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Khattar G, El Gharib K, Pokima N, Kotys J, Kandala V, Mina J, Haddadin F, Abu Baker S, Asmar S, Rizvi T, Flamenbaum M, Elsayegh D, Chalhoub M, El Hage H, El Sayegh S. Fluid Resuscitation Dilemma in End-stage Renal Disease Patients Presenting with Sepsis: A Systematic Review and Meta-analysis. J Intensive Care Med 2024:8850666241261673. [PMID: 39053444 DOI: 10.1177/08850666241261673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Background: This study aims to investigate the safety and efficacy of guideline-directed fluid resuscitation (GDFR) compared with conservative fluid management in end-stage renal disease (ESRD) patients with sepsis by evaluating 90-day mortality and intubation rate. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases using specific keywords and controlled vocabulary. The search strategy, implemented until October 1, 2023, aimed to identify studies examining fluid resuscitation in ESRD patients with sepsis. The review process was streamlined using Covidence software. A fourth reviewer resolved discrepancies in study inclusion. A random-effects model with the generic Mantel-Haenszel method was preferred for integrating odds ratios (ORs). Sensitivity analysis and publication bias analysis were performed. Results: Of the 1274 identified studies, 10 were selected for inclusion, examining 1184 patients, 593 of whom received GDFR. Four studies were selected to investigate the intubation rate, including 304 patients. No significant mortality or intubation rate difference was spotted between both groups [OR = 1.23; confidence interval (CI) = 0.92-1.65; I2 = 0% and OR = 1.91; CI = 0.91-4.04]. In most studies, sensitivity analysis using the leave-one-out approach revealed higher mortality and intubation rates. The Egger test results indicated no statistically significant publication bias across the included studies. Conclusion: Our research contradicts the common assumption about the effectiveness of GDFR for sepsis patients with ESRD. It suggests that this approach, while not superior to the conservative strategy, may potentially be harmful.
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Affiliation(s)
- Georges Khattar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Khalil El Gharib
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Ngowari Pokima
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Juliet Kotys
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Vineeth Kandala
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Jonathan Mina
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Fadi Haddadin
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Saif Abu Baker
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Samer Asmar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Taqi Rizvi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Matthew Flamenbaum
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Dany Elsayegh
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Michel Chalhoub
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Halim El Hage
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Suzanne El Sayegh
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
- Department of Nephrology, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
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Herndon JM, Blackwell SB, Pinner N, Achey TS, Holder HB, Tidwell C. Assessment of Outcomes in Patients with Heart Failure and End-Stage Kidney Disease after Fluid Resuscitation for Sepsis and Septic Shock. J Emerg Med 2024; 66:e670-e679. [PMID: 38777707 DOI: 10.1016/j.jemermed.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Sepsis fluid resuscitation is controversial, especially for patients with volume overload risk. The Surviving Sepsis Campaign recommends a 30-mL/kg crystalloid fluid bolus for patients with sepsis-induced hypoperfusion. Criticism of this approach includes excessive fluid resuscitation in certain patients. OBJECTIVE The aim of this study was to assess the efficacy and safety of guideline-concordant fluid resuscitation in patients with sepsis and heart failure (HF) or end-stage kidney disease (ESKD). METHODS A retrospective cohort study was conducted in patients with sepsis who qualified for guideline-directed fluid resuscitation and concomitant HF or ESKD. Those receiving crystalloid fluid boluses of at least 30 mL/kg within 3 h of sepsis diagnosis were placed in the concordant group and all others in the nonconcordant group. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS); vasoactive medications and net volume over 24 h; new mechanical ventilation, new or increased volume removal, and acute kidney injury within 48 h; and shock-free survival at 7 days. RESULTS One hundred twenty-five patients were included in each group. In-hospital mortality was 34.4% in the concordant group and 44.8% in the nonconcordant group (p = 0.1205). The concordant group had a shorter ICU LOS (7.6 vs. 10.5 days; p = 0.0214) and hospital LOS (12.9 vs. 18.3 days; p = 0.0163), but increased new mechanical ventilation (37.6 vs. 20.8%; p = 0.0052). No differences in other outcomes were observed. CONCLUSIONS Receipt of a 30-mL/kg fluid bolus did not affect outcomes in a cohort of patients with mixed types of HF and sepsis-induced hypoperfusion.
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Affiliation(s)
- John Michael Herndon
- Department of Pharmacy Services, Princeton Baptist Medical Center, Birmingham, Alabama
| | - Sarah B Blackwell
- Department of Pharmacy Services, Princeton Baptist Medical Center, Birmingham, Alabama
| | - Nathan Pinner
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Birmingham, Alabama
| | - Thomas S Achey
- Department of Pharmacy Services, Princeton Baptist Medical Center, Birmingham, Alabama; Department of Pharmacy Services, MUSC Health, Charleston, South Carolina
| | - Hillary B Holder
- Department of Pharmacy Services, Princeton Baptist Medical Center, Birmingham, Alabama; Department of Pharmacy Services, UVA University Hospital, Charlottesville, Virginia
| | - Cruz Tidwell
- Department of Pharmacy Services, Princeton Baptist Medical Center, Birmingham, Alabama; McWhorter School of Pharmacy, Samford University, Birmingham, Alabama; Department of Pharmacy Services, Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, Alabama
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Ablordeppey EA, Zhao A, Ruggeri J, Hassan A, Wallace L, Agarwal M, Stickles SP, Holthaus C, Theodoro D. Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review. Emerg Med Int 2024; 2024:5675066. [PMID: 38742136 PMCID: PMC11090677 DOI: 10.1155/2024/5675066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 03/27/2024] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Background Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. Methods We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. Results 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Conclusions Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.
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Affiliation(s)
- Enyo A. Ablordeppey
- Department of Anaesthesiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amy Zhao
- Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffery Ruggeri
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ahmad Hassan
- Washington University School of Medicine, St. Louis, MO, USA
| | - Laura Wallace
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mansi Agarwal
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Sean P. Stickles
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher Holthaus
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Theodoro
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Beagle AJ, Prasad PA, Hubbard CC, Walderich S, Oreper S, Abe-Jones Y, Fang MC, Kangelaris KN. Associations Between Volume of Early Intravenous Fluid and Hospital Outcomes in Septic Patients With and Without Heart Failure: A Retrospective Cohort Study. Crit Care Explor 2024; 6:e1082. [PMID: 38694845 PMCID: PMC11057813 DOI: 10.1097/cce.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
OBJECTIVES To evaluate the relationship between early IV fluid volume and hospital outcomes, including death in-hospital or discharge to hospice, in septic patients with and without heart failure (HF). DESIGN A retrospective cohort study using logistic regression with restricted cubic splines to assess for nonlinear relationships between fluid volume and outcomes, stratified by HF status and adjusted for propensity to receive a given fluid volume in the first 6 hours. An ICU subgroup analysis was performed. Secondary outcomes of vasopressor use, mechanical ventilation, and length of stay in survivors were assessed. SETTING An urban university-based hospital. PATIENTS A total of 9613 adult patients were admitted from the emergency department from 2012 to 2021 that met electronic health record-based Sepsis-3 criteria. Preexisting HF diagnosis was identified by the International Classification of Diseases codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 1449 admissions from patients with HF. The relationship between fluid volume and death or discharge to hospice was nonlinear in patients without HF, and approximately linear in patients with HF. Receiving 0-15 mL/kg in the first 6 hours was associated with lower likelihood of death or discharge to hospice compared with 30-45 mL/kg (odds ratio = 0.61; 95% CI, 0.41-0.90; p = 0.01) in HF patients, but no significant difference for non-HF patients. A similar pattern was identified in ICU admissions and some secondary outcomes. Volumes larger than 15-30 mL/kg for non-HF patients and 30-45 mL/kg for ICU-admitted non-HF patients were not associated with improved outcomes. CONCLUSIONS Early fluid resuscitation showed distinct patterns of potential harm and benefit between patients with and without HF who met Sepsis-3 criteria. Restricted cubic splines analysis highlighted the importance of considering nonlinear fluid outcomes relationships and identified potential points of diminishing returns (15-30 mL/kg across all patients without HF and 30-45 mL/kg when admitted to the ICU). Receiving less than 15 mL/kg was associated with better outcomes in HF patients, suggesting small volumes may be appropriate in select patients. Future studies may benefit from investigating nonlinear fluid-outcome associations and a focus on other conditions like HF.
