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Guo C, Lou F, Wu J, Zhang J. ERAS-Based Anesthetic Management of Patients Undergoing Abdominal-Based Free Flap Breast Reconstruction: A Narrative Review. JPRAS Open 2024; 42:22-32. [PMID: 39279847 PMCID: PMC11399473 DOI: 10.1016/j.jpra.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 07/30/2024] [Indexed: 09/18/2024] Open
Abstract
Microsurgical breast reconstruction after mastectomy is emerging as the standard of care for patients with breast cancer. The enhanced recovery after surgery (ERAS) pathway in abdominal-based free flap breast reconstruction is in its early stage of development and lacks established consensus or guidelines. In the multidisciplinary ERAS team, the anesthesia sub-team is responsible for the provision of several core elements in the ERAS pathway including anesthetic protocol optimization, perioperative fluid management and homeostasis regulation, normothermia maintenance, perioperative analgesia, and postoperative nausea and vomiting prophylaxis. Here, we summarized the state-of-the-art in anesthetic practice for the patients undergoing abdominal-based free flap breast reconstruction within an ERAS framework, and also introduced the perioperative strategy for this surgical population based on the ERAS pathway in our center, aiming to improve free flap outcome and patient satisfaction, and accelerating their recovery following surgery.
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Affiliation(s)
- Chenyue Guo
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Feifei Lou
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
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2
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Guo Q, Lian H, Wang G, Zhang H, Wang X. Prospective Evaluation of the Peripheral Perfusion Index in Assessing the Organ Dysfunction and Prognosis of Adult Patients With Sepsis in the ICU. J Intensive Care Med 2024:8850666241252758. [PMID: 38748544 DOI: 10.1177/08850666241252758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Background: The peripheral perfusion index (PI) reflects microcirculatory blood flow perfusion and indicates the severity and prognosis of sepsis. Method: The cohort comprised 208 patients admitted to the intensive care unit (ICU) with infection, among which 117 had sepsis. Demographics, medication history, ICU variables, and laboratory indexes were collected. Primary endpoints were in-hospital mortality and 28-day mortality. Secondary endpoints included organ function variables (coagulation function, liver function, renal function, and myocardial injury), lactate concentration, mechanical ventilation time, and length of ICU stay. Univariate and multivariate analyses were conducted to assess the associations between the PI and clinical outcomes. Sensitivity analyses were performed to explore the associations between the PI and organ functions in the sepsis and nonsepsis groups. Result: The PI was negatively associated with in-hospital mortality (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.15 to 0.55), but was not associated with 28-day mortality. The PI was negatively associated with the coagulation markers prothrombin time (PT) (β -0.36, 95% CI -0.59 to 0.13) and activated partial thromboplastin time (APTT) (β -1.08, 95% CI -1.86 to 0.31), and the myocardial injury marker cardiac troponin I (cTnI) (β -2085.48, 95% CI -3892.35 to 278.61) in univariate analysis, and with the PT (β -0.36, 95% CI -0.60 to 0.13) in multivariate analysis. The PI was negatively associated with the lactate concentration (β -0.57, 95% CI -0.95 to 0.19), mechanical ventilation time (β -23.11, 95% CI -36.54 to 9.69), and length of ICU stay (β -1.28, 95% CI -2.01 to 0.55). Sensitivity analyses showed that the PI was significantly associated with coagulation markers (PT and APTT) and a myocardial injury marker (cTnI) in patients with sepsis, suggesting that the associations between the PI and organ function were stronger in the sepsis group than the nonsepsis group. Conclusion: The PI provides new insights for assessing the disease severity, short-term prognosis, and organ function damage in ICU patients with sepsis, laying a theoretical foundation for future research.
