Predictors, Prevalence, and Outcomes of Early Crystalloid Responsiveness Among Initially Hypotensive Patients With Sepsis and Septic Shock

Relationship Between Fluid Administration During the First Three Hours of Sepsis Resuscitation and Mortality: A Multicenter Observational Study

Background Timely and effective fluid resuscitation is vital for stabilizing sepsis while avoiding volume overload. We aimed to assess how the administration of a 30 mL/kg bolus fluid affects patients with sepsis within three hours of clinical outcomes. Methods This multicenter observational study included adult patients diagnosed with sepsis in 17 intensive care units at tertiary hospitals in Japan between July 2019 and August 2020. The clinical outcomes of patients with sepsis who received ≥30 mL/kg bolus fluid within three hours (30 × 3 group) were compared with those who received <30 mL/kg fluid (non-30 × 3 group). Results Of 172 eligible patients, 74 (43.0%) belonged to the 30 × 3 group, and 98 (57.0%) belonged to the non-30 × 3 group. The median Sequential Organ Failure Assessment score was 9 (interquartile range (Q1-Q3): 7-11) in the 30 × 3 group and 7 (Q1-Q3: 4-9) in the non-30 × 3 group (P < 0.01). The 28-day mortality rate was 29.7% in the 30 × 3 group and 12.2% in the non-30 × 3 group (P < 0.01). However, the adjusted odds ratio by the inverse probability of treatment weighting analysis with propensity score for the 28-day mortality rate of the 30 × 3 group compared with that in the non-30 × 3 group was 2.17 (95% confidence interval: 0.85-5.54). Among the propensity score-matched patients, the 28-day mortality rate was 30% in the 30 × 3 (n = 70) and non-30 × 3 (n = 95) groups, respectively (P = 0.72). Conclusions Patients with sepsis who received the 30 mL/kg bolus fluid within three hours experienced more severe clinical outcomes. However, it was not associated with the increased odds of the 28-day mortality.

Cost-effectiveness of intravenous resuscitation fluids in sepsis patients: a patient-level data analysis in Jordan

AIM

Albumin role as fluid resuscitation in sepsis remains understudied in low- and middle-income countries. This study aimed to evaluate the cost-effectiveness of intravenous (IV) Albumin compared to Crystalloids in sepsis patients using patient-level data in Jordan.

METHODS

This was a retrospective cohort study of sepsis patients aged 18 or older admitted to intensive care units (ICU) at two major tertiary hospitals during the period 2018-2019. Patients information, type of IV fluid, and clinical outcomes were retrieved from medical records, and charges were retrieved from the billing system. A 90-day partitioned survival model with two health states (alive and dead) was constructed to estimate the survival of sepsis patients receiving either Albumin or Crystalloids as IV fluids for resuscitation. Overall survival was predicted by fitting a Weibull model on the patient-level data from the current study. To further validate the results, and to support the assessment of uncertainty, time-dependent transition probabilities of death at each cycle were estimated and used to construct a state-transition patient-level simulation model with 10,000 microsimulation trials. Adopting the healthcare system perspective, incremental cost-effectiveness ratios(ICERs) of Albumin versus Crystalloids were calculated in terms of the probability to be discharged alive from the ICU. Uncertainty was explored using probabilistic sensitivity analysis.

RESULTS

In the partitioned survival model, Albumin was associated with an incremental cost of $1,007 per incremental1% in the probability of being discharged alive from the ICU. In the state-transition patient-level simulation model, ICER was $1,268 per incremental 1% in the probability of being discharged alive. Probabilistic sensitivity analysis showed that Albumin was favored at thresholds >$800 per incremental 1%in the probability of being discharged alive from the ICU.

CONCLUSION

IV Albumin use in sepsis patients might not be cost-effective from the healthcare perspective of Jordan. This has important implications for policymakers to readdress Albumin prescribing practice in sepsis patients.

The Effect of Fluid Resuscitation Timing in Early Sepsis Resuscitation

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.

Precision fluid and vasoactive drug therapy for critically ill patients

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.

Association between input/weight ratio and acute kidney injury in obese critical ill patients: a propensity analysis of multicenter clinical databases

Rehydration volume may be underestimated in obese critically ill patients, which can lead to acute kidney injury (AKI). This study aimed to investigate the association between input/weight ratio (IWR) and AKI risk in obese critical patients. This retrospective observational study analyzed data from three large open databases. Patients were divided into lean and obese groups and matched 1:1 based on age, sex, APACHE II score, SOFA score, sepsis status, mechanical ventilation status, renal replacement therapy status, and hospital type. The exposure of interest was the mean IWR during the first three ICU admission days. The primary outcome was the incidence of AKI within 28 days after ICU admission. Cox regression analysis was used to evaluate the association between IWR and AKI risk. A total of 82,031 eligible patients were included in the study, with 25,427 obese patients matched with 25,427 lean patients. The IWRs were significantly lower in the obese groups in both the unmatched cohort (35.85 ± 19.05 vs. 46.01 ± 30.43 ml/kg, p < 0.01) and the matched cohort (36.13 ± 19.16 vs. 47.34 ± 31.13 ml/kg, p < 0.01). An increase in IWR was significantly associated with decreased creatinine levels, increased urine output and a lower AKI risk. The interaction terms of IWR and obesity were significantly associated with decreased AKI incidence in both the unmatched cohort (hazard ratio [HR] = 0.97, 95% CI 0.96-0.97, p < 0.01) and the matched cohort (HR = 0.97, 95% CI 0.96-0.97, p < 0.01). Inadequate rehydration of patients with obesity may contribute to an increased risk of AKI in patients with obesity. These results highlight the need for better rehydration management in patients with obesity.

Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines

Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.

Practice and effect evaluation of early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department: a retrospective cohort study

OBJECTIVE

To explore the practice and effect evaluation of the early restrictive fluid resuscitation strategy in the nursing care of patients with sepsis in the emergency department.

METHODS

A total of 239 sepsis patients, who were treated in the emergency department of our hospital from January to September 2020, were selected as the participants of this study, and a retrospective analysis was performed. According to different methods of fluid resuscitation, they were divided into an improved group and a control group. One hundred and twelve patients who received restrictive fluid resuscitation were in the improved group; another 127 patients who received adequate fluid resuscitation were in the control group. The ICU stay time, ventilator use time, and 28-day mortality rate of the two groups were observed. The hemodynamic indices, acute physiology and chronic health evaluation (APACHE) II score, sequential organ failure assessment (SOFA) score, and complications of the two groups before and after treatment were compared.

RESULTS

After treatment, in the improved group, the APACHE II and SOFA scores were lower than in the control group, fluid replacement decreased, lactate clearance increased, ICU admission time shortened and the proportion of ventilator time to ICU admission time decreased. The incidence of acute respiratory distress syndrome (ARDS), cTn I and brain natriuretic peptic in the improved group were significantly lower than those in the control group. From the dimension within the group, the APACHE II score, SOFA score, heart rate and shock index were lower after treatment than before treatment in both the improved and control groups.

CONCLUSION

Restricted fluid resuscitation can effectively alleviate the condition of emergency sepsis patients, improve hemodynamics, reduce the incidence of ARDS, and prevent patient deaths. It is worthy of clinical application.

Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock

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.

Fluids in the ICU: which is the right one?

The administration of fluids is one of the most common interventions in the intensive care unit. The effects and side effects of intravenous fluids depend on the amount administered and their specific composition. Intravenous fluid solutions are either considered crystalloids (for example 0.9% saline, lactated Ringer's solution) or colloids (artificial colloids such as gelatins, and albumin). This narrative review summarizes the physiological principles of fluid therapy and reviews the most important studies on crystalloids, artificial colloids and albumin in the context of critically ill patients.

Volume Management with Kidney Replacement Therapy in the Critically Ill Patient

While the administration of intravenous fluids remains an important treatment, the negative consequences of subsequent fluid overload have raised questions about when and how clinicians should pursue avenues of fluid removal. Decisions regarding fluid removal during critical illness are complex even for patients with preserved kidney function. This article seeks to apply general concepts of fluid management to the care of patients who also require KRT. Because optimal fluid management for any specific patient is likely to change over the course of critical illness, conceptual models using phases of care have been developed. In this review, we will examine the implications of one such model on the use of ultrafiltration during KRT for volume removal in distributive shock. This will also provide a useful lens to re-examine published data of KRT during critical illness. We will highlight recent prospective trials of KRT as well as recent retrospective studies examining ultrafiltration rate and mortality, review the results, and discuss applications and shortcomings of these studies. We also emphasize that current data and techniques suggest that optimal guidelines will not consist of recommendations for or against absolute fluid removal rates but will instead require the development of dynamic protocols involving frequent cycles of reassessment and adjustment of net fluid removal goals. If optimal fluid management is dynamic, then frequent assessment of fluid responsiveness, fluid toxicity, and tolerance of fluid removal will be needed. Innovations in our ability to assess these parameters may improve our management of ultrafiltration in the future.

New Insights into the Fluid Management in Patients with Septic Shock

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.

The time cost of physiologically ineffective intravenous fluids in the emergency department: an observational pilot study employing wearable Doppler ultrasound

BACKGROUND

Little data exist on the time spent by emergency department (ED) personnel providing intravenous (IV) fluid to 'responsive' versus 'unresponsive' patients.

METHODS

A prospective, convenience sample of adult ED patients was studied; patients were enrolled if preload expansion was indicated for any reason. Using a novel, wireless, wearable ultrasound, carotid artery Doppler was obtained before and throughout a preload challenge (PC) prior to each bag of ordered IV fluid. The treating clinician was blinded to the results of the ultrasound. IV fluid was deemed 'effective' or 'ineffective' based on the greatest change in carotid artery corrected flow time (ccFT_∆) during the PC. The duration, in minutes, of each bag of IV fluid administered was recorded.

