Hemodynamic support in septic shock

Comparison of High-Normal Versus Low-Normal Mean Arterial Pressure at Target on Outcomes in Sepsis or Shock Patients: A Meta-Analysis of Randomized Control Trials

The objective of this meta-analysis was to compare the impact of a high-normal and a low-normal mean arterial pressure (MAP) target on outcomes in patients with sepsis or shock. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, two investigators conducted a thorough literature search across online databases, including PubMed, Cochrane Library, Web of Science, and EMBASE, spanning from inception to December 10, 2023. The assessed outcomes encompassed all-cause mortality, the need for renal replacement therapy, and the length of intensive care unit (ICU) stay. A total of four randomized controlled trials (RCTs) were included, involving 3507 participants with individual study participant counts ranging from 118 to 2463. The pooled analysis revealed no statistically significant difference in the risk of all-cause mortality between the two groups (Risk Ratio (RR): 0.94, 95% Confidence Interval (CI): 0.87 to 1.01). Furthermore, there was no disparity in the rates of renal replacement therapy and the duration of ICU stay between the high-normal and low-normal MAP groups. Our findings indicate no significant distinctions in mortality, rates of renal replacement therapy, or ICU stay duration between the two groups. However, future trials with larger sample sizes are warranted to comprehensively understand the nuanced effects of different MAP settings on outcomes in patients with sepsis and shock.

Association between different MAP levels and 30-day mortality in sepsis patients: a propensity-score-matched, retrospective cohort study

BACKGROUND

Sepsis is a life-threatening organ dysfunction caused by the infection-related host response disorder. Adequate mean arterial pressure is an important prerequisite of tissue and organ perfusion, which runs through the treatment of sepsis patients, and an appropriate mean arterial pressure titration in the early-stage correlates to the positive outcome of the treatment. Therefore, in the present study, we aimed to elucidate the relationship between early mean arterial pressure levels and short-term mortality in sepsis patients.

METHODS

We included all suspected sepsis patients from MIMIC-III database with average mean arterial pressure ≥ 60 mmHg on the first day of intensive care unit stay. Those patients were then divided into a permissive low-mean arterial pressure group (60-65 mmHg) and a high-mean arterial pressure group (> 65 mmHg). Multivariate Cox regression analysis was conducted to analyze the relationship between MAP level and 30-day, 60-day, and 100-day mortality of suspected sepsis patients in the two groups. Propensity score matching, inverse probability of treatment weighing, standardized mortality ratio weighting, PA weighting, overlap weighting, and doubly robust analysis were used to verify our results.

RESULTS

A total of 14,031 suspected sepsis patients were eligible for inclusion in our study, among which 1305 (9.3%) had an average first-day mean arterial pressure of 60-65 mmHg, and the remaining 12,726 patients had an average first-day mean arterial pressure of more than 65 mmHg. The risk of 30-day mortality was reduced in the high mean arterial pressure group compared with the permissive low-mean arterial pressure group (HR 0.67 (95% CI 0.60-0.75; p < 0.001)). The higher mean arterial pressure was also associated with lower 60-day and 100-day in-hospital mortality as well as with shorter duration of intensive care unit stay. Patients in the high-mean arterial pressure group also had more urine output on the first and second days of intensive care unit admission.

CONCLUSIONS

After risk adjustment, the initial mean arterial pressure of above 65 mmHg was associated with reduced short-term mortality, shorter intensive care unit stay, and higher urine volume in the first two days among patients with sepsis.

[Haemodynamic monitoring in sepsis and septic shock]

Cardiovascular disturbances associated with sepsis cause hypoperfusion situations, which will negatively impact these patients' prognosis. The aim of haemodynamic monitoring is to guide the detection and correction of this hypoperfusion, and assist in decision making in optimising oxygen transport to tissues, primarily by manipulating cardiac output. This review seeks to summarise the different parameters of haemodynamic monitoring, the objectives of resuscitation, the physiological parameters, and the tools available to us for appropriate cardiac output manipulation.

[Resuscitation strategy for patients with sepsis and septic shock]

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.

[Pathophysiology of septic shock]

Sepsis and septic shock result from an inadequate host response to an infection, which causes organ dysfunction. The progression of this condition is manifested by the occurrence of successive clinical stages, resulting from the systemic inflammatory response secondary to the activation of different inflammatory mediators, leading to organ dysfunction. There is a high burden of evidence on the role of endotoxin in the pathogenesis of sepsis and its crucial role in triggering the inflammatory response in sepsis caused by gram-negative bacteria. The coagulation cascade activation in sepsis patients is part of the host's adaptive immune response to infection. The endothelium is the main target in sepsis, which is metabolically active and can.

Evidence for the Application of Sepsis Bundles in 2021

Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.