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Affiliation(s)
- Qirui Guo
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangjian Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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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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Fernández-Sarmiento J, Lamprea S, Barrera S, Acevedo L, Duque C, Trujillo M, Aguirre V, Jimenez C. The association between prolonged capillary refill time and microcirculation changes in children with sepsis. BMC Pediatr 2024; 24:68. [PMID: 38245695 PMCID: PMC10799439 DOI: 10.1186/s12887-024-04524-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/01/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUNDS In children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis. METHODS This was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]-a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes. RESULTS A total of 132 children with sepsis were included, with a median age of two years (IQR 0.6-12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09-6.34; p = 0.02) and fewer 4-6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06-6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO2 difference (DCO2) had an abnormal PBR (aOR 1.13, 95% CI 1.01-1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64-0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58-1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94-0.99; p < 0.05). CONCLUSIONS We found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia.
| | - Shirley Lamprea
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Sofia Barrera
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Lorena Acevedo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Catalina Duque
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Manuela Trujillo
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Valeria Aguirre
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
| | - Carolina Jimenez
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana, Fundación Cardioinfantil-Institute of Cardiology, Bogotà, Colombia
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Fage N, Moretto F, Rosalba D, Shi R, Lai C, Teboul JL, Monnet X. Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock. Crit Care 2023; 27:429. [PMID: 37932812 PMCID: PMC10629142 DOI: 10.1186/s13054-023-04714-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Capillary refill time (CRT) has been suggested as a variable to follow during the course of septic shock. We systematically investigated the effects on CRT of volume expansion and norepinephrine. METHODS In 69 septic shock patients, we recorded mean arterial pressure (MAP), cardiac index (CI), and 5 consecutive CRT measurements (video method, standardized pressure applied on the fingertip) before and after a 500-mL saline infusion in 33 patients and before and after an increase of the norepinephrine dose in 36 different patients. Fluid responders were defined by an increase in CI ≥ 15%, and norepinephrine responders by an increase in MAP ≥ 15%. RESULTS The least significant change of CRT was 23%, so that changes in CRT were considered significant if larger than 23%. With volume expansion, CRT remained unchanged on average in patients with baseline CRT < 3 s (n = 7) and in all but one patient with baseline CRT ≥ 3 s in whom fluid increased CI < 15% (n = 13 "fluid non-responders"). In fluid responders with baseline CRT ≥ 3 s (n = 13), CRT decreased in 8 patients and remained unchanged in the others, exhibiting a dissociation between CI and CRT responses. The proportion of patients included > 24 h after starting norepinephrine was higher in patients with such a dissociation than in the other ones (60% vs. 0%, respectively). Norepinephrine did not change CRT significantly (except in one patient) if baseline CRT was ≥ 3 s and the increase in MAP < 15% (n = 6). In norepinephrine responders with prolonged baseline CRT (n = 11), it increased in 4 patients and remained unchanged in the other ones, which exhibited a dissociation between MAP and CRT responses. CONCLUSIONS In septic shock patients with prolonged CRT, CRT very rarely improves with treatment when volume expansion increases cardiac output < 15% and increasing norepinephrine increases MAP < 15%. When the effects of fluid infusion on cardiac output and of norepinephrine on MAP are significant, the response of CRT is variable, as it decreases in some patients and remains stable in others which exhibit a dissociation between changes in macrohemodynamic variables and in CRT. In this regard, CRT behaves as a marker of microcirculation. TRIAL REGISTRATION ClinicalTrial.gov (NCT04870892). Registered January15, 2021. Ethics committee approval CE SRLF 21-25.
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Affiliation(s)
- Nicolas Fage
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France.
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France.
- MITOVASC Laboratory UMR INSERM (French National Institute of Health and Medical Research), 1083-CNRS 6015, University of Angers, Angers, France.
