Passive leg raise testing effectively reduces fluid administration in septic shock after correction of non-compliance to test results

Septic shock in the prehospital setting: a scoping review

Septic shock (SS) is a potential life-threatening condition in which an early identification and immediate therapy stand out as the main cornerstones to improve survival chance; in this context, emergency medical services (EMS) become key to reduce the time between diagnosis and management in the ICU or emergency department. However, guidelines for the prehospital management of SS patients remains unclear, and literature around this topic is scant. Our scoping review was conducted following the PICO framework and a search strategy related to septic shock management and diagnosis in prehospital settings was executed in PubMed, Scopus and Virtual Health Library; articles in English and Spanish from 2015, onwards, were screened by the authors and selected by mutual consensus. Our aim is to analyze the prehospital management strategies of SS reported in the literature, and to showcase and summarize the screening tools, demographic factors, clinical manifestations and prognostic factors of SS in the prehospital setting.

Evaluating fluid overload in critically ill children

PURPOSE OF REVIEW

To review the evaluation and management of fluid overload in critically ill children.

RECENT FINDINGS

Emerging evidence associates fluid overload, i.e. having a positive cumulative fluid balance, with adverse outcome in critically ill children. This is most likely the result of impaired organ function due to increased extravascular water content. The combination of a number of parameters, including physical, laboratory and radiographic markers, may aid the clinician in monitoring and quantifying fluid status, but all have important limitations, in particular to discriminate between intra- and extravascular water volume. Current guidelines advocate a restrictive fluid management, initiated early during the disease course, but are hampered by the lack of high quality evidence.

SUMMARY

Recent advances in early evaluation of fluid status and (tailored) restrictive fluid management in critically ill children may decrease complications of fluid overload, potentially improving outcome. Further clinical trials are necessary to provide the clinician with solid recommendations.

Differences in Hemodynamic Response to Passive Leg Raising Tests during the Day in Healthy Individuals: The Question of Normovolemia

BACKGROUND

The passive leg-raising (PLR) test was developed to predict fluid responsiveness and reduce fluid overload. However, the hemodynamic response of healthy individuals to the PLR test and how it changes during the day, between the morning and evening, after individuals have consumed food and fluids, has not been profoundly explored. This study aimed to compare the systemic hemodynamic changes in healthy individuals between morning and evening PLR tests.

METHODS

In this study, the PLR test was performed twice a day. The first PLR test was performed between 08h00 and 09h00 in the morning, while the second PLR test was performed between 20h00 and 21h00 in the evening. Hemodynamic parameters were measured using an impedance cardiography monitor, and a cutoff value of a 10% increase in stroke volume (SV) during the PLR test was used to differentiate between preload responders and non-responders.

RESULTS

We included 50 healthy volunteers in this study. When comparing the morning and evening PLR test results, we found no PLR-induced differences in heart rate (-3 [-8-2] vs. -2 [-8-4] beats/min, p = 0.870), SV (11 [5-22] vs. 12 [4-20] mL, p = 0.853) or cardiac output (0.7 [0.2-1.3] vs. 0.8 [0.1-1.4] L/min, p = 0.639). We also observed no differences in the proportion of preload responders during the PLR test between the morning and evening (64% vs. 66%, p = 0.99). However, there was a moderate agreement between the two PLR tests (morning and evening) (kappa = 0.429, p = 0.012). There was a moderate correlation between the changes in SV between the two PLR tests (r_s = 0.50, p < 0.001).

CONCLUSION

In young, healthy individuals, we observed no change in the systemic hemodynamic responsiveness to the PLR test between the morning and evening, without restriction of fluid and food intake.

Changes in Stroke Volume Variation Induced by Passive Leg Raising to Predict Fluid Responsiveness in Cardiac Surgical Patients With Protective Ventilation

OBJECTIVES

Stroke volume variation (SVV) has been used to predict fluid responsiveness. The authors hypothesized the changes in SVV induced by passive leg raising (PLR) might be an indicator of fluid responsiveness in patients with protective ventilation after cardiac surgery.

