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Hernández G, Valenzuela ED, Kattan E, Castro R, Guzmán C, Kraemer AE, Sarzosa N, Alegría L, Contreras R, Oviedo V, Bravo S, Soto D, Sáez C, Ait-Oufella H, Ospina-Tascón G, Bakker J. Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study. Ann Intensive Care 2024; 14:49. [PMID: 38558268 PMCID: PMC10984906 DOI: 10.1186/s13613-024-01275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Several studies have validated capillary refill time (CRT) as a marker of tissue hypoperfusion, and recent guidelines recommend CRT monitoring during septic shock resuscitation. Therefore, it is relevant to further explore its kinetics of response to short-term hemodynamic interventions with fluids or vasopressors. A couple of previous studies explored the impact of a fluid bolus on CRT, but little is known about the impact of norepinephrine on CRT when aiming at a higher mean arterial pressure (MAP) target in septic shock. We designed this observational study to further evaluate the effect of a fluid challenge (FC) and a vasopressor test (VPT) on CRT in septic shock patients with abnormal CRT after initial resuscitation. Our purpose was to determine the effects of a FC in fluid-responsive patients, and of a VPT aimed at a higher MAP target in chronically hypertensive fluid-unresponsive patients on the direction and magnitude of CRT response. METHODS Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80-85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions). RESULTS CRT decreased significantly with both tests (from 5 [3.5-7.6] to 4 [2.4-5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3-5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin. CONCLUSIONS Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research.
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Camila Guzmán
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Alicia Elzo Kraemer
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Nicolás Sarzosa
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Roberto Contreras
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Sebastián Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Claudia Sáez
- Departamento de Hematología Oncología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Gustavo Ospina-Tascón
- Cardiovascular Research Center, INSERM U970, Université de Paris, Paris, France
- Department of Intensive Care Medicine, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
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2
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Messina A, Chew MS, Poole D, Calabrò L, De Backer D, Donadello K, Hernandez G, Hamzaoui O, Jozwiak M, Lai C, Malbrain MLNG, Mallat J, Myatra SN, Muller L, Ospina-Tascon G, Pinsky MR, Preau S, Saugel B, Teboul JL, Cecconi M, Monnet X. Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine. Intensive Care Med 2024; 50:548-560. [PMID: 38483559 DOI: 10.1007/s00134-024-07344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/31/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU). METHODS The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively). RESULTS We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting. CONCLUSION This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.
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Affiliation(s)
- Antonio Messina
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy.
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy.
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Daniele Poole
- Anesthesia and Intensive Care Operative Unit, S. Martino Hospital, Belluno, Italy
| | - Lorenzo Calabrò
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Paediatrics, University of Verona, Via Dell'artigliere 8, 37129, Verona, Italy
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Olfa Hamzaoui
- Service de Médecine Intensive Réanimation Polyvalente, Robert Debré Hospital, University Hospitals of Reims, Unité HERVI « Hémostase et Remodelage Vasculaire Post-Ischémie » - EA 3801, University of Reims, Reims, France
| | - Mathieu Jozwiak
- Centre Hospitalier Universitaire L'Archet 1, Service de Médecine Intensive Réanimation, Nice, France
- Equipe 2 CARRES, UR2CA Unité de Recherche Clinique Université Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Christopher Lai
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Sheyla Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Laurent Muller
- Department of Anaesthesia, Critical Care and Emergency Medicine, Nîmes University Hospital, Place du Professeur Debré, 30029, Nîmes, France
- Hôpital universitaire Carémeau, University of Montpellier (MUSE), Nîmes, France
| | - Gustavo Ospina-Tascon
- Department of Intensive Care, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sebastian Preau
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, 59000, Lille, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jean-Louis Teboul
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Maurizio Cecconi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano (Milan), Italy
- Department of Biomedical Sciences, Humanitas University, via Levi Montalcin,i 4, Pieve Emanuele (Milan), Italy
| | - Xavier Monnet
- DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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3
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Muñoz F, Born P, Bruna M, Ulloa R, González C, Philp V, Mondaca R, Blanco JP, Valenzuela ED, Retamal J, Miralles F, Wendel-Garcia PD, Ospina-Tascón GA, Castro R, Rola P, Bakker J, Hernández G, Kattan E. Coexistence of a fluid responsive state and venous congestion signals in critically ill patients: a multicenter observational proof-of-concept study. Crit Care 2024; 28:52. [PMID: 38374167 PMCID: PMC10877871 DOI: 10.1186/s13054-024-04834-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/10/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Current recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission. METHODS Multicenter, prospective cross-sectional observational study conducted in three medical-surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected. RESULTS Ninety patients were included. Median age was 63 [45-71] years old, and median SOFA score was 9 [7-11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR-). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR- groups (53% vs. 57%, p = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals. CONCLUSIONS Venous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.
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Affiliation(s)
- Felipe Muñoz
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Pablo Born
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Mario Bruna
- Unidad de Cuidados Intensivos, Hospital de Quilpué, Quilpué, Chile
| | - Rodrigo Ulloa
- Unidad de Cuidados Intensivos, Hospital Las Higueras, Talcahuano, Chile
| | - Cecilia González
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Valerie Philp
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Roberto Mondaca
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Juan Pablo Blanco
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | | | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Cali, Colombia
- Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Philippe Rola
- Intensive Care Unit, Hopital Santa Cabrini, CIUSSS EMTL, Montreal, Canada
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.
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4
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Ramasco F, Aguilar G, Aldecoa C, Bakker J, Carmona P, Dominguez D, Galiana M, Hernández G, Kattan E, Olea C, Ospina-Tascón G, Pérez A, Ramos K, Ramos S, Tamayo G, Tuero G. Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:112-124. [PMID: 38244774 DOI: 10.1016/j.redare.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/04/2023] [Indexed: 01/22/2024]
Abstract
Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.
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Affiliation(s)
- F Ramasco
- Hospital Universitario de La Princesa, Madrid, Spain.
| | - G Aguilar
- Hospital Clínico Universitario de Valencia, Spain
| | - C Aldecoa
- Hospital Universitario Río Hortega, Valladolid, Spain
| | - J Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN); Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, Netherlands; Division of Pulmonary Critical Care, and Sleep Medicine, New York University and Columbia University, New York, USA
| | - P Carmona
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - D Dominguez
- Hospital Universitario Ntra. Sra. de Candelaria, Santa Cruz de Tenerife, Spain
| | - M Galiana
- Hospital General Universitario Doctor Balmis, Alicante, Spain
| | - G Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - E Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - C Olea
- Hospital Universitario 12 de Octubre, Madrid. Spain
| | - G Ospina-Tascón
- The Latin American Intensive Care Network (LIVEN); Department of Intensive Care, Fundación Valle del Lili, Cali, Colombia; Translational Research Laboratory in Critical Care Medicine (TransLab-CCM), Universidad Icesi, Cali, Colombia
| | - A Pérez
- Hospital General Universitario de Elche, Spain
| | - K Ramos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile; The Latin American Intensive Care Network (LIVEN)
| | - S Ramos
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - G Tamayo
- Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
| | - G Tuero
- Hospital Can Misses, Ibiza, Spain
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5
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Valeanu L, Andrei S, Ginghina C, Robu C, Ciurciun A, Balan C, Stefan M, Stoian A, Stanculea I, Cheta A, Dima L, Stiru O, Filipescu D, Bubenek-Turconi SI, Longrois D. Perioperative trajectory of plasma viscosity: a prospective, observational, exploratory study in cardiac surgery. Microcirculation 2022; 29:e12777. [PMID: 35837796 DOI: 10.1111/micc.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 06/01/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Plasma viscosity is one of the critical factors that regulate microcirculatory flow but has received scant research attention. The main objective of this study was to evaluate plasma viscosity in cardiac surgery with respect to perioperative trajectory, main determinants and impact on outcome. METHODS Prospective, single center, observational study, including 50 adult patients undergoing cardiac surgery with cardiopulmonary bypass between 1 February 2020 - 31 May 2021. Clinical perioperative characteristics, short term outcome, standard blood analysis, plasma viscosity, total proteins and fibrinogen concentrations were recorded at ten distinct time points during the first perioperative week. RESULTS The longitudinal analysis showed that plasma viscosity is strongly influenced by proteins and measurement time points. Plasma viscosity showed a coefficient of variation of 11.3 +/- 1.08 for EDTA and 12.1 +/-2.1 for citrate, similarly to total proteins and hemoglobin, but significantly lower than fibrinogen (p<0.001). Plasma viscosity had lower percentage changes compared to hemoglobin (RANOVA, p<0.001), fibrinogen (RANOVA, p<0.001), and total proteins (RANOVA, p<0.001). The main determinant of plasma viscosity was protein concentrations. No association with outcome was found, but the study may have been underpowered to detect it. CONCLUSION Plasma viscosity had a low coefficient of variation and low perioperative changes, suggesting tight regulation. Studies linking plasma viscosity with outcome would require large patient cohorts.