RESULTS

53 patients were recruited and 2 excluded for Doppler artifact. There were 86 total PCs included in the investigation comprising 81.7 L of administered IV fluid. 19,667 carotid Doppler cardiac cycles were analyzed. Using ccFT_∆ ≥  + 7 ms to discriminate 'physiologically effective' from 'ineffective' IV fluid, we observed that 54 PCs (63%) were 'effective', comprising 51.7 L of IV fluid, whereas, 32 (37%) were 'ineffective' comprising 30 L of IV fluid. 29.75 total hours across all 51 patients were spent in the ED providing IV fluids categorized as 'ineffective.'

CONCLUSIONS

We report the largest-known carotid artery Doppler analysis (i.e., roughly 20,000 cardiac cycles) in ED patients requiring IV fluid expansion. A clinically significant amount of time was spent providing physiologically ineffective IV fluid. This may represent an avenue to improve ED care efficiency.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Balanced Salt Solutions for Critically Ill Patients: Nonplused and Back to Basics

OBJECTIVES

The purpose of this article is to summarize the results of major randomized controlled trials (RCTs) comparing clinical outcomes of critically ill patients treated with normal saline (NS) or balanced salt solutions (BSSs), address discordant results of these studies, and provide direction for future investigations.

DATA SOURCES

PubMed (2011 to January 2022) with bibliographies of retrieved articles searched for additional articles.

STUDY SELECTION AND DATA EXTRACTION

RCTs comparing NS and BSSs in critically ill adult patients.

DATA SYNTHESIS

Recently published large RCTs comparing NS with BSSs in heterogeneous populations of intensive care unit patients did not find significant differences in mortality, despite positive findings in some end points in prior RCTs. However, there were a number of methodologic issues common to the RCTs including: varying study designs and end points, clinician discretion for the majority or all treatments other than the primary intervention fluid, heterogeneous patients with varying levels of acuity, and lack of power to investigate potential subgroup differences. In addition, there were problematic issues related to blinding and use of nonstudy fluids.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Intravenous fluids are a mainstay of supportive care for critically ill patients. Similar to the so-called crystalloid-colloid debate, there has been a long-standing debate among critical care clinicians and researchers concerning the preferred crystalloid solution, NS versus one of the available BSSs.

CONCLUSIONS

Despite the recent publication of large multicenter RCTs, the preferred resuscitation fluid, NS or a BSS, for critically ill patients is still open for debate, although the available investigations do provide some direction for clinicians and for future investigations.

Intravenous fluid therapy in sepsis

Sepsis is the dysregulated immune response to severe infection that is common and lethal among critically ill patients. Fluid administration is a common treatment for hypotension and shock in early sepsis. Fluid therapy can also cause edema and organ dysfunction. Research on the best treatment strategies for sepsis has provided insights on the optimal timing, dose, and type of fluid to treat patients with sepsis. Initial research on early goal-directed therapy for sepsis included an initial bolus of 30 ml/kg of fluid, but more recent research has supported use of smaller volumes. After initial fluid resuscitation, minimizing additional fluid administration may be beneficial, but no single measure has been established as the best method to guide ongoing fluid management in sepsis. Dynamic measures of "fluid responsiveness" can predict which patients will experience an increase in cardiac output from a fluid bolus. Use of such a measure in clinical care remains limited by applicability to patient populations and uncertainty regarding the effect on clinical outcomes. Recent research informs the effect of fluid composition on outcomes for patients with sepsis. Current data support the use of balanced crystalloids, rather than saline, and the use of crystalloids, rather than semisynthetic colloids. The role for albumin administration in sepsis remains uncertain. Future research should focus on determining the optimal volume of fluid during sepsis resuscitation, the effectiveness of measures of "fluid responsiveness" in improving outcomes, the optimal composition of crystalloid solutions, the role of albumin, and the effects of "deresuscitation" after septic shock.

[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.

When Minutes Matter: Rapid Infusion in Emergency Care

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?

Relationship Between First 24-h Mean Body Temperature and Clinical Outcomes of Post-cardiac Surgery Patients

Background: This study was aimed to investigate the relationship between first 24-h mean body temperature and clinical outcomes of post cardiac surgery patients admitted to intensive care unit (ICU) in a large public clinical database.

Methods: This is a retrospectively observational research of MIMIC III dataset, a total of 6,122 patients included. Patients were divided into 3 groups according to the distribution of body temperature. Multivariate cox analysis and logistic regression analysis were used to investigate the association between abnormal temperature, and clinical outcomes.