| | - Francesca Moretto
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Daniela Rosalba
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Rui Shi
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Christopher Lai
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
| | - Xavier Monnet
- Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Université Paris-Saclay, AP-HP, Le Kremlin-Bicêtre, France
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6
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Zheng J, Zhu J, Cao L, Dong M, Mao Y, Zhao Z, Liu Y. Effect of restrictive fluid resuscitation on the coagulation function and hemodynamic parameters in patients with hemorrhagic traumatic shock. Clinics (Sao Paulo) 2023; 78:100300. [PMID: 37931530 PMCID: PMC10654136 DOI: 10.1016/j.clinsp.2023.100300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 09/18/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVES To investigate the changes in the coagulation function and hemodynamic parameters in patients with Hemorrhagic Traumatic Shock (HTS) after restrictive fluid resuscitation. METHODS A total of 139 patients with HTS admitted to our hospital were enrolled, among which 69 HTS patients were divided into the control group and the remaining 70 HTS patients as the observation group. Patients in the control group underwent regular fluid resuscitation, while those in the observation group underwent restrictive fluid resuscitation. RESULTS During treatment, 70 patients in the observation group had a lower bleeding amount, infusion amount, and blood transfusion volume than those in the control group (p < 0.05). After treatment, patients in the observation group had better hemodynamic parameters and blood coagulation than those in the control group (p < 0.05), and the incidence rate in the observation group was only 12.9%, which was significantly lower than 60.87% in the control group, while the cure rate in the observation group was 100%, which was significantly higher than that in the control group (p < 0.05). CONCLUSIONS Restrictive fluid resuscitation could remarkably increase the cure rate and reduce the bleeding amount during HTS treatment, thereby benefiting the recovery of the patient's blood coagulation.
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Affiliation(s)
- Junfen Zheng
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China
| | - Jinqiang Zhu
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China
| | - Liexiang Cao
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China
| | - Meiping Dong
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China
| | - Yi Mao
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China
| | - Zhiwei Zhao
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China
| | - Yao Liu
- Department of Emergency Center, The First People's Hospital of Wenling, Wenling, China.
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7
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Putowski Z, Gołdyn M, Pluta MP, Krzych ŁJ, Hernández G, Kattan E. Correlation Between Mean Arterial Pressure and Capillary Refill Time in Patients with Septic Shock: A Systematic Review and Meta-analysis. J Intensive Care Med 2023; 38:838-846. [PMID: 37042043 DOI: 10.1177/08850666231168038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Background: The initial hemodynamic goal during septic shock resuscitation is to achieve a mean arterial pressure (MAP) above 65 mm Hg, although this does not assure a normal tissue perfusion. Capillary refill time (CRT), a marker of skin blood flow, has been validated as a marker of the reperfusion process. The aim of the study was to explore the relationship between MAP and CRT in patients in septic shock. Methods: We systematically reviewed studies which reported CRT and MAP in septic shock patients. Authors of eligible studies were asked to provide necessary data for performing a meta-correlation of Spearman's rank correlation coefficients. Subgroup analyses were performed, including studies of good quality and studies with higher/lower norepinephrine doses. Results: We identified 10 studies, comprising 917 patients. There were 5 studies considered to be of good quality. A meta-correlation showed a statistically significant but poor negative correlation between MAP and CRT (R = -0.158, range -0.221 to -0.093, P < .001, I2 = 0.0%). Subgroup analysis of best-quality studies gave similar results (R = -0.201, range -0.282 to -0.116, P < .001, I2 = 0.0%). In subanalysis concerning norepinephrine doses, no significant correlations were found. Conclusions: In patients with septic shock, there is poor inverse correlation between MAP and CRT. MAP > 65 mm Hg does not guarantee normalization of CRT.Registration code: PROSPERO: CRD42022355996. Registered on 5 September 2022.