DESIGN

A prospective single-center observational study.

SETTING

A single cardiac surgery intensive care unit at a tertiary hospital.

PARTICIPANTS

A total of 123 patients undergoing cardiac surgery with hemodynamic instability. Tidal volume was set between 6 and 8 mL/kg of ideal body weight.

INTERVENTIONS

PLR maneuver, fluid challenge.

MEASUREMENTS AND MAIN RESULTS

SVV was continuously recorded using pulse contour analysis before and immediately after a PLR test and after fluid challenge (500 mL of colloid given over 30 min). Sixty-three (51.22%) patients responded to fluid challenge, in which PLR and fluid challenge significantly increased the SV and decreased the SVV. The decrease in SVV induced by PLR was correlated with the SV changes induced by fluid challenge. A 4% decrease in the SVV induced by PLR-discriminated responders to fluid challenge with an area under the curve of 0.90. The gray zone identified a range of SVV changes induced by PLR (between -3.94% and -2.91%) for which fluid responsiveness could not be predicted reliably. The gray zone included 15.45% of the patients. The SVV at baseline predicted fluid responsiveness with an area under the curve of 0.72.

CONCLUSIONS

Changes in the SVV induced by PLR predicted fluid responsiveness in cardiac surgical patients with protective ventilation.

Physician factors in utilizing haemodynamic data in patient care

PURPOSE OF REVIEW

To focus on the missing link between accuracy and precision of monitoring devices and effective implementation of therapeutic strategies.

RECENT FINDINGS

Haemodynamic monitoring is generally considered to be an essential part of intensive care medicine. However, randomized controlled trials fail to demonstrate improved outcome unequivocally as a result of hemodynamic monitoring. This absence of solid proof renders doctors to hesitance to apply haemodynamic monitoring in clinical practise. Profound understanding of the underlying mechanisms, adequate patient selection and timing, meaningful representation and software-supported interpretation of data all play an important role. Furthermore, protocol adherence and human behaviour seem to form the often missing link between a solid physiologic principle and clinically relevant outcome. Introduction of haemodynamic monitoring should therefore not be limited to theoretical and practical issues, but also involve integration strategies. By learning from others, we might be able to implement haemodynamic monitoring in such a way that it has potential to modify the course of a disease.

SUMMARY

The clinical success of haemodynamic monitoring goes far beyond accuracy and precision of monitoring devices. Understanding of the factors influencing the effective implementation of therapeutic strategies plays an important role in the meaningful introduction of haemodynamic monitoring.

The effects of static and dynamic measurements using transpulmonary thermodilution devices on fluid therapy in septic shock: A systematic review

Transpulmonary thermodilution devices have been widely shown to be accurate in septic shock patients in assessing fluid responsiveness. We conducted a systematic review to assess the relationship between fluid therapy protocols guided by transpulmonary thermodilution devices on fluid balance and the amount of intravenous fluid used in septic shock. We searched MEDLINE, Embase and The Cochrane Library. Studies were eligible for inclusion if they were prospective, parallel trials that were conducted in an intensive care setting in patients with septic shock. The comparator group was either central venous pressure, early goal-directed therapy or pulmonary artery occlusion pressure. Studies assessing only the accuracy of fluid responsiveness prediction by transpulmonary thermodilution devices were excluded. Two reviewers independently performed the search, extracted data and assessed the bias of each study. In total 27 full-text articles were identified for eligibility; of these, nine studies were identified for inclusion in the systematic review. Three of these trials used dynamic parameters derived from transpulmonary thermodilution devices and six used primarily static parameters to guide fluid therapy. There was evidence for a significant reduction in positive fluid balance in four out of the nine studies. From the available studies, the results suggest the benefit of transpulmonary thermodilution monitoring in the septic shock population with regard to reducing positive fluid balance is seen when the devices are utilised for at least 72 hours. Both dynamic and static parameters derived from transpulmonary thermodilution devices appear to lead to a reduction in positive fluid balance in septic shock patients compared to measurements of central venous pressure and early goal-directed therapy.