Results: Hypothermia (<36°C) significantly associated with increasing in-hospital mortality (HR 1.665, 95%CI 1.218–2.276; p = 0.001), 1-year mortality (HR 1.537, 95% CI 1.205–1.961; p = 0.001), 28-day mortality (HR 1.518, 95% CI 1.14–2.021; p = 0.004), and 90-day mortality (HR 1.491, 95% CI 1.144–1.943; p = 0.003). No statistical differences were observed between short-term or long-term mortality and hyperthermia (>38°C). Hyperthermia was related to the extended length of ICU stay (p < 0.001), and hospital stay (p < 0.001).

Conclusion: Hypothermia within 24h after ICU admission was associated with the increased mortality of post cardiac surgery patients. Enhanced monitoring of body temperature within 24h after cardiac surgery should be taken into account for improving clinical outcomes.

Initial fluid resuscitation (30 mL/kg) in patients with septic shock: More or less?

OBJECTIVES

The 2018 Surviving Sepsis Campaign (SSC) recommends rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥4 mmol/L in patients with septic shock; however, there is limited evidence to support this recommendation. The purpose of this study was to examine the relationship between initial fluid resuscitation doses and prognosis in patients with septic shock.

METHODS

This was a multicenter prospective observational study of adult patients with septic shock who were admitted to four intensive care units (ICUs) in a total of three Jiangsu Province teaching hospitals over a 3-year span from May 8, 2018, to June 15, 2021. Each enrolled patients with septic shock was categorized into the low-volume (below 20 mL/kg fluid), medium-volume (20-30 mL/kg fluid) or high-volume (above 30 mL/kg fluid) fluid group according to the initial infusion dose given for fluid resuscitation. Various demographic attributes and other variables were collected from medical records. Logistic regression and Kaplan-Meier curve analysis were used to determine the relationship between initial fluid resuscitation doses and patient outcomes.

MEASUREMENTS AND MAIN RESULTS

A total of 302 patients who presented to the ICU were diagnosed with septic shock. The 28-day mortality was highest in the high-volume group (48.3%) and lowest in the medium-volume group (26.3%, P < 0.05). Patients who completed 30 mL/kg initial fluid resuscitation in the first 1-2 h had the lowest 28-day mortality rate (22.8%, P < 0.05). Logistic regression showed that a medium initial fluid volume dose was an independent protective factor, with the odds ratio (OR) indicating significantly decreased mortality (OR, 0.507; 95% confidence interval, 0.310-0.828; P = 0.007; P < 0.05). A Kaplan-Meier curve stratified by initial fluid resuscitation dose was constructed for the probability of 28-day mortality. The medium-volume fluid group showed a significantly lower 28-day mortality rate than the high-volume group or the low-volume group (log-rank test, P = 0.0016).

CONCLUSION

In septic shock patients, an initial fluid resuscitation rate of 20-30 mL/kg within the first hour may be associated with reduced 28-day mortality; however, this result needs to be confirmed by further high-quality randomized controlled clinical trials.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-OOC-17013223. Registered 2 November 2017, http://www.chictr.org.cn/showproj.aspx?proj=22674.

Catecholaminergic Vasopressors Reduce Toll-Like Receptor Agonist-Induced Microvascular Endothelial Cell Permeability But Not Cytokine Production

Supplemental Digital Content is available in the text.

OBJECTIVES:

Catecholaminergic vasopressors are the cornerstone of circulatory shock management. Nevertheless, catecholamines have problematic side effects, arousing a growing interest in noncatecholaminergic agents such as vasopressin or angiotensin-II. However, their respective effects on sepsis-associated microvascular endothelial dysfunction such as permeability or inflammation remain elusive. We investigated the role of catecholamines and other vasopressors on Toll-like receptor agonists-induced microvascular endothelial permeability and inflammation.

SETTING:

University research laboratory/cell research.

SUBJECTS:

Human pulmonary microvascular endothelial cells from multiple donors.

INTERVENTION:

Confluent monolayers of human pulmonary microvascular endothelial cells were treated with Toll-like receptor agonists (lipopolysaccharide, Poly[I:C], or tripalmitoyl-S-glyceryl cysteine) in the presence or absence of epinephrine, norepinephrine, vasopressin, and angiotensin-II. Permeability was inferred from transendothelial resistance, measured using electrical cell impedance sensing, where decreased transendothelial resistance is consistent with increased permeability. Cell-cell junction molecule expression was assessed via immunofluorescence microscopy and flow cytometry. We quantified cytokines in supernatants of Toll-like receptor agonist-treated human pulmonary microvascular endothelial cells.

MEASUREMENTS AND MAIN RESULTS:

Epinephrine and norepinephrine both ameliorate lipopolysaccharide, polyinosinic:polycytidylic acid, or tripalmitoyl-S-glyceryl cysteine–induced reductions in transendothelial resistance, a surrogate for endothelial permeability. In contrast, the noncatecholaminergic agents, vasopressin, and angiotensin-II did not affect Toll-like receptor agonists-induced reductions in transendothelial resistance. β1- and β2-adrenergic receptor antagonists reduced the effects of the catecholamines on transendothelial resistance, whereas α-adrenergic receptor antagonists did not. We observed that epinephrine and norepinephrine induced actin cytoskeletal rearrangement and normalized the membrane expression of proteins involved with adherens-junctions (vascular endothelial-cadherin) and tight-junctions (zona occludens-1). Despite having a substantial effect on endothelial permeability, epinephrine and norepinephrine did not affect human pulmonary microvascular endothelial cell survival or production of interleukin-8, interleukin-6, or monocyte chemoattractant protein-1 (CCL-2) induced by Toll-like receptor agonists, suggesting that these functions are regulated separately from permeability.

