation of key therapies including appropriate antimicrobials and fluid resuscitation appears to reduce the mortality in this condition. This study examined whether early initiation of vasopressor therapy is associated with improved survival in fluid therapy-refractory septic shock. Methods Utilizing a well-established database, relevant information including duration of time to vasopressor administration following the initial documentation of recurrent/persistent hypotension associated with septic shock was assessed in 8,670 adult patients from 28 ICUs in Canada, the United States of America, and Saudi Arabia. The primary endpoint was survival to hospital discharge. Secondary endpoints were length of ICU and hospital stay as well as duration of ventilator support and vasopressor dependence. Analysis involved multivariate linear and logistic regression analysis. Results In total, 8,640 patients met the definition of septic shock with time of vasopressor/inotropic initiation documented. Of these, 6,514 were suitable for analysis. The overall unadjusted hospital mortality rate was 53%. Independent mortality correlates included liver failure (odds ratio (OR) 3.46, 95% confidence interval (CI), 2.67 to 4.48), metastatic cancer (OR 1.63, CI, 1.32 to 2.01), AIDS (OR 1.91, CI, 1.29 to 2.49), hematologic malignancy (OR 1.88, CI, 1.46 to 2.41), neutropenia (OR 1.78, CI, 1.27 to 2.49) and chronic hypertension (OR 0.62 CI, 0.52 to 0.73). Delay of initiation of appropriate antimicrobial therapy (OR 1.07/hr, CI, 1.06 to 1.08), age (OR 1.03/yr, CI, 1.02 to 1.03), and Acute Physiology and Chronic Health Evaluation (APACHE) II Score (OR 1.11/point, CI, 1.10 to 1.12) were also found to be significant independent correlates of mortality. After adjustment, only a weak correlation between vasopressor delay and hospital mortality was found (adjusted OR 1.02/hr, 95% CI 1.01 to 1.03, P <0.001). This weak effect was entirely driven by the group of patients with the longest delays (>14.1 hours). There was no significant relationship of vasopressor initiation delay to duration of vasopressor therapy (P = 0.313) and only a trend to longer duration of ventilator support (P = 0.055) among survivors. Conclusion Marked delays in initiation of vasopressor/inotropic therapy are associated with a small increase in mortality risk in patients with septic shock.
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