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Affiliation(s)
- Liana Valeanu
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Stefan Andrei
- Anesthesiology and Intensive Care Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, Bucharest, Romania.,Anesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, 2 Bd Maréchal de Lattre de Tassigny, Dijon, France
| | - Carmen Ginghina
- Cardiology Department III, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania.,Cardiology Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, Bucharest, Romania
| | - Cornel Robu
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Adrian Ciurciun
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Cosmin Balan
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Mihai Stefan
- Cardiac Anesthesiology and Intensive Care Department II, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Anca Stoian
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Iulia Stanculea
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Andreea Cheta
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Laura Dima
- Clinical Medical Laboratory, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Ovidiu Stiru
- Cardiovascular Surgery Department II, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania.,Cardiovascular Surgery Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, Bucharest, Romania
| | - Daniela Filipescu
- Anesthesiology and Intensive Care Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, Bucharest, Romania.,Cardiac Anesthesiology and Intensive Care Department II, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. dr. C. C. Iliescu, 258 Fundeni Road, Bucharest, Romania.,Anesthesiology and Intensive Care Department, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, Bucharest, Romania
| | - Dan Longrois
- Anesthesiology and Intensive Care Department, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, 46 Henri Huchard Street, Paris, France
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6
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Renner J, Bein B, Grünewald M. [Hemodynamic Monitoring in the ICU: the More Invasive, the Better?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:263-276. [PMID: 35451033 DOI: 10.1055/a-1472-4318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.
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7
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Lorenzen U, Grünewald M. [Targeted hemodynamic monitoring in the operating theatre: what for and by what means?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:246-262. [PMID: 35451032 DOI: 10.1055/a-1472-4285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Goal directed hemodynamic monitoring and the balance in goal directed therapy between adequate fluid/volume therapy and the application of vasoactive or inotropic drugs are the basic elements of modern perioperative therapy.Surgical procedures should be accompanied by as few side effects and complications as possible. Nevertheless, the number of postoperative complications remains surprisingly high, despite of the modern surgical procedures. Anticipation of potential complications in the perioperative period and their rapid treatment build a core competence of anesthesiological action. Thus, it is clear that anesthesia plays a central role in this balancing act.This article aims to provide an overview of the application of the currently available perioperative goal directed hemodynamic monitoring. The current possibilities are discussed by using a case example and an outlook on the future of hemodynamic monitoring is given.
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Affiliation(s)
- Ulf Lorenzen
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel
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8
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Abstract
Rationale & Objective Adaptive design methods are intended to improve the efficiency of clinical trials and are relevant to evaluating interventions in dialysis populations. We sought to determine the use of adaptive designs in dialysis clinical trials and quantify trends in their use over time. Study Design We completed a novel full-text systematic review that used a machine learning classifier (RobotSearch) for filtering randomized controlled trials and adhered to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Setting & Study Populations We searched MEDLINE (PubMed) and ClinicalTrials.gov using sensitive dialysis search terms. Selection Criteria for Studies We included all randomized clinical trials with patients receiving dialysis or clinical trials with dialysis as a primary or secondary outcome. There was no restriction of disease type or intervention type. Data Extraction & Analytical Approach We performed a detailed data extraction of trial characteristics and a completed a narrative synthesis of the data. Results 57 studies, available as 68 articles and 7 ClinicalTrials.gov summaries, were included after full-text review (initial search, 209,033 PubMed abstracts and 6,002 ClinicalTrials.gov summaries). 31 studies were conducted in a dialysis population and 26 studies included dialysis as a primary or secondary outcome. Although the absolute number of adaptive design methods is increasing over time, the relative use of adaptive design methods in dialysis trials is decreasing over time (6.12% in 2009 to 0.43% in 2019, with a mean of 1.82%). Group sequential designs were the most common type of adaptive design method used. Adaptive design methods affected the conduct of 50.9% of trials, most commonly resulting in stopping early for futility (41.2%) and early stopping for safety (23.5%). Acute kidney injury was studied in 32 trials (56.1%), kidney failure requiring dialysis was studied in 24 trials (42.1%), and chronic kidney disease was studied in 1 trial (1.75%). 27 studies (47.4%) were supported by public funding. 44 studies (77.2%) did not report their adaptive design method in the title or abstract and would not be detected by a standard systematic review. Limitations We limited our search to 2 databases (PubMed and ClinicalTrials.gov) due to the scale of studies sourced (209,033 and 6,002 results, respectively). Conclusions Adaptive design methods are used in dialysis trials but there has been a decline in their relative use over time.
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Kattan E, Hernández G. The role of peripheral perfusion markers and lactate in septic shock resuscitation. JOURNAL OF INTENSIVE MEDICINE 2021; 2:17-21. [PMID: 36789233 PMCID: PMC9924002 DOI: 10.1016/j.jointm.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/04/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
Septic shock leads to progressive hypoperfusion and tissue hypoxia. Unfortunately, numerous uncertainties exist around the best monitoring strategy, as available techniques are mere surrogates for these phenomena. Nevertheless, central venous oxygen saturation (ScvO2), venous-to-arterial CO2 gap, and lactate normalization have been fostered as resuscitation targets for septic shock. Moreover, recent evidence has challenged the central role of lactate. Following the ANDROMEDA-SHOCK trial, capillary refill time (CRT) has become a promissory target, considering the observed benefits in mortality, treatment intensity, and organ dysfunction. Interpretation of CRT within a multimodal approach may aid clinicians in guiding resuscitative interventions and stop resuscitation earlier, thus avoiding the risk of morbid fluid overload. Integrative assessment of a patient's perfusion status can be easily performed using bedside clinical tools. Based on its fast kinetics and recent supporting evidence, targeting CRT (within a holistic assessment of perfusion) may improve outcomes in septic shock resuscitation.
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10
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Sanfilippo F, Messina A, Cecconi M, Astuto M. Ten answers to key questions for fluid management in intensive care. Med Intensiva 2021; 45:552-562. [PMID: 34839886 DOI: 10.1016/j.medine.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/17/2020] [Indexed: 11/25/2022]
Abstract
This review focuses on fluid management of critically ill patients. The topic is addressed based on 10 single questions with simplified answers that provide clinicians with the basic information needed at the point of care in treating patients in the Intensive Care Unit. The review has didactic purposes and may serve both as an update on fluid management and as an introduction to the subject for novices in critical care. There is an urgent need to increase awareness regarding the potential risks associated with fluid overload. Clinicians should be mindful not only of the indications for administering fluid loads and of the type of fluids administered, but also of the importance to set safety limits. Lastly, it is important to implement proactive strategies seeking to establish negative fluid balance as soon as the clinical conditions are considered to be stable and the risk of deterioration is low.
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Affiliation(s)
- F Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy.
| | - A Messina
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Cecconi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy; School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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11
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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12
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Effect of mean arterial pressure change by norepinephrine on peripheral perfusion index in septic shock patients after early resuscitation. Chin Med J (Engl) 2021; 133:2146-2152. [PMID: 32842018 PMCID: PMC7508439 DOI: 10.1097/cm9.0000000000001017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The peripheral perfusion index (PI), as a real-time bedside indicator of peripheral tissue perfusion, may be useful for determining mean arterial pressure (MAP) after early resuscitation of septic shock patients. The aim of this study was to explore the response of PI to norepinephrine (NE)-induced changes in MAP. Methods Twenty septic shock patients with pulse-induced contour cardiac output catheter, who had usual MAP under NE infusion after early resuscitation, were enrolled in this prospective, open-label study. Three MAP levels (usual MAP −10 mmHg, usual MAP, and usual MAP +10 mmHg) were obtained by NE titration, and the corresponding global hemodynamic parameters and PI were recorded. The general linear model with repeated measures was used for analysis of variance of related parameters at three MAP levels. Results With increasing NE infusion, significant changes were found in MAP (F = 502.46, P < 0.001) and central venous pressure (F = 27.45, P < 0.001) during NE titration. However, there was not a significant and consistent change in continuous cardiac output (CO) (F = 0.41, P = 0.720) and PI (F = 0.73, P = 0.482) at different MAP levels. Of the 20 patients enrolled, seven reached the maximum PI value at usual MAP −10 mmHg, three reached the maximum PI value at usual MAP, and ten reached the maximum PI value at usual MAP +10 mmHg. The change in PI was not significantly correlated with the change in CO (r = 0.260, P = 0.269) from usual MAP −10 mmHg to usual MAP. There was also no significant correlation between the change in PI and change in CO (r = 0.084, P = 0.726) from usual MAP to usual MAP +10 mmHg. Conclusions Differing MAP levels by NE infusion induced diverse PI responses in septic shock patients, and these PI responses may be independent of the change in CO. PI may have potential applications for MAP optimization based on changes in peripheral tissue perfusion.