CONCLUSIONS:

Our findings demonstrate that treatment with epinephrine or norepinephrine strongly reduces endothelial permeability induced by agonists of multiple Toll-like receptors (Toll-like receptor-2, Toll-like receptor-3, Toll-like receptor-4) in vitro. Our studies suggest that both β1- and β2-adrenergic receptors mediate the stabilizing effects of epinephrine and norepinephrine on the endothelial barrier.

Association of fluid balance trajectories with clinical outcomes in patients with septic shock: a prospective multicenter cohort study

BACKGROUND

Septic shock has a high incidence and mortality rate in Intensive Care Units (ICUs). Earlier intravenous fluid resuscitation can significantly improve outcomes in septic patients but easily leads to fluid overload (FO), which is associated with poor clinical outcomes. A single point value of fluid cannot provide enough fluid information. The aim of this study was to investigate the impact of fluid balance (FB) latent trajectories on clinical outcomes in septic patients.

METHODS

Patients were diagnosed with septic shock during the first 48 h, and sequential fluid data for the first 3 days of ICU admission were included. A group-based trajectory model (GBTM) which is designed to identify groups of individuals following similar developmental trajectories was used to identify latent subgroups of individuals following a similar progression of FB. The primary outcomes were hospital mortality, organ dysfunction, major adverse kidney events (MAKE) and severe respiratory adverse events (SRAE). We used multivariable Cox or logistic regression analysis to assess the association between FB trajectories and clinical outcomes.

RESULTS

Nine hundred eighty-six patients met the inclusion criteria and were assigned to GBTM analysis, and three latent FB trajectories were detected. 64 (6.5%), 841 (85.3%), and 81 (8.2%) patients were identified to have decreased, low, and high FB, respectively. Compared with low FB, high FB was associated with increased hospital mortality [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.22-2.17], organ dysfunction [odds ratio (OR) 2.18, 95% CI 1.22-3.42], MAKE (OR 1.80, 95% CI 1.04-2.63) and SRAE (OR 2.33, 95% CI 1.46-3.71), and decreasing FB was significantly associated with decreased MAKE (OR 0.46, 95% CI 0.29-0.79) after adjustment for potential covariates.

CONCLUSION

Latent subgroups of septic patients followed a similar FB progression. These latent fluid trajectories were associated with clinical outcomes. The decreasing FB trajectory was associated with a decreased risk of hospital mortality and MAKE.

Non-invasive assessment of fluid responsiveness to guide fluid therapy in patients with sepsis in the emergency department: a prospective cohort study

Background

Little is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock.

Methods

In a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge.

Measurements and main results

Seven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44–78) vs 37 (23–47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p<0.001).

Conclusion

The results of the present study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardised fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.

The Effect of Body Mass Index and Weight-Adjusted Fluid Dosing on Mortality in Sepsis

PURPOSE

The Surviving Sepsis Campaign guidelines recommend 30 mL/kg of fluids within 3 hours (30by3) of sepsis-induced hypoperfusion, but a national mandate released an allowance for dosing based on ideal instead of actual body weight (IBW/ABW) for obese patients. This study aims to determine the dose-effect of 30by3 for patients with severe sepsis or septic shock (SS/SS) with respect to body mass index (BMI) categories and secondarily, examine the clinical impact of IBW vs. ABW-based dosing.

METHODS

Retrospective cohort study of adults (≥18 years; n = 1,032) with SS/SS presenting to an urban, tertiary-care emergency department. Models include MEDS score, antibiotic timing, lactate, renal and heart failure, among others.

RESULTS

The cohort was 10.2% underweight and 28.7% obese. Overall mortality was 17.1% with 20.4% shock mortality. An exponential increase in mortality was observed for each 5 mL/kg under 30by3 for underweight (p = 0.02), but not obese patients. ABW vs IBW-30by3 dosing was reached in 80.0 vs 52.4% (underweight), 56.4 vs 56.9% (normal/overweight), and 23.3 vs 46.0% (obese). Across all BMI categories, there was increased mortality for not reaching ABW-based 30by3 dosing (OR 1.78, 95% CI 1.18-2.69) with no significant impact for IBW (OR 1.28, 95% CI 0.87 -1.91). The increased mortality for failing to reach ABW-dosed 30by3 remained for underweight patients ABW (OR 5.82, 95% CI 1.32-25.57) but not obese patients. Longer ICU stays were observed for not reaching 30by3 based on ABW (β = 2.40, 95% CI 0.84-3.95) and IBW dosing (β = 1.58, 95% CI 0.07-3.08) overall. This effect remained for obese and underweight (except IBW dosing) patients.