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Affiliation(s)
- Alexander J Beagle
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Priya A Prasad
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sven Walderich
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sandra Oreper
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Yumiko Abe-Jones
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Margaret C Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA
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Fang Z, Wang G, Huang R, Liu C, Yushanjiang F, Mao T, Li J. Astilbin protects from sepsis-induced cardiac injury through the NRF2/HO-1 and TLR4/NF-κB pathway. Phytother Res 2024; 38:1044-1058. [PMID: 38153125 DOI: 10.1002/ptr.8093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/10/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
Cardiac dysfunction and arrhythmia are severe complications of sepsis-induced cardiomyopathy and are associated with an increased risk of morbidity and mortality. Currently, the precise mechanism for sepsis-induced myocardial damage remains unclear. Astilbin, a flavonoid, is reported to have anti-inflammatory, antioxidative, and antiapoptotic properties. However, the effects of astilbin on sepsis-induced cardiomyopathy have not been studied so far. This study aims to investigate the effect of astilbin in sepsis-induced myocardial injury and elucidate the underlying mechanism. In vivo and in vitro sepsis models were created using lipopolysaccharide (LPS) as an inducer in H9C2 cardiomyocytes and C57BL/6 mice, respectively. Our results demonstrated that astilbin reduced myocardial injury and improved cardiac function. Moreover, astilbin prolonged the QT and corrected QT intervals, attenuated myocardial electrical remodeling, and promoted gap junction protein (Cx43) and ion channels expression, thereby reducing the susceptibility of ventricular fibrillation. In addition, astilbin alleviated LPS-induced inflammation, oxidative stress, and apoptosis. Astilbin suppressed the toll-like receptor 4 (TLR4)/nuclear factor-κB (NF-κB) pathway in vivo and in vitro models. Astilbin remarkedly upregulated the nuclear factor erythroid 2-related factor 2 (NRF2) and heme oxygenase 1 (HO-1) expression. The in vitro treatment with an NRF2 inhibitor reversed the inhibition of the TLR4/NF-κB pathway and antioxidant properties of astilbin. Astilbin attenuated LPS-induced myocardial injury, cardiac dysfunction, susceptibility to VF, inflammation, oxidative stress, and apoptosis by activating the NRF2/HO-1 pathway and inhibiting TLR4/ NF-κB pathway. These results suggest that astilbin could be an effective and promising therapeutics target for the treatment of sepsis-induced cardiomyopathy.
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Affiliation(s)
- Zhao Fang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Guangji Wang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Huang
- Cardiovascular Disease Center, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
- Hubei Selenium and Human Health Institute, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, China
- Hubei Provincial Key Lab of Selenium Resources and Bioapplications, Enshi, China
| | - Chengyin Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Feierkaiti Yushanjiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Tuohua Mao
- Department of Endocrinology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jun Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
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Haley M, Foroutan NK, Gronquist JM, Reddy R, Wusirika R, Khan A. Fluid Resuscitation and Sepsis Management in Patients with Chronic Kidney Disease or End-Stage Renal Disease: Scoping Review. Am J Crit Care 2024; 33:45-53. [PMID: 38161173 DOI: 10.4037/ajcc2024756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Managing sepsis and fluid resuscitation in patients with chronic kidney disease or end-stage renal disease is challenging for health care providers. Nurses are essential for early identification and treatment of these patients. Nurse education on assessing perfusion and implementing 3-hour bundled care can improve mortality rates in patients with sepsis. In this scoping review, initial screening identified 1176 articles published from 2015 through 2023 in the National Library of Medicine database; 29 articles were included in the literature summary and evidence synthesis. A systematic review meta-analysis was not possible because of data heterogeneity. The review revealed that most patients with chronic kidney disease or end-stage renal disease received more conservative resuscitation than did the general population, most likely because of concerns about volume overload. However, patients with chronic kidney disease or end-stage renal disease could tolerate the standard initial fluid resuscitation bolus of 30 mL/kg for sepsis. Outcomes in patients with chronic kidney disease or end-stage renal disease were similar to outcomes in patients without those conditions, whether they received standard or conservative fluid resuscitation. Patients who received the standard (higher) fluid resuscitation volume did not have increased rates of complications such as longer duration of mechanical ventilation, increased mortality, or prolonged length of stay. Using fluid responsiveness to guide resuscitation was associated with improved outcomes. The standard initial fluid resuscitation bolus of 30 mL/kg may be safe for patients with chronic kidney disease or end-stage renal disease and sepsis. Fluid responsiveness could be a valuable resuscitation criterion, promoting better decision-making by multidisciplinary teams. Further research is required.
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Affiliation(s)
- Matt Haley
- Matt Haley is a hospitalist, Department of Medicine, Providence Saint Vincent Hospital, Portland, Oregon
| | - Nasim Khosravi Foroutan
- Nasim Khosravi Foroutan is a pulmonary and critical care fellow, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland
| | - Juliann M Gronquist
- Juliann M. Gronquist is a registered nurse, Department of Nursing, Mirabella Portland, Oregon
| | - Raju Reddy
- Raju Reddy is an assistant professor, pulmonologist, and critical care physician, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas at Austin
| | - Raghav Wusirika
- Raghav Wusirika is interim division chair, Department of Medicine, Division of Nephrology, Oregon Health & Science University
| | - Akram Khan
- Akram Khan is an associate professor of pulmonary and critical care, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University
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Fronrath MJ, Hencken L, Martz CR, Kelly B, Smith ZR. Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis. Pharmacotherapy 2024; 44:61-68. [PMID: 37728179 DOI: 10.1002/phar.2879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/14/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023]
Abstract
STUDY OBJECTIVE To compare guideline-based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH. DESIGN Single-center, retrospective cohort study. SETTING Tertiary care academic medical center in Detroit, Michigan. PATIENTS Adult patients with or without PH hospitalized and diagnosed with sepsis from November 1, 2013 through December 31, 2019. Patients with sepsis were assigned to one of two groups based on a previous PH diagnosis or no PH diagnosis. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The primary outcome was incidence of respiratory support escalation within 72 h from sepsis time zero. Respiratory support escalation included high-flow nasal cannula, bilevel positive airway pressure, or intubation. One-hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non-PH patients (32.7% vs. 11.5%; p = 0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 h of time zero compared with non-PH patients (3.8% vs. 42.3%; p < 0.001). Vasopressor initiation was more common in patients with PH compared with the non-PH group (40.4% vs. 19.2%; p = 0.018). PH diagnosis was the only independent predictor of respiratory support escalation. CONCLUSIONS During initial sepsis management when compared with patients without PH, patients with PH had increased instances of respiratory support escalation within 72 h of sepsis time zero despite lower fluid resuscitation volumes.