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Affiliation(s)
- Zbigniew Putowski
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Gołdyn
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Michał P Pluta
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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8
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Ahmad S. Capillary Refill Time Versus Sidestream Dark Field: Think Global, Act Local. Crit Care Med 2023; 51:977-978. [PMID: 37318294 DOI: 10.1097/ccm.0000000000005877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Salman Ahmad
- Division of Acute Care Surgery, Department of Surgery, University of Missouri Health Care, Columbia, MO
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9
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Kataria S, Singh O, Juneja D, Goel A, Bhide M, Yadav D. Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients: A comparative observational study. World J Clin Cases 2023; 11:3765-3779. [PMID: 37383132 PMCID: PMC10294150 DOI: 10.12998/wjcc.v11.i16.3765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/17/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization. Nevertheless, raised lactate levels should be interpreted in the clinical context, as there may be other causes of elevated lactate levels. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis. AIM To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context. METHODS This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context (Group 1, n = 95) and patients with hyperlactatemia in a non-hypoperfusion context (Group 2, n = 40). Hypoperfusion context was defined by a central venous saturation less than 70%, central venous-arterial PCO2 gradient [P(cv-a)CO2] ≥ 6 mmHg, and capillary refilling time (CRT) ≥ 4 s. The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals. Nominal categorical data were compared using the χ2 or Fisher's exact test. Non-normally distributed continuous variables were compared using the Mann-Whitney U test. Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate, CRT, and metabolic perfusion parameters to predict the 28-d all-cause mortality. A P value of < 0.05 was considered significant. RESULTS Patient demographics, comorbidities, baseline laboratory, vital parameters, source of infection, baseline lactate levels, and lactate clearance at 3 h and 6 h, Sequential Organ Failure scores, need for invasive mechanical ventilation, days on mechanical ventilation, and renal replacement therapy-free days within 28 d, duration of intensive care unit stay, and hospital stay were comparable between the two groups. The stratification of patients into hypoperfusion and non-hypoperfusion context did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO2 and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P > 0.05 at all measured intervals. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, P(cv-a)CO2 at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the curve lactate at 6 h: 0.845). CONCLUSION Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters. Persistently high P(cv-a)CO2 (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.
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Affiliation(s)
- Sahil Kataria
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Amit Goel
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Madhura Bhide
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Devraj Yadav
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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10
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Coen D. Fluids and vasopressors in septic shock: basic knowledge for a first approach in the emergency department. EMERGENCY CARE JOURNAL 2023. [DOI: 10.4081/ecj.2023.10810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Much research, both pathophysiological and clinical, has been produced about septic shock during the last 20 years. Nevertheless, many aspects of treatment are still controversial, among these the approach to the administration of fluids and vasopressors. After the first clinical trial on Early goal-directed therapy (EGDT) was published, a liberal approach to the use of fluids and conservative use of vasopressors prevailed, but in recent years a more restrictive use of fluids and an earlier introduction of vasopressors seem to be preferred. Although both treatments are based on sound pathophysiological knowledge, clinical evidence is still inadequate and somehow controversial. In this non-systematic review, recent research on the hemodynamics of septic shock and its treatment with fluids and inotropes is discussed. As a conclusion, general indications are proposed for a practical approach to patients in septic shock.
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11
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Zhou Y, Chi Y, He H, Cui N, Wang X, Long Y. High respiratory effort decreases splanchnic and peripheral perfusion in patients with respiratory failure during mechanical ventilation. J Crit Care 2023; 75:154263. [PMID: 36738632 DOI: 10.1016/j.jcrc.2023.154263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE This study aimed to evaluate the effects of high respiratory effort(HRE) on spleen, kidney, intestine, and peripheral perfusion in patients with respiratory failure during mechanical ventilation. METHODS HRE was defined as a pressure muscle index (PMI) > 6 cmH2O and airway pressure swing during occlusion (ΔPOCC) > 10 cmH2O. Capillary refill time(CRT) and peripheral perfusion index (PPI) were determined when HRE occurred. The resistance indices of the snuffbox, intestine, spleen, and kidney were measured using Doppler ultrasonography simultaneously. These parameters were re-measured when the patients had normal respiratory effort (NRE) following sedation and analgesia. RESULTS A total of 33 critically ill patients were enrolled in this prospective observational study. There was a significant increase in CRT (p = 0.0345) and PPI (p < 0.0001) from HRE to NRE; meanwhile, the resistance index of the snuffbox artery decreased (p < 0.0001). Regarding splanchnic perfusion indicators, all resistance indices of the superior mesenteric artery (p = 0.0002), spleen (p < 0.0001), and kidney (p < 0.0001) decreased significantly when the patient changed from HRE status to NRE. CONCLUSIONS HRE could decrease perfusion of peripheral tissues and splanchnic organs. The status of HRE should be avoided to protect splanchnic and peripheral organs in mechanically ventilated patients.
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Affiliation(s)
- Yuankai Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yi Chi
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China.