CONCLUSIONS

An exponential, dose-effect increase in mortality was observed for underweight patients not receiving 30by3. Therefore, the mortality impact of under-dosing may be amplified using ABW for underweight patients. Fluid dosing did not impact mortality for obese patients, but we caution against deviation from guidelines without further studies.

Review of Sepsis in Burn Patients in 2020

Background: Severe burn injury results in substantial damage to the skin, inhibiting its ability to perform as the primary barrier to infection. Additionally, severe burn injury can lead to critical illness and extensive time in the intensive care unit (ICU). These two factors work to increase the risk of sepsis in the burn patient compared with other hospitalized patients. The increased risk of sepsis is compounded by the difficulty of diagnosing sepsis in severely burned patients because the pathophysiology of large burns mimics sepsis, leading to possible delay in diagnosis and initiation of treatment. Methods: A literature review was performed to discuss and review the diagnostic difficulties and criteria used to identify patients with sepsis. Additionally, the most current management of sepsis was reviewed and described in caring for burn patients with sepsis. Results: The incidence of sepsis in patients with more than 20% total body surface area (TBSA) burns is between 3% and 30% and is the most common cause of death in the burn patient, with pneumonia being the most common etiology. Several different diagnostic criteria for diagnosing sepsis in burn patients exist, however, none of these criteria have proven to be superior to clinical diagnosis by an experienced burn surgeon. As with sepsis in other patient populations, prompt diagnosis, initiation of antibiotic agents, and source control remain the standard management of sepsis in the burn patient. Conclusions: Because of the loss of the primary infection barrier function of the skin after a substantial burn injury, this patient population is at increased risk for sepsis. Because of the pathophysiology of burn injuries, diagnosing sepsis in the burn population remains challenging. Understanding the most common etiologies of sepsis in burn patients may help with more expedient diagnosis and initiation of treatment.

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

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.

Evaluation and Predictors of Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock

OBJECTIVES

Rapid fluid resuscitation has become standard in sepsis care, despite "low-quality" evidence and absence of guidelines for populations "at risk" for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived "at-risk" volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume "overload" by bedside examination.

DESIGN

Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics.

SETTING

Urban, tertiary care center between January 1, 2014, and May 31, 2017.

PATIENTS

Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock.

INTERVENTIONS

Administration of IV fluids by bolus.

MEASUREMENTS AND MAIN RESULTS

In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46-0.83), male (odds ratio, 0.66; CI, 0.49-0.87), obese (odds ratio, 0.18; CI, 0.13-0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13-0.40), heart failure (odds ratio, 0.42; CI, 0.29-0.60), or documented volume "overload" (odds ratio, 0.30; CI, 0.20-0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03-2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02-1.99), and increased ICU stay (~2 d) (β = 2.0; CI, 0.5-3.6), without differential effects for "at-risk" groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p < 0.05).

CONCLUSIONS

Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation.

Effect of initial infusion rates of fluid resuscitation on outcomes in patients with septic shock: a historical cohort study

Background

Fluid resuscitation has become the cornerstone of early septic shock management, but the optimal fluid rate is still not well studied. The goal of this investigation is to examine the relationship between fluid resuscitation rate and septic shock resolution.

Method

We retrospectively studied adult (≥ 18 years) patients with septic shock, defined based on sepsis III definition, from January 1, 2006, through May 31, 2018, in the medical intensive care unit (MICU) of Mayo Clinic Rochester. The fluid resuscitation time was defined as the time required to infuse the initial fluid bolus of 30 ml/kg, based on the recommendations of the 2016 surviving sepsis campaign. The cohort was divided into four groups based on the average fluid rate (group 1 ≥ 0.5, group 2 0.25–0.49, group 3 0.17–0.24, and group 4 < 0.17 ml/kg/min). The primary outcome was the time to shock reversal. Multivariable regression analyses were conducted to account for potential confounders.

Result

A total of 1052 patients met eligibility criteria and were included in the analysis. The time-to-shock reversal was significantly different among the groups (P < .001). Patients in group 1 who received fluid resuscitation at a faster rate had a shorter time to shock reversal (HR = 0.78; 95% CI 0.66–0.91; P = .01) when compared with group 4 with a median (IQR) time-to-shock reversal of 1.7 (1.5, 2.0) vs. 2.8 (2.6, 3.3) days, respectively. Using 0.25 ml/kg/min as cutoff, the higher fluid infusion rate was associated with a shorter time to shock reversal (HR = 1.22; 95% CI 1.06–1.41; P = .004) and with decreased odds of 28-day mortality (HR = 0.71; 95% CI 0.60–0.85; P < .001).