Assessing Fluid Resuscitation in Adults with Sepsis Who Are Not Mechanically Ventilated: a Systematic Review of Diagnostic Test Accuracy Studies

BACKGROUND

Fluid resuscitation is a widely used intervention that is mandated in the management of sepsis. While its use can be life-saving, its overuse is associated with harm. Despite this, the best means of assessing a need for fluid resuscitation in an acute medical setting is unclear.

OBJECTIVE

To assess studies of diagnostic tests that identify the need for fluid resuscitation in adults with sepsis, as defined by the presence of fluid responsiveness.

DESIGN

Protocol registration was performed in advance (PROSPERO:CRD42017048651). Research database searches were performed alongside additional searches to identify grey literature. Diagnostic test accuracy studies that assessed any fluid assessment tool were identified independently by two authors, before data extraction and quality assessments were performed.

PARTICIPANTS

Adults with sepsis, without intensive care organ support, who would be appropriate for admission to an acute medical unit.

KEY RESULTS

Of the 26,841 articles that were screened, 14 studies were identified for inclusion, involving a combined total of 594 patients. Five categories of index test were identified: inferior vena cava collapsibility index (IVCCI), haemodynamic change with passive leg raise, haemodynamic change with respiration, haemodynamic change with intravenous fluid administration, and static assessment tools. Due to the high level of clinical heterogeneity affecting all aspects of study design, quantitative analysis was not feasible. There was a lack of consensus on reference tests to determine fluid responsiveness.

CONCLUSION

While fluid resuscitation is considered a key part of the management of sepsis, evidence to support fluid assessment in awake adults is lacking. This review has highlighted a number of research recommendations that should be addressed as a matter of urgency if patient harm is to be avoided.

Corporeal Compression at the Onset of Septic shock (COCOONs): a compression method to reduce fluid balance of septic shock patients

Fluid overload in septic intensive care unit (ICU) patients is common and strongly associated with poor outcome. There is currently no treatment for capillary leak, which is mainly responsible for high positive fluid balance (FB) in sepsis. We hypothesized that increasing interstitial pressure with extensive corporeal compression would reduce FB. The objective of this study was to evaluate the feasibility, efficacy, and safety of a compression treatment during sepsis. This pilot, two-center, single-arm trial enrolled critically ill, non-surgical, septic patients receiving mechanical ventilation. The therapeutic intervention was the early application of compression bandages on more than 80% of the body surface. The primary outcome was negative net FB on day 7. The primary endpoint was reached in 29 of 45 patients (64%) with available data, for a planned objective of 26. By day 4, cumulative FB was 7280 ml [3300–9700]. SOFA- and aged-matched patients from a historical cohort had a significantly higher FB at 1, 2 and 7 days. Tolerance was good, although low-stage pressure ulcers were observed in 16 patients (26%). No effect on intra-abdominal pressure or respiratory plateau pressure was observed. In conclusion, corporeal compression demonstrated potential efficacy in limiting FB during septic shock, with acceptable feasibility and tolerance.

Resuscitation Guided by Volume Responsiveness Does Not Reduce Mortality in Sepsis: A Meta-Analysis

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Resuscitation with IV fluids is a critical component in the management of sepsis. Although the optimal volume of IV fluid is unknown, there is evidence that excessive administration can be deleterious. Static measures of volume status have not proven to be meaningful resuscitative endpoints. Determination of volume responsiveness has putative benefits over static measures, but its effect on outcomes is unknown. The goal of this systematic review and meta-analysis was to determine if resuscitation with a volume responsiveness-guided approach leads to improved outcomes in septic patients.