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Kuttab HI, Evans CG, Lykins JD, Hughes MD, Kopec JA, Hernandez MA, Ward MA. The Effect of Fluid Resuscitation Timing in Early Sepsis Resuscitation. J Intensive Care Med 2023; 38:1051-1059. [PMID: 37287235 DOI: 10.1177/08850666231180530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE The dose and timing of early fluid resuscitation in sepsis remains a debated topic. The objective of this study is to evaluate the effect of fluid timing in early sepsis management on mortality and other clinical outcomes. METHODS Single-center, retrospective cohort study of emergency-department-treated adults (>18 years, n = 1032) presenting with severe sepsis or septic shock. Logistic regression evaluating the impact of 30 mL/kg crystalloids timing and mortality-versus-time plot controlling for mortality in emergency department sepsis score, lactate, antibiotic timing, obesity, sex, systemic inflammatory response syndrome criteria, hypotension, and heart and renal failures. This study is a subanalysis of a previously published investigation. RESULTS Mortality was 17.1% (n = 176) overall and 20.4% (n = 133 of 653) among those in septic shock. 30 mL/kg was given to 16.9%, 32.2%, 16.2%, 14.5%, and 20.3% of patients within ≤1, 1 ≤ 3, 3 ≤ 6, 6 ≤ 24, and not reached within 24 h, respectively. A 24-h plot of adjusted mortality versus time did not reach significance, but within the first 12 h, the linear function showed a per-hour mortality increase (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.02-1.67) which peaks around 5h, although the quadratic function does not reach significance (P = .09). When compared to patients receiving 30 mL/kg within 1 h, increased mortality was observed when not reached within 24 h (OR 2.69, 95% CI 1.37-5.37) but no difference when receiving this volume between 1 and 3 (OR 1.11, 95% CI 0.62-2.01), 3 and 6 (OR 1.83, 95% CI 0.97-3.52), or 6 and 24 h (OR 1.51, 95% CI 0.75-3.06). Receiving 30 mL/kg between 1 and 3 versus <1 h increased the incidence of delayed hypotension (OR 1.83, 95% CI 1.23-2.72) but did not impact need for intubation, intensive care unit admission, or vasopressors. CONCLUSIONS We observed weak evidence that supports that earlier is better for survival when reaching fluid goals of 30 mL/kg, but benefits may wane at later time points. These findings should be viewed as hypothesis generating.
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Affiliation(s)
- Hani I Kuttab
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Chad G Evans
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Joseph D Lykins
- Department of Emergency Medicine & Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Michelle D Hughes
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Jason A Kopec
- Division of Emergency Medicine, Carle Foundation Hospital, Urbana, IL, USA
| | - Michael A Hernandez
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Michael A Ward
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
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Bauer SR, Gellatly RM, Erstad BL. Precision fluid and vasoactive drug therapy for critically ill patients. Pharmacotherapy 2023; 43:1182-1193. [PMID: 36606689 PMCID: PMC10323046 DOI: 10.1002/phar.2763] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 01/07/2023]
Abstract
There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rochelle M Gellatly
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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10
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Mazumder NR, Junna S, Sharma P. The Diagnosis and Non-pharmacological Management of Acute Kidney Injury in Patients with Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:S11-S19. [PMID: 37625862 DOI: 10.1016/j.cgh.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/01/2023] [Accepted: 04/06/2023] [Indexed: 08/27/2023]
Abstract
Acute kidney injury in patients with cirrhosis is quite common, and is seen in up to 50% of patients hospitalized for decompensated cirrhosis. Causes of acute kidney injury include prerenal, renal, or postrenal etiologies. The diagnosis and early institution of nonpharmacologic and pharmacologic management are key to the recovery of renal function. The objective of this review is to provide a practical approach to the use of diagnostic biomarkers and highlight the nonpharmacologic management and prevention of acute kidney injury.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Shilpa Junna
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
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11
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Wiss AL, Doepker BA, Hoyte B, Olson LM, Disney KA, McLaughlin EM, Esguerra V, Elefritz JL. Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:254-260. [PMID: 37533810 PMCID: PMC10391556 DOI: 10.1016/j.jointm.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/13/2023] [Accepted: 05/08/2023] [Indexed: 08/04/2023]
Abstract
Background Fluid resuscitation is a key treatment for sepsis, but limited data exists in patients with existing heart failure (HF) and septic shock. The objective of this study was to determine the impact of initial fluid resuscitation volume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with septic shock. Methods This multicenter, retrospective, cohort study included patients with known HF (LVEF ≤50%) presenting with septic shock. Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h; <30 mL/kg or ≥30 mL/kg. The primary outcome was a composite of in-hospital mortality or renal replacement therapy (RRT) within 7 days. Secondary outcomes included acute kidney injury (AKI), initiation of mechanical ventilation, and length of stay (LOS). All related data were collected and compared between the two groups. A generalized logistic mixed model was used to assess the association between fluid groups and the primary outcome while adjusting for baseline LVEF, Acute Physiology and Chronic Health Evaluation (APACHE) II score, inappropriate empiric antibiotics, and receipt of corticosteroids. Results One hundred and fifty-four patients were included (93 patients in <30 mL/kg group and 61 patients in ≥30 mL/kg group). The median weight-based volume in the first 6 h was 17.7 (12.2-23.0) mL/kg in the <30 mL/kg group vs. 40.5 (34.2-53.1) mL/kg in the ≥30 mL/kg group (P <0.01). No statistical difference was detected in the composite of in-hospital mortality or RRT between the <30 mL/kg group compared to the ≥30 mL/kg group (55.9% vs. 45.9%, P=0.25), respectively. The <30 mL/kg group had a higher incidence of AKI, mechanical ventilation, and longer hospital LOS. Conclusions In patients with known reduced or mildly reduced LVEF presenting with septic shock, no difference was detected for in-hospital mortality or RRT in patients who received ≥30 mL/kg of resuscitation fluid compared to less fluid, although this study was underpowered to detect a difference. Importantly, ≥30 mL/kg fluid did not result in a higher need for mechanical ventilation.
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Affiliation(s)
- Adam L. Wiss
- Department of Pharmacy, Ascension Saint Thomas Hospital West, Nashville, TN 37205, USA
| | - Bruce A. Doepker
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Brittany Hoyte
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Logan M. Olson
- Department of Pharmacy, Nebraska Medicine, Omaha, NE 68105, USA
| | - Kathryn A. Disney
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT 84112, USA
| | - Eric M. McLaughlin
- Center for Biostatistics, The Ohio State University, Columbus, OH 43210, USA
| | - Vincent Esguerra
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine. The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jessica L. Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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12
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Dugar S, Sato R, Chawla S, You JY, Wang X, Grimm R, Collier P, Lanspa M, Duggal A. Is Left Ventricular Systolic Dysfunction Associated With Increased Mortality Among Patients With Sepsis and Septic Shock? Chest 2023; 163:1437-1447. [PMID: 36646415 DOI: 10.1016/j.chest.2023.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/13/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The impact of left ventricular (LV) systolic function on outcomes in patients with sepsis and septic shock remains uncertain. The association, if any, may be nonlinear. RESEARCH QUESTION Is LV systolic dysfunction associated with increased mortality among patients with sepsis and septic shock? STUDY DESIGN AND METHODS Retrospective cohort study comprising all adult patients admitted to the medical ICU from January 1, 2011, through December 31, 2020, with sepsis and septic shock as defined by the Third International Consensus Definitions for Sepsis and Septic Shock guidelines. All adult patients with sepsis or septic shock who underwent transthoracic echocardiography within 3 days from admission to the medical ICU were included. We divided patients into five groups based on LV ejection fraction (LVEF). In addition to univariate analysis, we also performed multivariate logistic regression analysis adjusting for patients' baseline characteristics and severity of illness. The primary outcome was the association between each classification of LVEF and in-hospital mortality. RESULTS A total of 3,151 patients were included in this study (LVEF < 25%, 133 patients; 25% ≤ LVEF < 40%, 305 patients; 40% ≤ LVEF < 55%, 568 patients; 55% ≤ LVEF < 70%, 1,792 patients; and LVEF ≥ 70%, 353 patients). In-hospital mortalities in each LVEF category were 51.1%, 34.8%, 26.6%, 26.2%, and 41.9%, respectively. In the multivariate logistic regression analysis, LVEF of < 25% (OR, 2.75; 95% CI, 1.82-4.17; P < .001) and LVEF of ≥ 70% (OR, 1.70; 95% CI, 1.09-1.88; P = .010) were associated independently with significantly higher in-hospital mortality compared with the reference LVEF category of 55% to 70%. INTERPRETATION The association of LVEF to in-hospital mortality in sepsis and septic shock was U-shaped. Both severe LV systolic dysfunction (LVEF < 25%) and hyperdynamic LVEF (LVEF ≥ 70%) were associated independently with significantly higher in-hospital mortality.