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13
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss the implication of microvascular dysfunction in septic shock. RECENT FINDINGS Resuscitation of sepsis has focused on systemic haemodynamics and, more recently, on peripheral perfusion indices. However, central microvascular perfusion is altered in sepsis and these alterations often persist despite normalization of various macro haemodynamic resuscitative goals. Endothelial dysfunction is a key element in sepsis pathophysiology. It is responsible for the sepsis-induced hypotension. In addition, endothelial dysfunction is also implicated involved in the activation of inflammation and coagulation processes leading to amplification of the septic response and development of organ dysfunction. It also promotes an increase in permeability, mostly at venular side, and impairs microvascular perfusion and hence tissue oxygenation.Microvascular alterations are characterized by heterogeneity in blood flow distribution, with adequately perfused areas in close vicinity to not perfused areas, thus characterizing the distributive nature of septic shock. Such microvascular alterations have profound implications, as these are associated with organ dysfunction and unfavourable outcomes. Also, the response to therapy is highly variable and cannot be predicted by systemic hemodynamic assessment and hence cannot be detected by classical haemodynamic tools. SUMMARY Microcirculation is a key element in the pathophysiology of sepsis. Even if microcirculation-targeted therapy is not yet ready for the prime time, understanding the processes implicated in microvascular dysfunction is important to prevent chasing systemic hemodynamic variables when this does not contribute to improve tissue perfusion.
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Sanfilippo F, Messina A, Cecconi M, Astuto M. Ten answers to key questions for fluid management in intensive care. Med Intensiva 2020; 45:S0210-5691(20)30338-7. [PMID: 33323286 DOI: 10.1016/j.medin.2020.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/05/2020] [Accepted: 10/17/2020] [Indexed: 12/16/2022]
Abstract
This review focuses on fluid management of critically ill patients. The topic is addressed based on 10 single questions with simplified answers that provide clinicians with the basic information needed at the point of care in treating patients in the Intensive Care Unit. The review has didactic purposes and may serve both as an update on fluid management and as an introduction to the subject for novices in critical care. There is an urgent need to increase awareness regarding the potential risks associated with fluid overload. Clinicians should be mindful not only of the indications for administering fluid loads and of the type of fluids administered, but also of the importance to set safety limits. Lastly, it is important to implement proactive strategies seeking to establish negative fluid balance as soon as the clinical conditions are considered to be stable and the risk of deterioration is low.
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Affiliation(s)
- F Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy.
| | - A Messina
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Cecconi
- Humanitas Clinical and Research Center - IRCCS, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - M Astuto
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy; School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy
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15
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Castro R, Kattan E, Ferri G, Pairumani R, Valenzuela ED, Alegría L, Oviedo V, Pavez N, Soto D, Vera M, Santis C, Astudillo B, Cid MA, Bravo S, Ospina-Tascón G, Bakker J, Hernández G. Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial. Ann Intensive Care 2020; 10:150. [PMID: 33140173 PMCID: PMC7606372 DOI: 10.1186/s13613-020-00767-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 10/17/2020] [Indexed: 02/08/2023] Open
Abstract
Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)
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Affiliation(s)
- Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Nicolás Pavez
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - César Santis
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Brusela Astudillo
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - María Alicia Cid
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Sebastian Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - Gustavo Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICES, Cali, Colombia
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA.,Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, CA, The Netherlands.,Division of Pulmonary, and Critical Care Medicine, New York University-Langone, New York, USA
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile.
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16
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De Backer D, Vincent JL. Noninvasive Monitoring in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:40-46. [PMID: 33065744 DOI: 10.1055/s-0040-1718387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
There has been considerable development in the field of noninvasive hemodynamic monitoring in recent years. Multiple devices have been proposed to assess blood pressure, cardiac output, and tissue perfusion. All have their own advantages and disadvantages and selection should be based on individual patient requirements and disease severity and adjusted according to ongoing patient evolution.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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17
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Kattan E, Hernández G, Ospina-Tascón G, Valenzuela ED, Bakker J, Castro R. A lactate-targeted resuscitation strategy may be associated with higher mortality in patients with septic shock and normal capillary refill time: a post hoc analysis of the ANDROMEDA-SHOCK study. Ann Intensive Care 2020; 10:114. [PMID: 32845407 PMCID: PMC7450018 DOI: 10.1186/s13613-020-00732-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 08/17/2020] [Indexed: 12/29/2022] Open
Abstract
Background Capillary refill time (CRT) may improve more rapidly than lactate in response to increments in systemic flow. Therefore, it can be assessed more frequently during septic shock (SS) resuscitation. Hyperlactatemia, in contrast, exhibits a slower recovery in SS survivors, probably explained by the delayed resolution of non-hypoperfusion-related sources. Thus, targeting lactate normalization may be associated with impaired outcomes. The ANDROMEDA-SHOCK trial compared CRT- versus lactate-targeted resuscitation in early SS. CRT-targeted resuscitation associated with lower mortality and organ dysfunction; mechanisms were not investigated. CRT was assessed every 30 min and lactate every 2 h during the 8-h intervention period, allowing a first comparison between groups at 2 h (T2). Our primary aim was to determine if SS patients evolving with normal CRT at T2 after randomization (T0) exhibited a higher mortality and organ dysfunction when allocated to the LT arm than when randomized to the CRT arm. Our secondary aim was to determine if those patients with normal CRT at T2 had received more therapeutic interventions when randomized to the LT arm. To address these issues, we performed a post hoc analysis of the ANDROMEDA-SHOCK dataset. Results Patients randomized to the lactate arm at T0, evolving with normal CRT at T2 exhibited significantly higher mortality than patients with normal CRT at T2 initially allocated to CRT (40 vs 23%, p = 0.009). These results replicated at T8 and T24. LT arm received significantly more resuscitative interventions (fluid boluses: 1000[500–2000] vs. 500[0–1500], p = 0.004; norepinephrine test in previously hypertensive patients: 43 (35) vs. 19 (19), p = 0.001; and inodilators: 16 (13) vs. 3 (3), p = 0.003). A multivariate logistic regression of patients with normal CRT at T2, including APACHE-II, baseline lactate, cumulative fluids administered since emergency admission, source of infection, and randomization group) confirmed that allocation to LT group was a statistically significant determinant of 28-day mortality (OR 3.3; 95%CI[1.5–7.1]); p = 0.003). Conclusions Septic shock patients with normal CRT at baseline received more therapeutic interventions and presented more organ dysfunction when allocated to the lactate group. This could associate with worse outcomes.
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Affiliation(s)
- Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, 362, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, 362, Chile
| | - Gustavo Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICESI, Carrera 98 # 18-49, Cali, Colombia
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, 362, Chile
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, 362, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, 630 W 168th St, New York, USA.,Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, CA, The Netherlands.,Division of Pulmonary, and Critical Care Medicine, New York University-Langone, New York, USA
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, 362, Chile.
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18
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Gao F, Huang XL, Cai MX, Lin MT, Wang BF, Wu W, Huang ZM. Prognostic value of serum lactate kinetics in critically ill patients with cirrhosis and acute-on-chronic liver failure: a multicenter study. Aging (Albany NY) 2020; 11:4446-4462. [PMID: 31259742 PMCID: PMC6660055 DOI: 10.18632/aging.102062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/25/2019] [Indexed: 12/23/2022]
Abstract
Lactate clearance (Δ24Lac) was reported to be inversely associated with mortality in critically ill patients. The aim of our study was to assess the value of Δ24Lac for the prognosis of critically ill patients with cirrhosis and acute-on-chronic liver failure (ACLF). We analysed 954 cirrhotic patients with hyperlactatemia admitted to intensive care units (ICUs) in the United States and eastern China. The patients were followed up for at least 1 year. In the unadjusted model, we observed a 15% decrease in hospital mortality with each 10% increase in Δ24Lac. In the fully adjusted model, the relationship between the risk of death and Δ24Lac remained statistically significant (hospital mortality: odds ratio [OR] 0.84, 95% confidence interval [CI]: 0.78- 0.90, p < 0.001; 90-day mortality: hazard ratio [HR] 0.94, 95%CI 0.92- 0.97, p < 0.001; for Δ24Lac per 10% increase). Similar results were found in patients with ACLF. We developed a Δ24Lac-adjusted score (LiFe-Δ24Lac), which performed significantly better in the area under the receiver operating characteristic curves (AUROCs) than the original LiFe score for predicting mortality. Lactate clearance is an independent predictor of death, and the LiFe-Δ24Lac score is a practical tool for stratifying the risk of death.