Conclusion

In septic shock patients, initial fluid resuscitation rate of 0.25–0.50 ml/kg/min (i.e., completion of the initial 30 ml/kg IV fluid resuscitation within the first 2 h), may be associated with early shock reversal and lower 28-day mortality compared with slower rates of infusion.

Heterogeneity of Cardiovascular Response to Standardized Sepsis Resuscitation

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Driving blind: instituting SEP-1 without high quality outcomes data

In 2015, the Centers for Medicare and Medicaid Services (CMS) instituted an all-or-none sepsis performance measure bundle (SEP-1) to promote high-quality, cost-effective care. Systematic reviews demonstrated only low-quality evidence supporting most of SEP-1's interventions. CMS has removed some but not all of these unproven components. The current SEP-1 version requires patients with suspected sepsis have a lactate level, blood cultures, broad-spectrum antibiotics and, if hypotensive, a fixed 30 mL/kg fluid infusion within 3 hours, and a repeat lactate if initially elevated within 6 hours. Experts have continued to raise concerns that SEP-1 remains overly prescriptive, lacks a sound scientific basis and presents risks (overuse of antibiotics and inappropriate fluids not titrated to need). To incentivize compliance with SEP-1, CMS now publicly publishes how often hospitals complete all interventions in individual patients. However, compliance measured across hospitals (5 studies, 48-2,851 hospitals) or patients (three studies, 110-851 patients) has been low (approximately 50%) which is not surprising given SEP-1's lack of scientific basis. The largest observational study (1,738 patients) reporting survival rates employing SEP-1 found they were not significantly improved with the measure (P=0.53) as did the next largest study (851 patients, adjusted survival odds ratio 1.36, 95% CI, 0.85 to 2.18). Two smaller observational studies (158 and 450 patients) reported SEP-1 improved unadjusted survival (P≤0.05) but were confounded either by baseline imbalances or by simultaneous introduction of a code sepsis protocol to improve compliance. Regardless, retrospective studies have well known biases related to non-randomized designs, uncontrolled data collection and failure to adjust for unrecognized influential variables. Such low-quality science should not be the basis for a national mandate compelling care for a rapidly lethal disease with a high mortality rate. Instead, SEP-1 should be based on high quality reproducible evidence from randomized controlled trials (RCT) demonstrating its benefit and thereby safety. Otherwise we risk not only doing harm but standardizing it.

The Effects of Abnormal Body Temperature on the Prognosis of Patients with Septic Shock

We aimed to use temperature and the area under temperature curve to represent the severity of abnormal body temperature of patients with septic shock and to observe their impact on the prognosis. Five hundred twenty-eight adult patients with septic shock admitted to intensive care unit (ICU) were analyzed. Within the first 24 hours and throughout the period in ICU, the maximum temperature (24hT_max, T_max), lowest temperature (24hT_min, T_min), and the temperature range (24hT_max-min, T_max-min) were aggregated. Patients were divided into the survival group and the death group. Binary logistic regression was used to assess the relationship between body temperature aberrations and survival. The following risk factors of death in 21 days were identified: T_max (odds ratio [OR] 2.967, 95% confidence interval [CI] 1.626-5.414, p < 0.001), T_min (OR 0.337, 95% CI 0.143-0.794, p = 0.013), and T_max-min (OR 3.259, 95% CI 1.847-5.749, p < 0.001). This is an observational study, so one can infer association but not causation. Therefore, we infer that abnormal body temperature is associated with an adverse prognosis in patients with septic shock.

Resuscitation fluids

PURPOSE OF REVIEW

Intravenous fluid administration is a fundamental therapy in critical care, yet key questions remain unanswered regarding optimal fluid composition and dose. This review evaluates recent evidence regarding the effects of fluid resuscitation on pathophysiology, organ function, and clinical outcomes for critically ill patients.

RECENT FINDINGS

Recent findings suggest that intravenous fluid composition affects risk of kidney injury and death for critically ill adults. Generally, the risk of kidney injury and death appears to be greater with semisynthetic colloids compared with crystalloids, and with 0.9% sodium chloride compared with balanced crystalloids. Whether a liberal, restrictive, or hemodynamic responsiveness-guided approach to fluid dosing improves outcomes during sepsis or major surgery remains uncertain.

SUMMARY

As evidence on fluid resuscitation evolves, a reasonable approach would be to use primarily balanced crystalloids, consider 2-3 l for initial fluid resuscitation of hypovolemic or distributive shock, and use measures of anticipated hemodynamic response to guide further fluid administration.

Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort

BACKGROUND

Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described.

OBJECTIVES

We aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities.

DESIGN

Retrospective consecutive-sample cohort.

SETTING

Nine hospitals from October 1, 2014, to March 31, 2016.

PATIENTS

All hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) ≥1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED.

MEASUREMENTS

We assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality.

RESULTS

Of 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsis mortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00).

CONCLUSIONS

HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.

Septic shock in the ER: diagnostic and management challenges

Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient's volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.