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Affiliation(s)
- Siddharth Dugar
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH.
| | - Ryota Sato
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Sanchit Chawla
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Jee Young You
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Richard Grimm
- Heart, Vascular, and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Patrick Collier
- Heart, Vascular, and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Michael Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Abhijit Duggal
- Respiratory Institute, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
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13
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Bharwani A, Pérez ML, Englesakis M, Meyhoff TS, Perner A, Sivapalan P, Wilcox ME. Protocol for a systematic review and meta-analysis assessing conservative versus liberal intravenous fluid administration in patients with sepsis or septic shock at risk of fluid overload. BMJ Open 2023; 13:e069601. [PMID: 37225275 DOI: 10.1136/bmjopen-2022-069601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Intravenous crystalloid fluid resuscitation forms a crucial part of the early intervention bundle for sepsis and septic shock, with the Surviving Sepsis Campaign guidelines recommending a 30 mL/kg fluid bolus within the first hour. Compliance with this suggested target varies in patients with comorbidities such as congestive heart failure, chronic kidney disease and cirrhosis due to concerns regarding iatrogenic fluid overload. However, it remains unclear whether resuscitation with higher fluid volumes puts them at greater risk of adverse outcomes. Thus, this systematic review will synthesise evidence from existing studies to assess the effects of a conservative as compared with a liberal approach to fluid resuscitation in patients at greater perceived risk of fluid overload due to comorbid conditions. METHODS AND ANALYSIS This protocol was registered on PROSPERO and has been drafted following the checklist of Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. We will search MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase, Embase Classic, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science Core Collection, CINAHL Complete and ClinicalTrials.gov. A preliminary search of these databases was performed from their inception to 30 August 2022. The risk of bias and random errors will be assessed using the revised Cochrane risk-of-bias tool for randomised clinical trials and the Newcastle-Ottawa Scale for case-control and cohort studies. If a sufficient number of comparable studies are identified, we will perform a meta-analysis applying random effects model. We will investigate heterogeneity using a combination of visual inspection of the funnel plot as well as the Egger's test. ETHICS AND DISSEMINATION No ethics approval is required for this study since no original data will be collected. The findings will be disseminated through peer-reviewed publication and conference presentation. PROSPERO REGISTRATION NUMBER CRD42022348181.
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Affiliation(s)
- Aadil Bharwani
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - María Lucía Pérez
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | | | - Anders Perner
- Department of Intensive Care, University of Copenhagen, Kobenhavn, Denmark
| | - Praleene Sivapalan
- Department of Intensive Care, University of Copenhagen, Kobenhavn, Denmark
| | - Mary Elizabeth Wilcox
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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14
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Urina Jassir D, Chaanine AH, Desai S, Rajapreyar I, Le Jemtel TH. Therapeutic Dilemmas in Mixed Septic-Cardiogenic Shock. Am J Med 2023; 136:27-32. [PMID: 36252709 DOI: 10.1016/j.amjmed.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 12/13/2022]
Abstract
Sepsis is an increasing cause of decompensation in patients with chronic heart failure with reduced or preserved ejection fraction. Sepsis and decompensated heart failure results in a mixed septic-cardiogenic shock that poses several therapeutic dilemmas: Rapid fluid resuscitation is the cornerstone of sepsis management, while loop diuretics are the main stay of decompensated heart failure treatment. Whether inotropic therapy with dobutamine or inodilators improves microvascular alterations remains unsettled in sepsis. When to resume loop diuretic therapy in patients with sepsis and decompensated heart failure is unclear. In the absence of relevant guidelines, we review vasopressor therapy, the timing and volume of fluid resuscitation, and the need for inotropic therapy in patients who, with sepsis and decompensated heart failure, present with a mixed septic-cardiogenic shock.
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Affiliation(s)
- Daniela Urina Jassir
- Department of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, La
| | - Antoine H Chaanine
- Department of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, La
| | - Sapna Desai
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, La
| | - Indranee Rajapreyar
- Department of Cardiovascular Medicine, Thomas Jefferson University Hospitals, Philadelphia, Penn
| | - Thierry H Le Jemtel
- Department of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, La.
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15
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Lehman KD. Evidence-based updates to the 2021 Surviving Sepsis Campaign guidelines Part 2: Guideline review and clinical application. Nurse Pract 2022; 47:28-35. [PMID: 36399145 DOI: 10.1097/01.npr.0000884888.21622.e3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT NPs should be prepared to screen for sepsis, initiate treatment, and optimize care for sepsis survivors. The 2021 Surviving Sepsis Campaign guidelines offer best practices for identification and management of sepsis and septic shock. This article, second in a 2-part series, presents evidence updates and discusses implications for NPs.
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Affiliation(s)
- Karen D Lehman
- Karen D. Lehman is a hospitalist NP and PRN ED NP at NMC Health in Newton, Kan., an ED NP with Docs Who Care based in Olathe, Kan., and a hospice NP with Harry Hynes Memorial Hospice in Wichita, Kan
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16
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Matsuda W, Funato Y, Miyazaki M, Tomiyama K. Fluid resuscitation of at least 30 mL/kg was not associated with decreased mortality in patients with infection, signs of hypoperfusion, and a do-not-intubate order. Acute Med Surg 2022; 9:e795. [PMID: 36203853 PMCID: PMC9525617 DOI: 10.1002/ams2.795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Aim Administration of at least 30 mL/kg of fluid as fluid resuscitation is recommended for patients with sepsis and signs of hypoperfusion. However, it is not clear whether this is appropriate for patients with a do‐not‐intubate (DNI) order. This study evaluated the association between volume of fluid resuscitation and outcomes in patients with infection, signs of hypoperfusion, and a DNI order in an emergency department. Methods This was a single‐center retrospective cohort study. We classified the infected patients with signs of hypoperfusion and a DNI order seen in our emergency department between April 1, 2015 and November 31, 2020 into the standard fluid resuscitation group (≥30 mL/kg) and the restricted fluid resuscitation group (<30 mL/kg). We compared with in‐hospital mortality and the rate of discharge to home in two groups. Results Of 367 patients, 149 received standard fluid resuscitation and 218 received restricted fluid resuscitation. In‐hospital mortality was similar in each group (40/149 and 62/218, respectively). Standard fluid resuscitation was not associated with in‐hospital mortality (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.62–1.77, P = 0.86), but was associated with a significantly lower rate of discharge to home (aOR, 0.55; 95% CI, 0.30–0.98, P = 0.043). There was no significant difference in respiratory rate or need for oxygen therapy post‐resuscitation between the two groups. Conclusion This study suggests that fluid resuscitation may be not beneficial for infected patients with signs of hypoperfusion and a DNI order. Further studies should be conducted on the options for resuscitation management for these patients.