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Affiliation(s)
- Feng Gao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xie-Lin Huang
- Department of Gastroenterology Surgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Meng-Xing Cai
- Department of Cardiovascular Medicine, The Heart Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Miao-Tong Lin
- Department of Emergency Medicine, Intensive Care, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bin-Feng Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei Wu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhi-Ming Huang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Rello J, Tejada S, Xu E, Solé-Lleonart C, Campogiani L, Koulenti D, Ferreira-Coimbra J, Lipman J. Quality of evidence supporting Surviving Sepsis Campaign Recommendations. Anaesth Crit Care Pain Med 2020; 39:497-502. [PMID: 32650126 PMCID: PMC7340061 DOI: 10.1016/j.accpm.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 01/06/2023]
Abstract
Introduction The Surviving Sepsis Campaign (SSC) guidelines, released in 2017, are a combination of expert opinion and evidence-based medicine, adopted by many institutions as a standard of practice. The aim was to analyse the quality of evidence supporting recommendations on the management of sepsis. Methods The strength and quality of evidence (high, moderate, low-very low and best practice statements) of each recommendation were extracted. Randomised controlled trials were required to qualify as high-quality evidence. Results A total of 96 recommendations were formulated, and 87 were included. Among thirty-one (43%) strong recommendations, only 15.2% were supported by high-quality evidence. Overall, thirty-seven (42.5%) recommendations were based on low-quality evidence, followed by 28 (32.2%) based on moderate-quality, 15 (17.2%) were best practice statements and only seven (8.0%) were supported by high-quality evidence. Randomised controlled trials supported 21.4%, 9.5% and 8.6% recommendations on mechanical ventilation, resuscitation, and management/adjuvant therapy, respectively. In contrast, none high-quality evidence recommendation supported antimicrobial/source control (82.4% were low-very low evidence or best practice statements), and nutrition. Conclusions In the SSC guidelines most recommendations were informed by indirect evidence and non-systematic observations. While awaiting trials results, Delphi-like approaches or multi-criteria decision analyses should guide recommendations.
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Affiliation(s)
- Jordi Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Scientifical Research, CHU Nîmes, University Montpellier-Nîmes, Nîmes, France
| | - Sofia Tejada
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Elena Xu
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | | | - Laura Campogiani
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, Rome, Italy
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Critical Care II, Attikon University Hospital, Athens, Greece
| | - João Ferreira-Coimbra
- Internal Medicine Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jeff Lipman
- Scientifical Research, CHU Nîmes, University Montpellier-Nîmes, Nîmes, France; UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
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Bakker J, Hernandez G. Can Peripheral Skin Perfusion Be Used to Assess Organ Perfusion and Guide Resuscitation Interventions? Front Med (Lausanne) 2020; 7:291. [PMID: 32656220 PMCID: PMC7324549 DOI: 10.3389/fmed.2020.00291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/22/2020] [Indexed: 11/17/2022] Open
Abstract
Although the definition of septic shock is straightforward, the physiological response to inadequate hemodynamics in patients with septic shock is variable. Therefore, the clinical recognition is limited not only by the patient's response but also by the clinical parameters we can use at the bedside. In this short overview we will argue that the state of the peripheral perfusion can help to identify and to treat patients with septic shock.
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Affiliation(s)
- Jan Bakker
- Department of Pulmonary and Critical Care, Bellevue Hospital, NYU Langone, New York, NY, United States.,Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY, United States.,Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Pontificia Universidad Católica de Chile, Department of Intensive Care, Santiago, Chile
| | - Glenn Hernandez
- Pontificia Universidad Católica de Chile, Department of Intensive Care, Santiago, Chile
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Arango-Granados MC, Cruz Mendoza DF, Salcedo Cadavid AE, García Marín AF. Amputation in crush syndrome: A case report. Int J Surg Case Rep 2020; 72:346-350. [PMID: 32563818 PMCID: PMC7306514 DOI: 10.1016/j.ijscr.2020.05.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/30/2020] [Indexed: 11/24/2022] Open
Abstract
Crush syndrome (CS) produces severe electrolyte disorders, circulatory and multiple organ failure due to severe rhabdomyolysis and reperfusion injuries. To date, the main stem of management is aggressive fluid resuscitation. Fasciotomy for the treatment of compartment syndromes due to crush injuries is still controversial, and it is still unknown if early amputation has patient-centered benefits. This case suggests a potential benefit of amputation in patients with CS and progressive deterioration. It also invites to think if this is a decision to consider early in the course of the disease. The presence of risk factors for poor prognosis and the natural course of the disease can favor amputation despite the apparent viability of the limb and the morbidity of losing of an extremity.
Introduction Crush syndrome (CS) is a condition with a high morbidity and mortality due to severe electrolyte disorders, circulatory dysfunction and multiple organ failure, secondary to severe rhabdomyolysis and reperfusion injuries. There is controversy about the role of fasciotomy in the treatment of compartment syndromes due to crush injuries and it is still unknown if early amputation has patient-centered benefits. Case presentation This is a 29-year-old patient whose lower body was trapped for 50 h under a 40-meter landslide. Upon admission the left thigh was edematous and painful. Laboratories revealed a creatinine of 1.58 mg/dL, hyperkalemia, metabolic acidosis, hyperlactatemia and creatinine phosphokinase (CPK) of 88,700 U/L, suggesting CS. Despite fluid and bicarbonate infusion his renal function worsened, CPK rose and left thigh became more tense, so a fasciotomy was performed. He developed a distributive shock refractory to vasopressors, steroids and methylene blue so amputation was proposed. Two hours after amputation the vasopressor support was nearly withdrawn. Discussion This case suggests a potential benefit of amputation in patients with CS and progressive deterioration despite aggressive resuscitation. It also invites to think if this is a decision that should be considered before the establishment or in the initial stages of the syndrome, even if the viability of the extremity is still questionable. Conclusion The presence of risk factors for poor prognosis can favor amputation despite the apparent viability of the limb and the morbidity of losing an extremity.
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Affiliation(s)
- María Camila Arango-Granados
- Fundación Valle del Lili, Cra. 98 ## 18-49, Cali, Valle del Cauca, Colombia; Universidad Icesi, Cl. 18 #122-135, Facultad de Medicina, Cali, Valle del Cauca, Colombia.
| | - Diego Fernando Cruz Mendoza
- Fundación Valle del Lili, Cra. 98 ## 18-49, Cali, Valle del Cauca, Colombia; Universidad Icesi, Cl. 18 #122-135, Facultad de Medicina, Cali, Valle del Cauca, Colombia.
| | - Alexander Ernesto Salcedo Cadavid
- Fundación Valle del Lili, Cra. 98 ## 18-49, Cali, Valle del Cauca, Colombia; Universidad Icesi, Cl. 18 #122-135, Facultad de Medicina, Cali, Valle del Cauca, Colombia.
| | - Alberto Federico García Marín
- Fundación Valle del Lili, Cra. 98 ## 18-49, Cali, Valle del Cauca, Colombia; Universidad Icesi, Cl. 18 #122-135, Facultad de Medicina, Cali, Valle del Cauca, Colombia.
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Silberberg B, Aston S, Boztepe S, Jacob S, Rylance J. Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines. Crit Care 2020; 24:286. [PMID: 32503647 PMCID: PMC7275525 DOI: 10.1186/s13054-020-02978-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/12/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sepsis guidelines are widely used in high-income countries and intravenous fluids are an important supportive treatment modality. However, fluids have been harmful in intervention trials in low-income countries, most notably in sub-Saharan Africa. We assessed the relevance, quality and applicability of available guidelines for the fluid management of adult patients with sepsis in this region. METHODS We identified sepsis guidelines by systematic review with broad search terms, duplicate screening and data extraction. We included peer-reviewed publications with explicit relevance to sepsis and fluid therapy. We excluded those designed exclusively for specific aetiologies of sepsis, for limited geographic locations, or for non-adult populations. We used the AGREE II tool to assess the quality of guideline development, performed a narrative synthesis and used theoretical case scenarios to assess practical applicability to everyday clinical practice in resource-constrained settings. RESULTS Published sepsis guidelines are heterogeneous in sepsis definition and in quality: 8/10 guidelines had significant deficits in applicability, particularly with reference to resource considerations in low-income settings. Indications for intravenous fluid were hypotension (8/10), clinical markers of hypoperfusion (6/10) and lactataemia (3/10). Crystalloids were overwhelmingly recommended (9/10). Suggested volumes varied; 5/10 explicitly recommended "fluid challenges" with reassessment, totalling between 1 L and 4 L during initial resuscitation. Fluid balance, including later de-escalation of therapy, was not specifically described in any. Norepinephrine was the preferred initial vasopressor (5/10), specifically targeted to MAP > 65 mmHg (3/10), with higher values suggested in pre-existing hypertension (1/10). Recommendations for guidelines were almost universally derived from evidence in high-income countries. None of the guidelines suggested any refinement for patients with malnutrition. CONCLUSIONS Widely used international guidelines contain disparate recommendations on intravenous fluid use, lack specificity and are largely unattainable in low-income countries given available resources. A relative lack of high-quality evidence from sub-Saharan Africa increases reliance on recommendations which may not be relevant or implementable.
