Adherence to surviving sepsis campaign guidelines 2016 regarding fluid resuscitation and vasopressors in the initial management of septic shock: The emerging part of the iceberg!

The association of diastolic arterial pressure and heart rate with mortality in septic shock: a retrospective cohort study

BACKGROUND

The effects of diastolic arterial pressure (DAP) and heart rate (HR) on the prognosis of patients with septic shock are unclear, and whether these effects persist over time is unknown. We aimed to investigate the relationship between exposure to different intensities of DAP and HR over time and mortality at 28 days in patients with septic shock.

METHODS

In this cohort study, we obtained data from the Medical Information Mart for Intensive Care IV, which includes the data of adult patients (≥ 18 years) with septic shock who underwent invasive blood pressure monitoring. We excluded patients who received extracorporeal membrane oxygenation (ECMO) or glucocorticoids within 48 h of ICU admission. The primary outcome was mortality at 28 days. Piece-wise exponential additive mixed models were used to estimate the strength of the associations over time.

RESULTS

In total, 4959 patients were finally included. The median length of stay in the ICU was 3.2 days (IQR: 1.5-7.1 days), and the mortality in the ICU was 12.9%, with a total mortality at 28 days of 15.9%. After adjustment for baseline and time-dependent confounders, both daily time-weighted average (TWA) DAP and HR were associated with increased mortality at 28 days and strong association, mainly in the early to mid-stages of the disease. The results showed that mortality in patients with septic shock was lowest at a DAP of 50-70 mm Hg and an HR of 60-90 beats per minute (bpm). Throughout, a significant increase in the risk of death was found with daily exposure to TWA-DAP ≤ 40 mmHg (hazard ratio 0.99, 95% confidence interval (CI) 0.94-1.03) or TWA-HR ≥ 100 bpm (hazard ratio 1.16, 95% CI 1.1-1.21). Cumulative and interactive effects of harmful exposure (TWA-DAP ≤ 40 mmHg and TWA-HR ≥ 100 bpm) were also observed.

CONCLUSION

The optimal ranges for DAP and HR in patients with septic shock are 50-70 mmHg and 60-90 bpm, respectively. The cumulative and interactive effects of exposure to low DAP (≤ 40 mmHg) and tachycardia (≥ 100 bpm) were associated with an increased risk of death.

Early administration of dobutamine in the treatment of septic shock patients with tumor-a retrospective comparative cohort study

Background

Studies have found that dobutamine may be beneficial to protect organs function in patients with septic shock, but there is still a lack of relevant research in septic shock patients with tumor. The study sought to explore the role of the early administration of dobutamine in the treatment of septic shock patients with tumors.

Methods

We retrospectively collected the data of tumor patients who developed septic shock at Sun Yat-sen University Cancer Center between June 2008 and November 2021. All the patients were divided into the following 3 groups: (I) the early administration group (<3 days, n=15); (II) the late administration group (≥3 days, n=22); and (III) the non-administration group (n=85). The primary observation indicator was 28-day mortality, and the secondary observation indicators included the shock reversal rate, the length of stay in the intensive care unit (ICU) and the duration of mechanical ventilation. There was no statistical difference in the basic data of the three groups.

Results

The early administration group had a significant decrease in 28-day mortality compared to the late and non-administration groups (log-rank P=0.018). The comparison between the groups showed that the 28-day mortality of the early administration group was significantly lower than that of the non-administration group [20.0% vs. 58.8%, P=0.013, hazard ratios (HRs) =0.248, 95% confidence intervals (CIs): 0.077-0.796]. There was no statistically significant difference in 28-day mortality between the late administration group and the non-administration group (63.6% vs. 58.8%, P=0.682, HR =0.983, 95% CI: 0.543-1.778). Additionally, the early administration group had a significantly increased shock reversal rate (P=0.014), shortened length of stay in the ICU (P<0.001), and reduced duration of mechanical ventilation (P=0.049).

Conclusions

Early use of dobutamine may be beneficial to reduce the in-hospital mortality of septic shock patients with tumor, but the sample size of this study was small, which still needs to be confirmed by a multi-center randomized controlled clinical study.

Alternatives to norepinephrine in septic shock: Which agents and when?

Vasopressors are the cornerstone of hemodynamic management in patients with septic shock. Norepinephrine is currently recommended as the first-line vasopressor in these patients. In addition to norepinephrine, there are many other potent vasopressors with specific properties and/or advantages that act on vessels through different pathways after activation of specific receptors; these could be of interest in patients with septic shock. Dopamine is no longer recommended in patients with septic shock because its use is associated with a higher rate of cardiac arrhythmias without any benefit in terms of mortality or organ dysfunction. Epinephrine is currently considered as a second-line vasopressor therapy, because of the higher rate of associated metabolic and cardiac adverse effects compared with norepinephrine; however, it may be considered in settings where norepinephrine is unavailable or in patients with refractory septic shock and myocardial dysfunction. Owing to its potential effects on mortality and renal function and its norepinephrine-sparing effect, vasopressin is recommended as second-line vasopressor therapy instead of norepinephrine dose escalation in patients with septic shock and persistent arterial hypotension. However, two synthetic analogs of vasopressin, namely, terlipressin and selepressin, have not yet been employed in the management of patients with septic shock, as their use is associated with a higher rate of digital ischemia. Finally, angiotensin Ⅱ also appears to be a promising vasopressor in patients with septic shock, especially in the most severe cases and/or in patients with acute kidney injury requiring renal replacement therapy. Nevertheless, due to limited evidence and concerns regarding safety (which remains unclear because of potential adverse effects related to its marked vasopressor activity), angiotensin Ⅱ is currently not recommended in patients with septic shock. Further studies are needed to better define the role of these vasopressors in the management of these patients.