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Affiliation(s)
- Wataru Matsuda
- Department of Emergency Medicine and Critical CareCenter Hospital of the National Center for Global Health and MedicineToyama, Shinjuku, TokyoJapan
| | - Yumi Funato
- Department of Emergency Medicine and Critical CareCenter Hospital of the National Center for Global Health and MedicineToyama, Shinjuku, TokyoJapan
| | - Momoyo Miyazaki
- Department of Emergency Medicine and Critical CareCenter Hospital of the National Center for Global Health and MedicineToyama, Shinjuku, TokyoJapan
| | - Koichiro Tomiyama
- Department of Emergency Medicine and Critical CareCenter Hospital of the National Center for Global Health and MedicineToyama, Shinjuku, TokyoJapan
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17
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Jones TW, Chase AM, Bruning R, Nimmanonda N, Smith SE, Sikora A. Early Diuretics for De-resuscitation in Septic Patients With Left Ventricular Dysfunction. Clin Med Insights Cardiol 2022; 16:11795468221095875. [PMID: 35592767 PMCID: PMC9112302 DOI: 10.1177/11795468221095875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/01/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction: De-resuscitation practices in septic patients with heart failure (HF) are not
well characterized. This study aimed to determine if diuretic initiation
within 48 hours of intensive care unit (ICU) admission was associated with a
positive fluid balance and patient outcomes. Methods: This single-center, retrospective cohort study included adult patients with
an established diagnosis of HF admitted to the ICU with sepsis or septic
shock. The primary outcome was the incidence of positive fluid balance in
patients receiving early (<48 hours) versus late (>48 hours)
initiation of diuresis. Secondary outcomes included hospital mortality,
ventilator-free days, and hospital and ICU length of stay. Continuous
variables were assessed using independent t-test or Mann-Whitney U, while
categorical variables were evaluated using the Pearson Chi-squared test. Results: A total of 101 patients were included. Positive fluid balance was
significantly reduced at 72 hours (−139 mL vs 4370 mL,
P < .001). The duration of mechanical ventilation (4 vs
5 days, P = .129), ventilator-free days (22 vs 18.5 days,
P = .129), and in-hospital mortality (28 (38%) vs 12
(43%), P = .821) were similar between groups. In a subgroup
analysis excluding patients not receiving renal replacement therap (RRT)
(n = 76), early diuretics was associated with lower incidence of mechanical
ventilation (41 [73.2%] vs 20 (100%), P = .01) and reduced
duration of mechanical ventilation (4 vs 8 days,
P = .018). Conclusions: Diuretic use within 48 hours of ICU admission in septic patients with HF
resulted in less incidence of positive fluid balance. Early diuresis in this
unique patient population warrants further investigation.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Aaron M Chase
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Rebecca Bruning
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Naphun Nimmanonda
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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18
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Del Río-Carbajo L, Nieto-Del Olmo J, Fernández-Ugidos P, Vidal-Cortés P. [Resuscitation strategy for patients with sepsis and septic shock]. Med Intensiva 2022; 46 Suppl 1:60-71. [PMID: 38341261 DOI: 10.1016/j.medine.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/11/2022] [Indexed: 02/12/2024]
Abstract
Fluid and vasopressor resuscitation is, along with antimicrobial therapy and control of the focus of infection, a basic issue of the treatment of sepsis and septic shock. There is currently no accepted protocol that we can follow for the resuscitation of these patients and the Surviving Sepsis Campaign proposes controversial measures and without sufficient evidence support to establish firm recommendations. We propose a resuscitation strategy adapted to the situation of each patient: in the patient in whom community sepsis is suspected, we consider that the early administration of 30mL/kg of crystalloids is effective and safe; in the patient with nosocomial sepsis, we must carry out a more in-depth evaluation before initiating aggressive resuscitation. In patients who do not respond to initial resuscitation, it is necessary to increase monitoring level and, depending on the hemodynamic profile, administer more fluids, a second vasopressor or inotropes.
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Affiliation(s)
- L Del Río-Carbajo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - J Nieto-Del Olmo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - P Fernández-Ugidos
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España
| | - P Vidal-Cortés
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense. Ourense, España.
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19
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Johnson AP, Fallon T, Thorgesen D. Dynamic and Static Cardiac Function Measurements During Sepsis. Crit Care Nurse 2022; 42:76-78. [PMID: 35362072 DOI: 10.4037/ccn2022643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Alexander P Johnson
- Alexander P. Johnson is a critical care clinical nurse specialist at Northwestern Medicine Huntley Hospital, Huntley, Illinois
| | - Tara Fallon
- Tara Fallon is a critical care manager, Northwestern Medicine Central DuPage Hospital, Winfield, Illinois
| | - Deborah Thorgesen
- Deborah Thorgesen is a clinical nurse manager, Northwestern Medicine Huntley Hospital
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20
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Treating Sepsis in Patients with Heart Failure. Crit Care Nurs Clin North Am 2022; 34:165-172. [DOI: 10.1016/j.cnc.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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The American College of Emergency Physicians Policy Statement on Sepsis-based Fluid Resuscitation Thirsts for Supporting Evidence and Balance. Ann Emerg Med 2022; 79:318-319. [DOI: 10.1016/j.annemergmed.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Indexed: 11/23/2022]
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22
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Estrategia integral de reanimación del paciente con sepsis y shock séptico. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med 2022; 55:157-166. [DOI: 10.1016/j.ajem.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022] Open
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Ehrman RR, Ottenhoff JD, Favot MJ, Harrison NE, Khait L, Welch RD, Levy PD, Sherwin RL. Do septic patients with reduced left ventricular ejection fraction require a low-volume resuscitative strategy? Am J Emerg Med 2021; 52:187-190. [PMID: 34952322 DOI: 10.1016/j.ajem.2021.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Many clinicians are wary of administering 30 cc/kg of intravenous fluid (IVF) to septic patients with reduced left-ventricular ejection fraction (rLVEF), fearing volume overload. Prior studies have used history of heart failure, rather than LVEF measured at presentation, thereby potentially distorting the relationship between rLVEF, IVF, and adverse outcomes. Our goal was to assess the relationship between IVF volume and outcomes in patients with, versus without, rLVEF. METHODS This was a prospective observational study performed at an urban Emergency Department (ED). Included patients were adults with suspected sepsis, defined as being treated for infection plus either systolic blood pressure <90 mm/Hg or lactate >2 mmol/L. All patients had LVEF assessed by ED echocardiogram, prior to receipt of >1 l IVF. MEASUREMENTS AND MAIN RESULTS We enrolled 73 patients, of whom 33 had rLVEF, defined as <40%. Patients with rLVEF were older, had greater initial lactate, more ICU admission, and more vasopressor use. IVF volume was similar between LVEF groups at 3-h (2.2 (IQR 0.8) vs 2.0 (IQR 2.4) liters) while patients with rLVEF were more likely to achieve 30 cc/kg (61% (CI 44-75) vs 45% (CI 31-60). In the reduced versus not-reduced LVEF groups, hospital days, ICU days, and ventilator days were similar: 8 (IQR 7) vs 6.5 (8.5) days, 7 (IQR 7) vs 5 (4) days, and 4 (IQR 8) vs. 5 (10) days, respectively. CONCLUSIONS Septic patients with rLVEF at presentation received similar volume of IVF as those without rLVEF, without an increase in adverse outcomes attributable to volume overload. While validation is needed, our results suggest that limiting IVF administration in the setting of rLVEF is not necessary.
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Affiliation(s)
- Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America.
| | - Jakob D Ottenhoff
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Mark J Favot
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Nicholas E Harrison
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Lyudmila Khait
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Robert D Welch
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Detroit Receiving Hospital, United States of America
| | - Philip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine; Integrative Biosciences Center, Detroit, MI 48201, United States of America
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
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25
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When Minutes Matter: Rapid Infusion in Emergency Care. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2021. [DOI: 10.1007/s40138-021-00237-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
This review provides historical context and an update on recent advancements in volume resuscitation for circulatory shock. Emergency department providers who manage critically ill patients with undifferentiated shock will benefit from the insights of early pioneers and an overview of newer techniques which can be used to optimize resuscitation in the first minutes of care.
Recent Findings
Rapid infusion of fluids and blood products can be a life-saving intervention in the management of circulatory and hemorrhagic shock. Recent controversy over the role of fluid resuscitation in sepsis and trauma management has obscured the importance of early and rapid infusion of sufficient volume to restore circulation and improve organ perfusion. Evidence from high-quality studies demonstrates that rapid and early resuscitation improves patient outcomes.
Summary
Current practice standards, guidelines, and available literature support the rapid reversal of shock as a key priority in the treatment of hypotension from traumatic and non-traumatic conditions. An improved understanding of the physiologic rationale of rapid infusion and the timing, volume, and methods of fluid delivery will help clinicians improve care for critically ill patients presenting with shock.
Clinical Case
A 23-year-old male presents to the emergency department (ED) after striking a tree while riding an all-terrain vehicle. On arrival at the scene, first responders found an unconscious patient with an open skull fracture and a Glasgow coma scale score of 3. Bag-valve-mask (BVM) ventilation was initiated, and a semi-rigid cervical collar was placed prior to transport to your ED for stabilization while awaiting air transport to the nearest trauma center. You are the attending emergency medicine physician at a community ED staffed by two attending physicians, two physicians assistants, and six nurses covering 22 beds. On ED arrival, the patient has no spontaneous respiratory effort, and vital signs are as follows: pulse of 140 bpm, blood pressure of 65/30 mmHg, and oxygen saturation 85% while receiving BVM ventilation with 100% oxygen. He is bleeding profusely through a gauze dressing applied to the exposed dura. The prehospital team was unable to establish intravenous access. What are the management priorities for this patient in shock, and how should his hypotension best be addressed?