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Affiliation(s)
- Benjamin Silberberg
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK.
- Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Stephen Aston
- Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Selda Boztepe
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Shevin Jacob
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jamie Rylance
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Shi R, Hamzaoui O, De Vita N, Monnet X, Teboul JL. Vasopressors in septic shock: which, when, and how much? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:794. [PMID: 32647719 PMCID: PMC7333107 DOI: 10.21037/atm.2020.04.24] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In addition to fluid resuscitation, the vasopressor therapy is a fundamental treatment of septic shock-induced hypotension as it aims at correcting the vascular tone depression and then at improving organ perfusion pressure. Experts’ recommendations currently position norepinephrine (NE) as the first-line vasopressor in septic shock. Vasopressin and its analogues are only second-line vasopressors as strong recent evidence suggests no benefit of their early administration in spite of promising preliminary data. Early administration of NE may allow achieving the initial mean arterial pressure (MAP) target faster and reducing the risk of fluid overload. The diastolic arterial pressure (DAP) as a marker of vascular tone, helps identifying the patients who need NE urgently. Available data suggest a MAP of 65 mmHg as the initial target but a more individualized approach is often required depending on several factors such as history of chronic hypertension or value of central venous pressure (CVP). In cases of refractory hypotension, increasing NE up to doses ≥1 µg/kg/min could be an option. However, current experts’ guidelines suggest to combine NE with other vasopressors such as vasopressin, with the intent to rising the MAP to target or to decrease the NE dosage.
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Affiliation(s)
- Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Olfa Hamzaoui
- Service de réanimation polyvalente, Hôpital Antoine Béclère, AP-HP, Université Paris-Saclay 92141, Clamart, France
| | - Nello De Vita
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S999 LabEx - LERMIT, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
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24
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Pavez N, Kattan E, Vera M, Ferri G, Valenzuela ED, Alegría L, Bravo S, Pairumani R, Santis C, Oviedo V, Soto D, Ospina-Tascón G, Bakker J, Hernández G, Castro R. Hypoxia-related parameters during septic shock resuscitation: Pathophysiological determinants and potential clinical implications. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:784. [PMID: 32647709 PMCID: PMC7333100 DOI: 10.21037/atm-20-2048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Assessment of tissue hypoxia at the bedside has yet to be translated into daily clinical practice in septic shock patients. Perfusion markers are surrogates of deeper physiological phenomena. Lactate-to-pyruvate ratio (LPR) and the ratio between veno-arterial PCO2 difference and Ca–vO2 (ΔPCO2/Ca–vO2) have been proposed as markers of tissue hypoxia, but they have not been compared in the clinical scenario. We studied acute septic shock patients under resuscitation. We wanted to evaluate the relationship of these hypoxia markers with clinical and biochemical markers of hypoperfusion during septic shock resuscitation. Methods Secondary analysis of a randomized controlled trial. Septic shock patients were randomized to fluid resuscitation directed to normalization of capillary refill time (CRT) versus normalization or significant lowering of lactate. Multimodal assessment of perfusion was performed at 0, 2, 6 and 24 hours, and included macrohemodynamic and metabolic perfusion variables, CRT, regional flow and hypoxia markers. Patients who attained their pre-specified endpoint at 2-hours were compared to those who did not. Results Forty-two patients were recruited, median APACHE-II score was 23 [15–31] and 28-day mortality 23%. LPR and ΔPCO2/Ca–vO2 ratio did not correlate during early resuscitation (0–2 h) and the whole study period (24-hours). ΔPCO2/Ca–vO2 ratio derangements were more prevalent than LPR ones, either in the whole cohort (52% vs. 23%), and in association with other perfusion abnormalities. In patients who reached their resuscitation endpoints, the proportion of patients with altered ΔPCO2/Ca-vO2 ratio decreased significantly (66% to 33%, P=0.045), while LPR did not (14% vs. 25%, P=0.34). Conclusions Hypoxia markers did not exhibit correlation during resuscitation in septic shock patients. They probably interrogate different pathophysiological processes and mechanisms of dysoxia during early septic shock. Future studies should better elucidate the interaction and clinical role of hypoxia markers during septic shock resuscitation.
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Affiliation(s)
- Nicolás Pavez
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sebastian Bravo
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - César Santis
- Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICES, Cali, Colombia
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY, USA.,Erasmus MC University Medical Center, Department Intensive Care Adults, Rotterdam, CA, The Netherlands.,Division of Pulmonary, and Critical Care Medicine, New York University-Langone, New York, NY, USA
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Monnet X, Teboul JL. Prediction of fluid responsiveness in spontaneously breathing patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:790. [PMID: 32647715 PMCID: PMC7333112 DOI: 10.21037/atm-2020-hdm-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In patients with acute circulatory failure, the primary goal of volume expansion is to increase cardiac output. However, this expected effect is inconstant, so that in many instances, fluid administration does not result in any haemodynamic benefit. In such cases, fluid could only exert some deleterious effects. It is now well demonstrated that excessive fluid administration is harmful, especially during acute respiratory distress syndrome and in sepsis or septic shock. This is the reason why some tests and indices have been developed in order to assess “fluid responsiveness” before deciding to perform volume expansion. While preload markers have been used for many years for this purpose, they have been repeatedly shown to be unreliable, which is mainly related to physiological issues. As alternatives, “dynamic” indices have been introduced. These indices are based upon the changes in cardiac output or stroke volume resulting from various changes in preload conditions, induced by heart-lung interactions, postural manoeuvres or by the infusion of small amounts of fluids. The haemodynamic effects and the reliability of these “dynamic” indices of fluid responsiveness are now well described. From their respective advantages and limitations, it is also possible to describe their clinical interest and the clinical setting in which they are applicable.
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Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Saclay, Assistance Publique - Hôpitaux de Paris, Hôpital de Bicêtre, Service de Médecine Intensive-Réanimation, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Saclay, Assistance Publique - Hôpitaux de Paris, Hôpital de Bicêtre, Service de Médecine Intensive-Réanimation, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Saclay, Le Kremlin-Bicêtre, France
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Kattan E, Castro R, Vera M, Hernández G. Optimal target in septic shock resuscitation. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:789. [PMID: 32647714 PMCID: PMC7333135 DOI: 10.21037/atm-20-1120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Septic shock presents a high risk of morbidity and mortality. Through therapeutic strategies, such as fluid administration and vasoactive agents, clinicians intend to rapidly restore tissue perfusion. Nonetheless, these interventions have narrow therapeutic margins. Adequate perfusion monitoring is paramount to avoid progressive hypoperfusion or detrimental over-resuscitation. During early stages of septic shock, macrohemodynamic derangements, such as hypovolemia and decreased cardiac output (CO) tend to predominate. However, during late septic shock, endothelial and coagulation dysfunction induce severe alterations of the microcirculation, making it more difficult to achieve tissue reperfusion. Multiple perfusion variables have been described in the literature, from bedside clinical examination to complex laboratory tests. Moreover, all of them present inherent flaws and limitations. After the ANDROMEDA-SHOCK trial, there is evidence that capillary refill time (CRT) is an interesting resuscitation target, due to its rapid kinetics and correlation with deep hypoperfusion markers. New concepts such as hemodynamic coherence and flow responsiveness may be used at the bedside to select the best treatment strategies at any time-point. A multimodal perfusion monitoring and an integrated analysis with macrohemodynamic parameters is mandatory to optimize the resuscitation of septic shock patients.