Cardiovascular determinants of resuscitation from sepsis and septic shock

BACKGROUND

We hypothesized that the cardiovascular responses to Surviving Sepsis Guidelines (SSG)-defined resuscitation are predictable based on the cardiovascular state.

METHODS

Fifty-five septic patients treated by SSG were studied before and after volume expansion (VE), and if needed norepinephrine (NE) and dobutamine. We measured mean arterial pressure (MAP), cardiac index (CI), and right atrial pressure (Pra) and calculated pulse pressure and stroke volume variation (PPV and SVV), dynamic arterial elastance (Ea_dyn), arterial elastance (Ea) and left ventricular (LV) end-systolic elastance (Ees), Ees/Ea (VAC), LV ejection efficiency (LVeff), mean systemic pressure analogue (Pmsa), venous return pressure gradient (Pvr), and cardiac performance (Eh), using standard formulae.

RESULTS

All patients were hypotensive (MAP 56.8 ± 3.1 mmHg) and tachycardic (113.1 ± 7.5 beat min^-1), with increased lactate levels (lactate = 5.0 ± 4.2 mmol L^-1) with a worsened VAC. CI was variable but > 2 L min^-1 M^-2 in 74%. Twenty-eight-day mortality was 48% and associated with admission lactate, blood urea nitrogen (BUN), and creatinine levels but not cardiovascular state. In all patients, both MAP and CI improved following VE, as well as cardiac contractility (Ees). Fluid administration improved Pra, Pmsa, and Pvr in all patients, whereas both HR and Ea decreased after VE, thus normalizing VAC. CI increases were proportional to baseline PPV and SVV. CI increases proportionally decreased PPV and SVV. VE increased MAP > 65 mmHg in 35/55 patients. MAP responders had higher PPV, SVV, and Ea_dyn than non-responders. NE was given to 20/55 patients in septic shock, but increased MAP > 65 mmHg in only 12. NE increased Ea, Ea_dyn, Pra, Pmsa, and VAC while decreasing HR, PPV, SVV, and LVeff. MAP responders had higher pre-NE Ees and lower VAC. Dobutamine was given to 6/8 patients who remained hypotensive following NE. It increased Ees, MAP, CI, and LVeff, while decreasing HR, Pra, and VAC. At all times and all steps of the protocol, CI changes were proportional to Pvr changes independent of treatment.

CONCLUSIONS

The cardiovascular response to SSG-based resuscitation is highly heterogeneous but predictable from pre-treatment measures of cardiovascular state.

Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the "one-size-fits-all" approach

OBJECTIVE

The Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality.

DESIGN

Retrospective, observational study.

SETTING

1136-bed academic and 235-bed community hospital (January 2015-June 2016).

PATIENTS

Patients with septic shock.

INTERVENTIONS

Crystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS.

MEASUREMENTS

Associations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported.

MAIN RESULTS

Overall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76-1.41.

CONCLUSIONS

These findings question a "one-size-fits-all" approach to fluid administration and performance measures for patients with sepsis.

Evidence-based updates to the 2016 Surviving Sepsis Guidelines and clinical implications

Despite numerous advances in understanding the pathophysiology of sepsis and its treatment, sepsis morbidity and mortality remain high. The 2016 Surviving Sepsis Campaign guidelines incorporated the latest research to formulate new sepsis diagnoses and updated treatment recommendations. This article reviews how to manage patients with sepsis and provides insight into the 2016 guidelines, updates, and suggestions.

Potential mortality and cost reduction in adult severe sepsis and septic shock through the use of an innovative fluid delivery device

Background

While early fluid resuscitation has been shown to significantly improve health and economic metrics in septic shock, providers are often unable to achieve fluid delivery guidelines using current techniques.

Purpose

To examine expected clinical and economic consequences of more consistent achievement of fluid resuscitation guidelines through use of a novel fluid delivery technology.

Patients and methods

A decision analytic model was developed to compare expected costs and outcomes associated with the standard technique vs a novel, faster technique for rapid fluid resuscitation in adult patients with severe sepsis or septic shock.

Results

Use of an innovative fluid delivery device (LifeFlow) resulted in lower expected mortality compared to standard intravenous fluid delivery methods (reduction of 10 fewer deaths per 500 cases). Compared to standard methods, use of the innovative rapid fluid delivery device also resulted in lower expected hospital costs (US$1,569,131 cost reduction per 500 cases), a lower required use of mechanical ventilation (24% vs 31%), decreased average length of stay (11 vs 13 days), decreased average intensive care unit length of stay (2 vs 3 days), and decreased use of vasopressors (17% vs 21%). A sensitivity analysis showed that utilization of the rapid fluid delivery device is more cost-effective than standard methods, even under the most conservative assumptions.

Conclusion

Based on existing data supporting the importance of early, controlled fluid resuscitation in septic shock patients, the analytical model developed in this study demonstrated the benefit of a novel device that facilitates earlier fluid bolus completion and better adherence to sepsis bundles.