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Acharya R, Patel A, Schultz E, Bourgeois M, Kandinata N, Paswan R, Kafle S, Sedhai YR, Younus U. Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study. PLoS One 2021; 16:e0256368. [PMID: 34411178 PMCID: PMC8376054 DOI: 10.1371/journal.pone.0256368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The use of ≥30 mL/Kg fluid bolus in congestive heart failure (CHF) patients presenting with severe sepsis or septic shock remained controversial due to the paucity of data. METHODS The retrospective case-control study included 671 adult patients who presented to the emergency department of a tertiary care hospital from January 01, 2017 to December 31, 2019 with severe sepsis or septic shock. Patients were categorized into the CHF group and the non-CHF group. The primary outcome was to evaluate the compliance with ≥30 mL/Kg fluid bolus within 6 hours of presentation. The comparison of baseline characteristics and secondary outcomes were done between the groups who received ≥30 mL/Kg fluid bolus. For the subgroup analysis of the CHF group, it was divided based on if they received ≥30 mL/Kg fluid bolus or not, and comparison was done for baseline characteristics and secondary outcomes. Univariate and multivariable analyses were performed to explore the differences between the groups for in-hospital mortality and mechanical ventilation. RESULTS The use of ≥30 mL/Kg fluid bolus was low in both the CHF and non-CHF groups [39% vs. 66% (p<0.05)]. Mortality was higher in the CHF group [33% vs 18% (p<0.05)]. Multivariable analysis revealed that the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 12% [OR 0.88, 95% CI 0.82-0.95 (p<0.05)]. The use of ≥30 mL/Kg fluid bolus did not increase the odds of mechanical ventilation [OR 0.99, 95% CI 0.93-1.05 (p = 0.78)]. In subgroup analysis, the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 5% [OR 0.95, 95% CI 0.90-0.99, (p<0.05)] and did not increase the odds of mechanical ventilation. The presence of the low ejection fraction did not influence the chance of getting fluid bolus. CONCLUSION The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.
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Affiliation(s)
- Roshan Acharya
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Aakash Patel
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Evan Schultz
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Michael Bourgeois
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Natalie Kandinata
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Rishi Paswan
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Smita Kafle
- RN-BSN Program, Fayetteville State University, Fayetteville, NC, United States of America
| | - Yub Raj Sedhai
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Usman Younus
- Department of Critical Care Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
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Lee H, Choi SH, Kim K, Shin TG, Park YS, Ryoo SM, Suh GJ, Kwon WY, Lim TH, Son D, Kim WY, Ko BS. Effect of rapid fluid administration on the prognosis of septic shock patients with isolated hyperlactatemia: A prospective multicenter observational study. J Crit Care 2021; 66:154-159. [PMID: 34294426 DOI: 10.1016/j.jcrc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND We aimed to investigate the association between initial fluid resuscitation in septic shock patients with isolated hyperlactatemia and outcomes. METHODS This multicenter prospective study was conducted using the data from the Korean Shock Society registry. Patients diagnosed with isolated hyperlactatemia between October 2015 and December 2018 were included and divided into those who received 30 mL/kg of fluid within 3 or 6 h and those who did not receive. The primary outcome was in-hospital mortality; the secondary outcomes were intensive care unit (ICU) admission, length of ICU stay, mechanical ventilation, and renal replacement therapy (RRT). RESULTS A total of 608 patients were included in our analysis. The administration of 30 mL/kg crystalloid within 3 or 6 h was not significantly associated with in-hospital mortality in multivariable logistic regression analysis ([OR, 0.8; 95% CI, 0.52-1.23, p = 0.31], [OR, 0.96; 95% CI, 0.59-1.57, p = 0.88], respectively). The administration of 30 mL/kg crystalloid within 3-h was not significantly associated with mechanical ventilation and RRT ([OR, 1.19; 95% CI, 0.77-1.84, p = 0.44], [OR, 1.2; 95% CI, 0.7-2.04, p = 0.5], respectively). However, the administration of 30 mL/kg crystalloid within 6 h was associated with higher ICU admission and RRT ([OR, 1.57; 95% CI, 1.07-2.28, p = 0.02], [OR, 2.08; 95% CI, 1.19-3.66, p = 0.01], respectively). CONCLUSIONS Initial fluid resuscitation of 30 mL/kg within 3 or 6 h was neither associated with an increased or decreased in-hospital mortality in septic shock patients with isolated hyperlactatemia.
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Affiliation(s)
- Heekyung Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA University School of Medicine, CHA Bundang Medical Center, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Donghee Son
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea.
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Litell JM, Guirgis F, Driver B, Jones AE, Puskarich MA. Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge. Acad Emerg Med 2021; 28:745-752. [PMID: 33872430 DOI: 10.1111/acem.14265] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 03/16/2021] [Accepted: 04/01/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Effective sepsis resuscitation depends on useful criteria for prompt identification of eligible patients. These criteria should reliably predict a discharge diagnosis of sepsis, ensuring that interventions are triggered for those who need it while avoiding potentially harmful interventions in those who do not. We sought to determine the proportion of patients meeting sepsis criteria in the emergency department (ED) that was ultimately diagnosed with sepsis and to quantify the subset of nonseptic patients with risk factors for harm from fluid resuscitation. METHODS This retrospective cohort study of adult ED patients at a tertiary academic medical center included vital signs and laboratory results from the first 6 hours, plus administration of intravenous antibiotics, to determine if patients met 2016 Sepsis-3 consensus criteria. If these patients also had hypotension and lactic acidosis, we categorized them as Sepsis-3 plus shock. We used discharge ICD-9 codes to determine if patients were ultimately diagnosed with sepsis. RESULTS Over 8 years, 3,121 ED patients met 2016 Sepsis-3 criteria in the first 6 hours. Of these, only 25% and 48% met explicit and implicit criteria for a discharge diagnosis of sepsis. Of 1,032 patients with Sepsis-3 plus shock, 48% and 62% met explicit and implicit criteria. Overall, 60% to 75% of ED patients meeting Sepsis-3 criteria with or without shock did not receive a sepsis discharge diagnosis. At least one plausible risk factor for harm from large-volume fluid resuscitation was identified among 19% to 36% of patients meeting sepsis criteria in the ED but not ultimately diagnosed with sepsis at discharge. CONCLUSIONS Most patients meeting sepsis criteria in the ED were not diagnosed with sepsis at discharge. Urgent treatment bundles triggered by consensus criteria in the early phase of ED care may be administered to several patients without sepsis, potentially exposing some to interventions of uncertain benefit and possible harm.