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Affiliation(s)
- Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Ospina-Tascón GA, Teboul JL, Hernandez G, Alvarez I, Sánchez-Ortiz AI, Calderón-Tapia LE, Manzano-Nunez R, Quiñones E, Madriñan-Navia HJ, Ruiz JE, Aldana JL, Bakker J. Diastolic shock index and clinical outcomes in patients with septic shock. Ann Intensive Care 2020; 10:41. [PMID: 32296976 PMCID: PMC7160223 DOI: 10.1186/s13613-020-00658-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/04/2020] [Indexed: 01/15/2023] Open
Abstract
Background Loss of vascular tone is a key pathophysiological feature of septic shock. Combination of gradual diastolic hypotension and tachycardia could reflect more serious vasodilatory conditions. We sought to evaluate the relationships between heart rate (HR) to diastolic arterial pressure (DAP) ratios and clinical outcomes during early phases of septic shock. Methods Diastolic shock index (DSI) was defined as the ratio between HR and DAP. DSI calculated just before starting vasopressors (Pre-VPs/DSI) in a preliminary cohort of 337 patients with septic shock (January 2015 to February 2017) and at vasopressor start (VPs/DSI) in 424 patients with septic shock included in a recent randomized controlled trial (ANDROMEDA-SHOCK; March 2017 to April 2018) was partitioned into five quantiles to estimate the relative risks (RR) of death with respect to the mean risk of each population (assumed to be 1). Matched HR and DAP subsamples were created to evaluate the effect of the individual components of the DSI on RRs. In addition, time-course of DSI and interaction between DSI and vasopressor dose (DSI*NE.dose) were compared between survivors and non-survivors from both populations, while ROC curves were used to identify variables predicting mortality. Finally, as exploratory observation, effect of early start of vasopressors was evaluated at each Pre-VPs/DSI quintile from the preliminary cohort. Results Risk of death progressively increased at gradual increments of Pre-VPs/DSI or VPs/DSI (One-way ANOVA, p < 0.001). Progressive DAP decrease or HR increase was associated with higher mortality risks only when DSI concomitantly increased. Areas under the ROC curve for Pre-VPs/DSI, SOFA and initial lactate were similar, while mean arterial pressure and systolic shock index showed poor performances to predict mortality. Time-course of DSI and DSI*NE.dose was significantly higher in non-survivors from both populations (repeated-measures ANOVA, p < 0.001). Very early start of vasopressors exhibited an apparent benefit at higher Pre-VPs/DSI quintile. Conclusions DSI at pre-vasopressor and vasopressor start points might represent a very early identifier of patients at high risk of death. Isolated DAP or HR values do not clearly identify such risk. Usefulness of DSI to trigger or to direct therapeutic interventions in early resuscitation of septic shock need to be addressed in future studies.
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Affiliation(s)
- Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia. .,Traslational Medicine in Critical Care and Experimental Surgery Laboratory (TransLab-CCM), Universidad ICESI, Cali, Colombia.
| | - Jean-Louis Teboul
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia.,Service de Réanimation Médicale, Hôpital Bicêtre, Hôpitaux Universitaires Paris-Sud, Paris, France.,Assistance Publique Hôpitaux de Paris, Université Paris-Sud, Paris, France
| | - Glenn Hernandez
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia.,Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ingrid Alvarez
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Alvaro I Sánchez-Ortiz
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Luis E Calderón-Tapia
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Ramiro Manzano-Nunez
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Edgardo Quiñones
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Humberto J Madriñan-Navia
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Juan E Ruiz
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - José L Aldana
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia
| | - Jan Bakker
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Av. Simón Bolívar Cra. 98, Cali, Colombia.,Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile.,Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Pulmonary and Critical Care, New York University, New York, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA
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Shinozaki K, Jacobson LS, Saeki K, Kobayashi N, Weisner S, Falotico JM, Li T, Kim J, Lampe JW, Becker LB. The standardized method and clinical experience may improve the reliability of visually assessed capillary refill time. Am J Emerg Med 2020; 44:284-290. [DOI: 10.1016/j.ajem.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/16/2020] [Accepted: 04/03/2020] [Indexed: 01/09/2023] Open
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Kattan E, Ospina-Tascón GA, Teboul JL, Castro R, Cecconi M, Ferri G, Bakker J, Hernández G. Systematic assessment of fluid responsiveness during early septic shock resuscitation: secondary analysis of the ANDROMEDA-SHOCK trial. Crit Care 2020; 24:23. [PMID: 31973735 PMCID: PMC6979284 DOI: 10.1186/s13054-020-2732-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Fluid boluses are administered to septic shock patients with the purpose of increasing cardiac output as a means to restore tissue perfusion. Unfortunately, fluid therapy has a narrow therapeutic index, and therefore, several approaches to increase safety have been proposed. Fluid responsiveness (FR) assessment might predict which patients will effectively increase cardiac output after a fluid bolus (FR+), thus preventing potentially harmful fluid administration in non-fluid responsive (FR-) patients. However, there are scarce data on the impact of assessing FR on major outcomes. The recent ANDROMEDA-SHOCK trial included systematic per-protocol assessment of FR. We performed a post hoc analysis of the study dataset with the aim of exploring the relationship between FR status at baseline, attainment of specific targets, and clinically relevant outcomes. METHODS ANDROMEDA-SHOCK compared the effect of peripheral perfusion- vs. lactate-targeted resuscitation on 28-day mortality. FR was assessed before each fluid bolus and periodically thereafter. FR+ and FR- subgroups, independent of the original randomization, were compared for fluid administration, achievement of resuscitation targets, vasoactive agents use, and major outcomes such as organ dysfunction and support, length of stay, and 28-day mortality. RESULTS FR could be determined in 348 patients at baseline. Two hundred and forty-two patients (70%) were categorized as fluid responders. Both groups achieved comparable successful resuscitation targets, although non-fluid responders received less resuscitation fluids (0 [0-500] vs. 1500 [1000-2500] mL; p 0.0001), exhibited less positive fluid balances, but received more vasopressor testing. No difference in clinically relevant outcomes between FR+ and FR- patients was found, including 24-h SOFA score (9 [5-12] vs. 8 [5-11], p = 0.4), need for MV (78% vs. 72%, p = 0.16), need for RRT (18% vs. 21%, p = 0.7), ICU-LOS (6 [3-11] vs. 6 [3-16] days, p = 0.2), and 28-day mortality (40% vs. 36%, p = 0.5). Only thirteen patients remained fluid responsive along the intervention period. CONCLUSIONS Systematic assessment allowed determination of fluid responsiveness status in more than 80% of patients with early septic shock. Fluid boluses could be stopped in non-fluid responsive patients without any negative impact on clinical relevant outcomes. Our results suggest that fluid resuscitation might be safely guided by FR assessment in septic shock patients. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03078712. Registered retrospectively on March 13, 2017.
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Affiliation(s)
- Eduardo Kattan
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICESI, Cali, Colombia
| | - Jean-Louis Teboul
- Service de réanimation médicale, Hopital Bicetre, Hopitaux Universitaires Paris-Sud; Assistance Publique Hôpitaux de Paris, Université Paris-Sud, Paris, France
| | - Ricardo Castro
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Jan Bakker
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - Glenn Hernández
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Avenida Diagonal Paraguay 362, Santiago, Chile.
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Shinozaki K, Jacobson LS, Saeki K, Hirahara H, Kobayashi N, Weisner S, Falotico JM, Li T, Kim J, Becker LB. Comparison of point-of-care peripheral perfusion assessment using pulse oximetry sensor with manual capillary refill time: clinical pilot study in the emergency department. J Intensive Care 2019; 7:52. [PMID: 31798887 PMCID: PMC6880499 DOI: 10.1186/s40560-019-0406-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/09/2019] [Indexed: 01/09/2023] Open
Abstract
Background Traditional capillary refill time (CRT) is a manual measurement that is commonly used by clinicians to identify deterioration in peripheral perfusion status. Our study compared a novel method of measuring peripheral perfusion using an investigational device with standardized visual CRT and tested the clinical usefulness of this investigational device, using an existing pulse oximetry sensor, in an emergency department (ED) setting. Material and methods An ED attending physician quantitatively measured CRT using a chronometer (standardized visual CRT). The pulse oximetry sensor was attached to the same hand. Values obtained using the device are referred to as blood refill time (BRT). These techniques were compared in its numbers with the Bland-Altman plot and the predictability of patients' admissions. Results Thirty ED patients were recruited. Mean CRT of ED patients was 1.9 ± 0.8 s, and there was a strong correlation with BRT (r = 0.723, p < 0.001). The Bland-Altman plot showed a proportional bias pattern. The ED physician identified 3 patients with abnormal CRT (> 3 s). Area under the receiver operator characteristic curve (AUC) of BRT to predict whether or not CRT was greater than 3 s was 0.82 (95% CI, 0.58-1.00). Intra-rater reliability of BRT was 0.88 (95% CI, 0.79-0.94) and that of CRT was 0.92 (0.85-0.96). Twelve patients were admitted to the hospital. AUC to predict patients' admissions was 0.67 (95% CI, 0.46-0.87) by BRT and 0.76 (0.58-0.94) by CRT. Conclusions BRT by a pulse oximetry sensor was an objective measurement as useful as the standardized CRT measured by the trained examiner with a chronometer at the bedside.