Calibrated cardiac output monitoring versus standard care for fluid management in the shocked ICU patient: a pilot randomised controlled trial

Background

Despite the evidence for calibrated cardiac monitored devices to determine fluid responsiveness, there is minimal evidence that the use of cardiac output monitor devices leads to an overall change in IV fluid use. We sought to investigate the feasibility of performing a randomised controlled study using calibrated cardiac output monitoring devices in shocked ICU patients and whether the use of these devices led to a difference in total volume of IV fluid administered.

Methods

We performed a single-centre non-blinded randomised controlled study which included patients who met the clinical criteria for shock on admission to ICU. Patients were divided into two groups (cardiac output monitors or standard) by block randomisation. Patients allocated to the cardiac output monitor all received EV1000 with Volume View sets. Daily intravenous fluid administration and cumulative fluid balance was recorded for 3 days. The primary outcome assessed was the difference in daily intravenous fluid administration and cumulative fluid balance at 72 h between the two groups. We also assessed how often the clinicians used the cardiac monitor to guide fluid therapy and the different reasoning for initiating further intravenous fluids.

Results

Eighty patients were randomised and 37 received calibrated cardiac output monitors. We found no adverse outcomes in the use of calibrated cardiac output monitoring devices and that was feasible to perform a randomised controlled trial. There was no significant difference between the standard care group vs the cardiac monitoring group for cumulative fluid balance (2503 ± 3764 ml vs 2458 ± 3560 ml, p = 0.96). There was no significant difference between the groups for daily intravenous fluid administration on days 1, 2 or 3. In the cardiac monitored group, only 43% of the time was the EV1000 output incorporated into the decision to give further intravenous fluids.

Conclusion

It is feasible to perform a randomised controlled trial using calibrated cardiac output monitoring devices. In addition, there was no trend to suggest that the use of a cardiac monitors leads to lower IV fluid use in the shocked patient. Further trials will require study designs to optimise the use of a cardiac output monitor to determine the utility of these devices in the shocked patient.

Trial registration

ANZCTR, ACTRN12618001373268. Registered 15 August 2018-retrospectively registered.

Septic shock resuscitation in the first hour

PURPOSE OF REVIEW

We reviewed the recent advances in the initial approach to resuscitation of sepsis and septic shock patients.

RECENT FINDINGS

Sepsis and septic shock are life-threatening emergencies. Two key interventions in the first hour include timely antibiotic therapy and resuscitation. Before any laboratory results, the need for resuscitation is considered if a patient with suspected infection has low blood pressure (BP) or impaired peripheral circulation found at clinical examination. Until now, this early resuscitation in sepsis and septic shock was supported by improvements in outcome seen with goal-directed therapy. However, three recent, goal-directed therapy trials failed to replicate the originally reported mortality reductions, prompting a debate on how this early resuscitation should be performed. As resuscitation is often focussed on macrociculatory goals such as optimizing central venous pressure, the discordance between microcirculatory and macrocirculatory optimization during resuscitation is a potential argument for the lack of outcome benefit in the newer trials. Vasoactive drug dose and large volume resuscitation-associated-positive fluid balance, are independently associated with worse clinical outcomes in critically ill sepsis and septic shock patients. As lower BP targets and restricted volume resuscitation are feasible and well tolerated, should we consider a lower BP target to reduce the adverse effects of catecholamine' and excess resuscitation fluids. Evidence guiding fluids, vasopressor, and inotrope selection remains limited.

SUMMARY

Though the early resuscitation of sepsis and septic shock is key to improving outcomes, ideal resuscitation targets are elusive. Distinction should be drawn between microcirculatory and macrocirculatory changes, and corresponding targets. Common components of resuscitation bundles such as large volume resuscitation and high-dose vasopressors may not be universally beneficial. Microcirculatory targets, individualized resuscitation goals, and reassessment of completed trials using the updated septic shock criteria should be focus areas for future research.