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Affiliation(s)
- John M. Litell
- Department of Emergency Medicine Hennepin Healthcare Minneapolis Minnesota USA
- Department of Emergency Medicine University of Minnesota Minneapolis Minnesota USA
| | - Faheem Guirgis
- Department of Emergency Medicine University of Florida Jacksonville Florida USA
| | - Brian Driver
- Department of Emergency Medicine Hennepin Healthcare Minneapolis Minnesota USA
- Department of Emergency Medicine University of Minnesota Minneapolis Minnesota USA
| | - Alan E. Jones
- Department of Emergency Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Michael A. Puskarich
- Department of Emergency Medicine Hennepin Healthcare Minneapolis Minnesota USA
- Department of Emergency Medicine University of Minnesota Minneapolis Minnesota USA
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30
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Lat I, Coopersmith CM, De Backer D. The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients. Crit Care Med 2021; 49:623-635. [PMID: 33731607 PMCID: PMC7963440 DOI: 10.1097/ccm.0000000000004864] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Original article, literature search. STUDY SELECTION Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. DATA EXTRACTION None. DATA SYNTHESIS None. CONCLUSION In the second of a series of manuscripts subsequent to the original article, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan AbilityLab, Chicago, IL
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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Wang Y, Zhai X, Zhu M, Pan Y, Yang M, Yu K, He B. Risk factors for postoperative sepsis-induced cardiomyopathy in patients undergoing general thoracic surgery: a single center experience. J Thorac Dis 2021; 13:2486-2494. [PMID: 34012595 PMCID: PMC8107539 DOI: 10.21037/jtd-21-492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The current study aimed to investigate the incidence of sepsis-induced cardiomyopathy (SICM) in patients who received general thoracic surgery, along with the risk factors and management strategies for this complication. Methods The clinical records of 163 patients with postoperative sepsis were retrospectively reviewed. After propensity score matching, 144 patients were divided into 2 groups by stroke volume: the SICM group (n=72) and the non-SICM group (n=72). Results The overall incidence of postoperative SICM was 53.99%. Multiple logistic regression analysis showed that stroke volume and C-reactive protein were independent predictors of mortality in patients with postoperative sepsis. Statistical analysis by t-test and χ2 test indicated that mortality (P=0.000), B-type natriuretic peptide (P=0.001), left ventricular ejection fraction (P=0.000), the mitral peak velocity of early filling/early diastolic mitral annular velocity (E/e’) (P=0.049), C-reactive protein (P=0.016), procalcitonin (P=0.013), serum creatinine (P=0.016), platelets (P=0.028), and lactic acid (P=0.002) were significantly associated with the occurrence of postoperative SICM. Among these parameters, B-type natriuretic peptide was identified as the best biomarker for predicting SICM by receiver operating characteristic (ROC) curve analysis. Conclusions It is vital to improve the diagnosis and standard management of SICM. A combined strategy comprising early detection of suspected infection, adequate use of antibiotics, close monitoring, effective drainage, and supportive care may improve the outcomes of patients with postoperative SICM.
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Affiliation(s)
- Yinghua Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Intensive Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xinming Zhai
- Department of Intensive Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Minfang Zhu
- Department of Intensive Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Pan
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Min Yang
- Department of Intensive Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Kaiyan Yu
- Department of Intensive Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Lat I, Coopersmith CM, De Backer D, Coopersmith CM. The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. Intensive Care Med Exp 2021; 9:10. [PMID: 33644843 PMCID: PMC7917035 DOI: 10.1186/s40635-021-00369-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective To expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Data Sources Original paper and literature search. Study Selection Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. Data Extraction None. Data Synthesis None. Conclusion In the second of a series of manuscripts subsequent to the original paper, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan Abilitylab, Chicago, IL, USA.
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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Musikatavorn K, Plitawanon P, Lumlertgul S, Narajeenron K, Rojanasarntikul D, Tarapan T, Saoraya J. Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock. West J Emerg Med 2021; 22:369-378. [PMID: 33856325 PMCID: PMC7972359 DOI: 10.5811/westjem.2020.11.48571] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/10/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy. Methods This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups. Results A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm. Conclusion In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used.
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Affiliation(s)
- Khrongwong Musikatavorn
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand.,Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Department of Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Poj Plitawanon
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Suthaporn Lumlertgul
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Khuansiri Narajeenron
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Dhanadol Rojanasarntikul
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Tanawat Tarapan
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand
| | - Jutamas Saoraya
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Department of Emergency Medicine, Faculty of Medicine, Bangkok, Thailand.,Chulalongkorn University, Faculty of Medicine, Division of Academic Affairs, Bangkok, Thailand
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Huebinger RM, Walia S, Yealy DM, Kellum JA, Huang DT, Wang HE. Outcomes of end-stage renal disease patients in the PROCESS trial. J Am Coll Emerg Physicians Open 2021; 2:e12358. [PMID: 33506231 PMCID: PMC7813517 DOI: 10.1002/emp2.12358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/01/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Intravenous fluid administration is a main component of sepsis therapy, but physicians are cautious about giving fluids to end-stage renal disease (ESRD) patients out of concern for causing volume overload. We compared the outcomes of septic shock patients with and without ESRD and evaluated the association between early intravenous fluid administration and outcomes. METHODS We analyzed patients enrolled in the Protocolized Care for Early Septic Shock (PROCESS) trial, which studied different resuscitation strategies for early septic shock. Stratifying for ESRD, we compared patient characteristics, course of care, and outcomes between ESRD and non-ESRD. Using multivariable logistic regression, we determined the association between 6-hour total fluid volume (> = 30 mL/kg vs < 30 mL/kg) from preenrollment and outcomes. RESULTS There were 84 ESRD and 1257 non-ESRD patients. ESRD patients had a higher median Charlson Comorbidity score (5 vs 2, P < .001), higher median acute physiology and chronic health evaluation (APACHE) II score (26.5 vs 20.0, P < .001), and lower 6-hour intravenous fluid administration (54.7 vs 68.3 mL/kg, P < .001). Ninety-day mortality (33.3% vs 29.3%, P = .43) and intubation rate (31.0% vs 33.4%, P = .64) did not differ between groups. Fewer ESRD received > = 30 mL/kg (66.6% vs 86.7% P < .001). For ESRD, receipt of > = 30 mL/kg intravenous fluid did not alter any outcome. For non-ESRD patients, receiving ≥30 mL/kg of intravenous fluid was associated with increased 90-day mortality (adjusted odds ratio = 1.64; 95% confidence interval, 1.03-2.61). CONCLUSIONS In the PROCESS trial, ESRD patients had similar outcomes to non-ESRD patients. Although ESRD patients received less intravenous fluid administration, most received over 30 mL/kg in the first 6 hours. In contrast to non-ESRD patients, receiving ≥30 mL/kg of intravenous fluid was not associated with worse outcomes in ESRD.
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Affiliation(s)
- Ryan M. Huebinger
- Department of Emergency MedicineMcGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)HoustonTexasUSA
| | - Shabana Walia
- Department of Emergency MedicineMcGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)HoustonTexasUSA
| | - Donald M. Yealy
- Department of Emergency MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - John A. Kellum
- Department of Critical Care MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - David T. Huang
- Department of Emergency MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Henry E. Wang
- Department of Emergency MedicineMcGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth)HoustonTexasUSA
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Zhang Y, Ding XH, Pang F, Zhang L, Wang Y, Wang W, Rao R, Bian SZ. The Prevalence and Independent Risk Factors of Significant Tricuspid Regurgitation Jets in Maintenance Hemodialysis Patients With ESRD. Front Physiol 2021; 11:568812. [PMID: 33391009 PMCID: PMC7773604 DOI: 10.3389/fphys.2020.568812] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/30/2020] [Indexed: 01/19/2023] Open
Abstract
Background and Aim Tricuspid regurgitation (TR) is a frequent complication in various cardiovascular diseases. However, few studies have reported the prevalence of TR especially the moderate to severe or significant TR (ms-TR) maintenance dialysis patients. Thus, we aimed to identify the prevalence of ms-TR and its associated factors. Methods A total of 491 maintenance dialysis patients underwent echocardiographic examinations, while a subgroup (n = 283) also received routine blood tests, renal function examinations, and electrolyte analysis. We first compared the differences in abovementioned parameters among groups with various TR areas (TRAs). Finally, univariate and adjusted regression were also used to identify factors that were independently associated with ms-TR. Results The incidence of TR jets was 62.6%, which included a mildly increased TRA (47.8%), moderately increased TRA (10.4%), and severely increased TRA (3.5%). Most of the cardiac structures and functional parameters, such as the end-diastolic internal diameters of the left atrium (LA), left ventricle (LVDD), right atrium (RA), right ventricle (RV), left ventricular ejection fraction (LVEF), and fractional shortening (FS), were significantly associated with ms-TR. Among serum ions, only total CO2 (TCO2; r = −0.141, p = 0.047) was negatively correlated with TRA. After adjusted, only Na+ [odds ratio (OR): 0.871 0.888, p = 0.048], RA (OR: 1.370, p < 0.001), and FS (OR: 0.887, p < 0.001) were independently associated with ms-TR. Conclusion Tricuspid regurgitation occurs in maintenance hemodialysis patients with ESRD. Na+ FS and RA were independently associated with ms-TR, and these parameters may be potential risk factors/predictors for ms-TR.