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Affiliation(s)
- Koichiro Shinozaki
- 1The Feinstein Institute for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY 11030 USA.,2Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY USA
| | - Lee S Jacobson
- 2Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY USA
| | - Kota Saeki
- Nihon Kohden Innovation Center, Cambridge, MA USA
| | | | | | | | - Julianne M Falotico
- 2Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY USA
| | - Timmy Li
- 2Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY USA
| | - Junhwan Kim
- 1The Feinstein Institute for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY 11030 USA
| | - Lance B Becker
- 1The Feinstein Institute for Medical Research, Northwell Health, 350 Community Dr., Manhasset, NY 11030 USA.,2Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY USA
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Hallisey SD, Greenwood JC. Beyond Mean Arterial Pressure and Lactate: Perfusion End Points for Managing the Shocked Patient. Emerg Med Clin North Am 2019; 37:395-408. [PMID: 31262411 DOI: 10.1016/j.emc.2019.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients in shock present frequently to the emergency department. The emergency physician must be skilled in the resuscitation of both differentiated and undifferentiated shock. Early, aggressive resuscitation of patients in shock is essential, using macrocirculatory, microcirculatory, and clinical end points to guide interventions. Therapy should focus on the restoration of oxygen delivery to match tissue demand. This article reviews the evidence supporting common end points of resuscitation for common etiologies of shock and limitations to their use.
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Affiliation(s)
- Stephen D Hallisey
- Department of Emergency Medicine, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA.
| | - John C Greenwood
- Department of Emergency Medicine, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19014, USA
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Hariri G, Joffre J, Leblanc G, Bonsey M, Lavillegrand JR, Urbina T, Guidet B, Maury E, Bakker J, Ait-Oufella H. Narrative review: clinical assessment of peripheral tissue perfusion in septic shock. Ann Intensive Care 2019; 9:37. [PMID: 30868286 PMCID: PMC6419794 DOI: 10.1186/s13613-019-0511-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/01/2019] [Indexed: 12/21/2022] Open
Abstract
Sepsis is one of the main reasons for intensive care unit admission and is responsible for high morbidity and mortality. The usual hemodynamic targets for resuscitation of patients with septic shock use macro-hemodynamic parameters (hearth rate, mean arterial pressure, central venous pressure). However, persistent alterations of microcirculatory blood flow despite restoration of macro-hemodynamic parameters can lead to organ failure. This dissociation between macro- and microcirculatory compartments brings a need to assess end organs tissue perfusion in patients with septic shock. Traditional markers of tissue perfusion may not be readily available (lactate) or may take time to assess (urine output). The skin, an easily accessible organ, allows clinicians to quickly evaluate the peripheral tissue perfusion with noninvasive bedside parameters such as the skin temperatures gradient, the capillary refill time, the extent of mottling and the peripheral perfusion index.
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Affiliation(s)
- Geoffroy Hariri
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France
| | - Jérémie Joffre
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France
| | - Guillaume Leblanc
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de recherche du CHU de Québec - Université Laval, Université Laval, Québec City, QC, Canada
| | - Michael Bonsey
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Jean-Remi Lavillegrand
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France
| | - Tomas Urbina
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Bertrand Guidet
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France.,Inserm U1136, Paris, 75012, France
| | - Eric Maury
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France.,Inserm U1136, Paris, 75012, France
| | - Jan Bakker
- Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA.,Department of Pulmonology and Critical Care, New York University Medical Center - Bellevue Hospital, New York, USA.,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hafid Ait-Oufella
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. .,Sorbonne Université, Université Pierre-et-Marie Curie-Paris 6, Paris, France. .,Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
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Hernández G, Ospina-Tascón GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, Friedman G, Castro R, Alegría L, Teboul JL, Cecconi M, Ferri G, Jibaja M, Pairumani R, Fernández P, Barahona D, Granda-Luna V, Cavalcanti AB, Bakker J. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA 2019; 321:654-664. [PMID: 30772908 PMCID: PMC6439620 DOI: 10.1001/jama.2019.0071] [Citation(s) in RCA: 402] [Impact Index Per Article: 80.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. OBJECTIVE To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. INTERVENTIONS Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. RESULTS Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. CONCLUSIONS AND RELEVANCE Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03078712.
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Affiliation(s)
- Glenn Hernández
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Gustavo A. Ospina-Tascón
- Fundación Valle del Lili, Universidad ICESI, Department of Intensive Care Medicine, Cali, Colombia
| | - Lucas Petri Damiani
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martín de La Plata, La Plata, Argentina
| | - Arnaldo Dubin
- Sanatorio Otamendi, Buenos Aires, Argentina
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Javier Hurtado
- Intensive Care Unit, Hospital Español–ASSE, Montevideo, Uruguay
- Department of Pathophysiology, School of Medicine Universidad de la República, Montevideo, Uruguay
| | - Gilberto Friedman
- Post-Graduation Program in Pneumological Sciences, Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ricardo Castro
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Leyla Alegría
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hopital Bicetre, Hopitaux Universitaires Paris–Sud, Paris, France
- Assistance Publique Hôpitaux de Paris, Université Paris–Sud, Paris, France
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center, Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Ferri
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Manuel Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Escuela de Medicina, Universidad Internacional del Ecuador, Quito
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Paula Fernández
- Unidad de Pacientes Críticos, Hospital Guillermo Grant Benavente, Concepción, Chile
| | - Diego Barahona
- Unidad de Cuidados Intensivos, Hospital General Docente de Calderón, Universidad Central del Ecuador, Quito
| | - Vladimir Granda-Luna
- Unidad de Cuidados Intensivos, Hospital San Francisco, Pontificia Universidad Católica de Quito, Quito, Ecuador
| | - Alexandre Biasi Cavalcanti
- HCor Research Institute–Hospital do Coração, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jan Bakker
- Departmento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pulmonary and Critical Care, New York University, New York, New York
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
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Scheeren TWL, Bakker J, De Backer D, Annane D, Asfar P, Boerma EC, Cecconi M, Dubin A, Dünser MW, Duranteau J, Gordon AC, Hamzaoui O, Hernández G, Leone M, Levy B, Martin C, Mebazaa A, Monnet X, Morelli A, Payen D, Pearse R, Pinsky MR, Radermacher P, Reuter D, Saugel B, Sakr Y, Singer M, Squara P, Vieillard-Baron A, Vignon P, Vistisen ST, van der Horst ICC, Vincent JL, Teboul JL. Current use of vasopressors in septic shock. Ann Intensive Care 2019; 9:20. [PMID: 30701448 PMCID: PMC6353977 DOI: 10.1186/s13613-019-0498-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/22/2019] [Indexed: 12/29/2022] Open
Abstract
Background Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use. Methods From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 17 questions focused on the profile of respondents, triggering factors, first choice agent, dosing, timing, targets, additional treatments, and effects of vasopressors. We investigated whether the answers complied with current guidelines. In addition, a group of 34 international ESICM experts was asked to formulate recommendations for the use of vasopressors based on 6 questions with sub-questions (total 14). Results A total of 839 physicians from 82 countries (65% main specialty/activity intensive care) responded. The main trigger for vasopressor use was an insufficient mean arterial pressure (MAP) response to initial fluid resuscitation (83%). The first-line vasopressor was norepinephrine (97%), targeting predominantly a MAP > 60–65 mmHg (70%), with higher targets in patients with chronic arterial hypertension (79%). The experts agreed on 10 recommendations, 9 of which were based on unanimous or strong (≥ 80%) agreement. They recommended not to delay vasopressor treatment until fluid resuscitation is completed but rather to start with norepinephrine early to achieve a target MAP of ≥ 65 mmHg. Conclusion Reported vasopressor use in septic shock is compliant with contemporary guidelines. Future studies should focus on individualized treatment targets including earlier use of vasopressors.