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Affiliation(s)
- Ying Zhang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiao-Han Ding
- Department of Health Care and Geriatrics, The 940th Hospital of PLA Joint Logistics Support Force, Lanzhou, China
| | - Fang Pang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Laiping Zhang
- Institute of Cardiovascular Diseases of PLA, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Cardiology, Xinqiao Hospital, Chongqing, China
| | - Yiqin Wang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weili Wang
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Rongsheng Rao
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shi-Zhu Bian
- Institute of Cardiovascular Diseases of PLA, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Cardiology, Xinqiao Hospital, Chongqing, China
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Jagan N, Morrow LE, Walters RW, Plambeck RW, Patel TM, Kalian KF, Macaraeg JC, Dyer ED, Bergh AA, Fried AJ, Moore DR, Malesker MA. Sepsis, the Administration of IV Fluids, and Respiratory Failure: A Retrospective Analysis-SAIFR Study. Chest 2020; 159:1437-1444. [PMID: 33197405 DOI: 10.1016/j.chest.2020.10.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/18/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although resuscitation with IV fluids is the cornerstone of sepsis management, consensus regarding their association with improvement in clinical outcomes is lacking. RESEARCH QUESTION Is there a difference in the incidence of respiratory failure in patients with sepsis who received guideline-recommended initial IV fluid bolus of 30 mL/kg or more conservative resuscitation of less than 30 mL/kg? STUDY DESIGN AND METHODS This was a retrospective analysis of prospectively collected clinical data conducted at an academic medical center in Omaha, Nebraska. We abstracted data from 214 patients with sepsis admitted to a single academic medical center between June 2017 and June 2018. Patients were stratified by receipt of guideline-recommended fluid bolus. The primary outcome was respiratory failure defined as an increase in oxygen flow rate or more intense oxygenation and ventilation support; oxygen requirement and volume were measured at admission, 6 h, 12 h, 24 h, and at discharge. Subgroup analyses were conducted in high-risk patients with congestive heart failure (CHF) as well as those with chronic kidney disease (CKD). RESULTS A total of 62 patients (29.0%) received appropriate bolus treatment. The overall rate of respiratory failure was not statistically different between patients who received appropriate bolus or did not (40.3% vs 36.8%; P = .634). Likewise, no differences were observed in time to respiratory failure (P = .645) or risk of respiratory failure (adjusted hazard ratio, 1.1 [95% CI, 0.7-1.7]; P = .774). Results were similar within the high-risk CHF and CKD subgroups. INTERPRETATION In this single-center retrospective study, we found that by broadly defining respiratory failure as an increase in oxygen requirements, a conservative initial IV fluid resuscitation strategy did not correlate with decreased rates of hypoxemic respiratory failure.
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Affiliation(s)
- Nikhil Jagan
- From the Division of Pulmonary & Critical Care, Omaha, NE.
| | - Lee E Morrow
- From the Division of Pulmonary & Critical Care, Omaha, NE
| | - Ryan W Walters
- Division of Clinical Research and Evaluative Sciences, Omaha, NE
| | | | - Tej M Patel
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | | | | | - Emily D Dyer
- Creighton University School of Medicine, Omaha, NE
| | - Adam A Bergh
- Creighton University School of Medicine, Omaha, NE
| | - Aaron J Fried
- Department of Internal Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Mark A Malesker
- From the Division of Pulmonary & Critical Care, Omaha, NE; Creighton University School of Pharmacy and Health Professions, Omaha, NE
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Taenzer AH, Patel SJ, Allen TL, Doerfler ME, Park TR, Savitz LA, Park JG. Improvement in Mortality With Early Fluid Bolus in Sepsis Patients With a History of Congestive Heart Failure. Mayo Clin Proc Innov Qual Outcomes 2020; 4:537-541. [PMID: 33083702 PMCID: PMC7557190 DOI: 10.1016/j.mayocpiqo.2020.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To determine whether rapid administration of a crystalloid bolus of 30 mL/kg within 3 hours of presentation harms or benefits hypotensive patients with sepsis with a history of congestive heart failure (CHF). Patients and Methods A retrospective cohort study using Medicare claims data enhanced by medical record data from members of the High Value Healthcare Collaborative from July 1, 2013, to June 30, 2015, examining patients with a history of CHF who did (fluid bundle compliant [FBC]) or did not (NFBC) receive a volume bolus of 30 mL/kg within 3 hours of presentation to the emergency department. A proportional Cox hazard model was used to evaluate the association of FBC with 1-year survival. Results Of the 211 patients examined, 190 were FBC and 21 were NFBC. The FBC patients had higher average hierarchical condition category scores but were otherwise similar to NFBC patients. The NFBC patients had higher adjusted in-hospital and postdischarge mortality rates. The risk-adjusted 1-year mortality rate was higher for NFBC patients (hazard ratio, 2.18; 95% CI, 1.2 to 4.0; P=.01) than for FBC patients. Conclusion In a retrospective claim data-based study of elderly patients with a history of CHF presenting with severe sepsis or septic shock, there is an association of improved mortality with adherence to the initial fluid resuscitation guidelines as part of the 3-hour sepsis bundle.
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Affiliation(s)
- Andreas H. Taenzer
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Shilpa J. Patel
- Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI
- Kapiolani Medical Center for Women & Children, Honolulu, HI
| | - Todd L. Allen
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, UT
| | - Martin E. Doerfler
- Clinical Strategy and Development, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Tae-Ryong Park
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH
| | - Lucy A. Savitz
- Center for Health Research, Kaiser Permanente, Portland, OR
| | - John G. Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
- Correspondence: Address to John G. Park, MD, 200 First Ave SW, Gonda 17W, Rochester, MN 55905. @intub8_pccm
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Association Between Intravenous Fluid Resuscitation and Hospital Mortality in Post Cardiac Arrest Patients: A Retrospective Study. Shock 2020; 55:224-229. [PMID: 32769815 DOI: 10.1097/shk.0000000000001617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the role for intravenous fluid (IVF) resuscitation in the postarrest state. Primary outcome was survival to hospital discharge and 30-day mortality. Secondary outcomes were associations with amount of vasopressor use and mechanical ventilation days. DESIGN Retrospective study design. SETTING Single-center tertiary hospital in Philadelphia, Pennsylvania. PATIENTS All patients admitted to the intensive care unit between 2018 and 2019. INTERVENTIONS Patients were divided into two groups based on amount of IVF received within 24 h <30 mL/kg (restricted) and over 30 mL/kg (liberal). MEASUREMENTS AND MAIN RESULTS A total of 264 patients were included in the study, with 200 included in the restrictive (<30 mL/kg) group and 64 included in the liberal (>30 mg/kg) group. There was no difference in 30-day mortality between the two groups with 146 (73%) deaths in the restrictive groups and 44 (69%) deaths in the liberal group (P = 0.53). There was also no significant difference between those who survived to hospital discharge in the liberal and restrictive groups on Kaplan-Meier analysis (Log-rank = 1.476 P = 0.224). However, there was a significant difference between restrictive and liberal groups with the duration of mechanical ventilation (4 ± 6 days vs. 6 ± 9 days; P = 0.03) and in the rates of two or more vasopressor use (38% vs. 59%; P = 0.002). End-stage renal disease (ESRD) (OR = 2.39; P = 0.03) and volume of fluids in mL/kg/24 h (OR = 1.025; P < 0.0001) were independently associated with higher vasopressor need. Volume of fluid in mL/kg/24 h (P = 0.01), ESRD (P = 0.015), and chronic obstructive pulmonary disease (P = 0.04) were significantly associated with duration of mechanical ventilation, even after adjusting for demographic factors, comorbidities, and mortality. CONCLUSIONS A liberal strategy of IVF used in resuscitation after cardiac arrest is not associated with higher mortality. However, it predicts higher vasopressor use and duration of mechanical ventilation.
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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