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Affiliation(s)
- Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700RB, Groningen, The Netherlands.
| | - Jan Bakker
- New York University Medical Center, New York, USA.,Columbia University Medical Center, New York, USA.,Erasmus MC University Medical Center, Rotterdam, Netherlands.,Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Djillali Annane
- Department of Intensive Care Medicine, School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), University of Versailles-University Paris Saclay, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Institut MITOVASC, CNRS, UMR 6214, INSERM U1083, Angers University, Angers, France
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Units, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | - Jacques Duranteau
- Assistance Publique des Hopitaux de Paris, Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Olfa Hamzaoui
- Assistance Publique-Hôpitaux de Paris Paris-Sud University Hospitals, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marc Leone
- Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois et pôle cardio-médico-chirurgical, CHRU, INSERM U1116, Université de Lorraine, Brabois, 54500, Vandoeuvre les Nancy, France
| | - Claude Martin
- Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis Lariboisière, U942 Inserm, Université Paris Diderot, Paris, France
| | - Xavier Monnet
- Assistance Publique-Hôpitaux de Paris, Paris-Sud University Hospitals, Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Paris-Saclay University, Le Plessis-Robinson, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome "La Sapienza", Rome, Italy
| | - Didier Payen
- INSERM 1160 and Hôpital Lariboisière, APHP, University Paris 7 Denis Diderot, Paris, France
| | | | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | - Daniel Reuter
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Pierre Squara
- ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France
| | - Antoine Vieillard-Baron
- Assistance Publique-Hôpitaux de Paris, Intensive Care Unit, University Hospital Ambroise Paré, Boulogne-Billancourt, France.,INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, University of Limoges, Limoges, France
| | - Simon T Vistisen
- Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
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De Backer D, Vieillard-Baron A. Clinical examination: a trigger but not a substitute for hemodynamic evaluation. Intensive Care Med 2019; 45:269-271. [PMID: 30680443 DOI: 10.1007/s00134-019-05538-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium.
| | - Antoine Vieillard-Baron
- Medical-surgical Intensive Care Unit, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France.,Université Versailles Saint Quentin, INSERM UMR1018, Team Kidney and Heart, CESP, Villejuif, France
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Araujo DT, Felice VB, Meregalli AF, Friedman G. Value of Central Venous to Arterial CO 2 Difference after Early Goal-directed Therapy in Septic Shock Patients. Indian J Crit Care Med 2019; 23:449-453. [PMID: 31749552 PMCID: PMC6842832 DOI: 10.5005/jp-journals-10071-23262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background and aims Venous to arterial difference of carbon dioxide (Pv–aCO2) tracks tissue blood flow. We aimed to evaluate if Pv–aCO2 measured from a superior central vein sample is a prognostic index (ICU length of stay, SOFA score, 28th mortality rate) just after early goal-directed therapy (EGDT)comparing its ICU admission values between patients with normal and abnormal (>6 mm Hg) Pv–aCO2. As secondary objectives, we evaluated the relationship of Pv–aCO2 with other variables of perfusion during the 24 hours that followed EGDT. Materials and methods Prospective observational study conducted in an academic ICU adult septic shock patients after a 6-hour complete EGTD. Hemodynamic measurements, arterial/central venous blood gases, and arterial lactate were obtained on ICU admission and after 6, 18 and 24 hours. Results Sixty patients were included. Admission Pv–aCO2 values showed no prognostic value. Admission Pv–aCO2 (ROC curve 0.527 [CI 95% 0.394 to 0.658]) values showed low specificity and sensitivity as predictors of mortality. There was a difference observed in the mean Pv–aCO2 between nonsurvivors (NS) and survivors (S) after 6 hours. Central venous oxygen saturation (ScvO2) and Pv–aCO2 showed significant correlation (R2 = –0.41, P < 0.0001). Patients with normal ScvO2 (>70%) and abnormal Pv–aCO2 (>6 mm Hg) showed higher SOFA scores. Normal Pv–aCO2 group cleared their lactate levels in comparison to the abnormal Pv–aCO2 group. Conclusion In septic shock, admission Pv–aCO2 after EGDT is not related to worse outcomes. An abnormal Pv–aCO2 along with a normal ScvO2 is related to organ dysfunction. How to cite this article Araujo DT, Felice VB, Meregalli AF, Friedman G. Value of Central Venous to Arterial CO2 Difference after Early Goal-directed Therapy in Septic Shock Patients. Indian J Crit Care Med 2019;23(10):449–453.
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Affiliation(s)
- David Theophilo Araujo
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
| | - Vinicius Brenner Felice
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
| | - Andre Felipe Meregalli
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
| | - Gilberto Friedman
- Central ICU, Santa Casa Hospital, Porto Alegre, Rio Grande do Su, Brazil; Programa de Pós-graduação em Ciências Pneumológicas, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Su, Brazil
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Prognostic relevance of serum lactate kinetics in critically ill patients. Intensive Care Med 2018; 45:55-61. [PMID: 30478622 DOI: 10.1007/s00134-018-5475-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 11/19/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE Changes of lactate concentration over time were reported to be associated with survival in septic patients. We aimed to evaluate delta-lactate (ΔLac) 24 h after admission (Δ24Lac) to an intensive care unit (ICU) in critically ill patients for short- and long-term prognostic relevance. METHODS In total, 26,285 lactate measurements of 2191 patients admitted to a German ICU were analyzed. Inclusion criterion was a lactate concentration at admission above 2.0 mmol/L. Maximum lactate concentrations of day 1 and day 2 were used to calculate Δ24Lac. Follow-up of patients was performed retrospectively. Association of Δ24Lac and both in-hospital and long-term mortality were investigated. An optimal cut-off was calculated by means of the Youden index. RESULTS Patients with lower Δ24Lac were of similar age, but clinically sicker. As continuous variable, higher Δ24Lac was associated with decreased in-hospital mortality (per 1% Δ24Lac; HR 0.987 95%CI 0.985-0.990; p < 0.001) and an optimal Δ24Lac cut-off was calculated at 19%. Δ24Lac ≤ 19% was associated with both increased in-hospital (15% vs 43%; OR 4.11; 95%CI 3.23-5.21; p < 0.001) and long-term mortality (HR 1.54 95%CI 1.28-1.87; p < 0.001), even after correction for APACHE II, need for catecholamines and intubation. We matched 256 patients with Δ24Lac ≤ 19% to case-controls > 19% corrected for APACHE II scores, baseline lactate level and sex: Δ24Lac ≤ 19% remained associated with lower in-hospital and long-term survival. CONCLUSIONS Lower Δ24Lac was robustly associated with adverse outcome in critically ill patients, even after correction for confounders. Δ24Lac might constitute an independent, easily available and important parameter for risk stratification in the critically ill.
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Cecconi M, Hernandez G, Dunser M, Antonelli M, Baker T, Bakker J, Duranteau J, Einav S, Groeneveld ABJ, Harris T, Jog S, Machado FR, Mer M, Monge García MI, Myatra SN, Perner A, Teboul JL, Vincent JL, De Backer D. Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force. Intensive Care Med 2018; 45:21-32. [DOI: 10.1007/s00134-018-5415-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 10/11/2018] [Indexed: 12/21/2022]
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Hernández G, Cavalcanti AB, Ospina-Tascón G, Dubin A, Hurtado FJ, Damiani LP, Friedman G, Castro R, Alegría L, Cecconi M, Teboul JL, Bakker J. Statistical analysis plan for early goal-directed therapy using a physiological holistic view - the ANDROMEDA-SHOCK: a randomized controlled trial. Rev Bras Ter Intensiva 2018; 30:253-263. [PMID: 30066731 PMCID: PMC6180476 DOI: 10.5935/0103-507x.20180041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/11/2018] [Indexed: 01/13/2023] Open
Abstract
Background ANDROMEDA-SHOCK is an international, multicenter, randomized controlled trial
comparing peripheral perfusion-targeted resuscitation to lactate-targeted
resuscitation in patients with septic shock in order to test the hypothesis
that resuscitation targeting peripheral perfusion will be associated with
lower morbidity and mortality. Objective To report the statistical analysis plan for the ANDROMEDA-SHOCK trial. Methods We describe the trial design, primary and secondary objectives, patients,
methods of randomization, interventions, outcomes, and sample size. We
describe our planned statistical analysis for the primary, secondary and
tertiary outcomes. We also describe the subgroup and sensitivity analyses.
Finally, we provide details for presenting our results, including mock
tables showing baseline characteristics, the evolution of hemodynamic and
perfusion variables, and the effects of treatments on outcomes. Conclusion According to the best trial practice, we report our statistical analysis plan
and data management plan prior to locking the database and initiating the
analyses. We anticipate that this procedure will prevent analysis bias and
enhance the utility of the reported results.
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Affiliation(s)
- Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | | | - Gustavo Ospina-Tascón
- Departamento de Medicina Intensiva, Fundación Valle del Lili, Universidad ICESI - Cali, Colômbia
| | - Arnaldo Dubin
- Serviço de Terapia Intensiva, Sanatorio Otamendi y Miroli - Ciudad Autónoma de Buenos Aires, Argentina
| | - Francisco Javier Hurtado
- Centro de Terapia Intensiva, Hospital Español, Escuela de Medicina, Universidad de la República - Montevidéu, Uruguai
| | | | - Gilberto Friedman
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | - Leyla Alegría
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile
| | - Maurizio Cecconi
- St George's University Hospitals NHS Foundation Trust - Londres, Reino Unido
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris - Paris, França
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile - Santiago, Chile.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center - Nova Iorque, Estados Unidos.,Erasmus MC University Medical Center, Department Intensive Care Adults - Rotterdam, CA, Holanda.,Division of Pulmonary, and Critical Care Medicine, New York University - Langone - Nova Iorque, Estados Unidos
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