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12
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Yumoto T, Kuribara T, Yamada K, Sato T, Koba S, Tetsuhara K, Kashiura M, Sakuraya M. Clinical parameter-guided initial resuscitation in adult patients with septic shock: A systematic review and network meta-analysis. Acute Med Surg 2023; 10:e914. [PMID: 38148753 PMCID: PMC10750303 DOI: 10.1002/ams2.914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 12/28/2023] Open
Abstract
Aim To identify the most useful tissue perfusion parameter for initial resuscitation in sepsis/septic shock adults using a network meta-analysis. Methods We searched major databases until December 2022 for randomized trials comparing four tissue perfusion parameters or against usual care. The primary outcome was short-term mortality up to 90 days. The Confidence in Network Meta-Analysis web application was used to assess the quality of evidence. Results Seventeen trials were identified. Lactate-guided therapy (risk ratios, 0.59; 95% confidence intervals [0.45-0.76]; high certainty) and capillary refill time-guided therapy (risk ratios, 0.53; 95% confidence intervals [0.33-0.86]; high certainty) were significantly associated with lower short-term mortality compared with usual care, whereas central venous oxygen saturation-guided therapy (risk ratio, 1.50; 95% confidence intervals [1.16-1.94]; moderate certainty) increased the risk of short-term mortality compared with lactate-guided therapy. Conclusions Lactate or capillary refill time-guided initial resuscitation for sepsis/septic shock patients may decrease short-term mortality. More research is essential to personalize and optimize treatment strategies for septic shock resuscitation.
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Affiliation(s)
- Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | | | - Kohei Yamada
- Department of Traumatology and Critical Care MedicineNational Defense Medical College HospitalSaitamaJapan
| | - Takehito Sato
- Department of AnesthesiologyNagoya University HospitalNagoyaJapan
| | - Shigeru Koba
- Department of Critical Care MedicineNerima Hikarigaoka HospitalTokyoJapan
| | - Kenichi Tetsuhara
- Department of Critical Care MedicineFukuoka Children's HospitalFukuokaJapan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care MedicineJA Hiroshima General HospitalHiroshimaJapan
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13
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Effects of Fluids on the Sublingual Microcirculation in Sepsis. J Clin Med 2022; 11:jcm11247277. [PMID: 36555895 PMCID: PMC9786137 DOI: 10.3390/jcm11247277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Sepsis is one of the most common and deadly syndromes faced in Intensive Care settings globally. Recent advances in bedside imaging have defined the changes in the microcirculation in sepsis. One of the most advocated interventions for sepsis is fluid therapy. Whether or not fluid bolus affects the microcirculation in sepsis has not been fully addressed in the literature. This systematic review of the evidence aims to collate studies examining the microcirculatory outcomes after a fluid bolus in patients with sepsis. We will assimilate the evidence for using handheld intra vital microscopes to guide fluid resuscitation and the effect of fluid bolus on the sublingual microcirculation in patients with sepsis and septic shock. We conducted a systematic search of Embase, CENTRAL and Medline (PubMed) using combinations of the terms "microcirculation" AND "fluid" OR "fluid resuscitation" OR "fluid bolus" AND "sepsis" OR "septic shock". We found 3376 potentially relevant studies. Fifteen studies published between 2007 and 2021 fulfilled eligibility criteria to be included in analysis. The total number of participants was 813; we included six randomized controlled trials and nine non-randomized, prospective observational studies. Ninety percent used Sidestream Dark Field microscopy to examine the microcirculation and 50% used Hydroxyethyl Starch as their resuscitation fluid. There were no clear effects of fluid on the microcirculation parameters. There was too much heterogeneity between studies and methodology to perform meta-analysis. Studies identified heterogeneity of affect in the sepsis population, which could mean that current clinical classifications were not able to identify different microcirculation characteristics. Use of microcirculation as a clinical endpoint in sepsis could help to define sepsis phenotypes. More research into the effects of different resuscitation fluids on the microcirculation is needed.
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14
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Valenzuela ED, Mercado P, Pairumani R, Medel JN, Petruska E, Ugalde D, Morales F, Eisen D, Araya C, Montoya J, Gonzalez A, Rovegno M, Ramirez J, Aguilera J, Hernández G, Bruhn A, Slama M, Bakker J. Cardiac function in critically ill patients with severe COVID: A prospective cross-sectional study in mechanically ventilated patients. J Crit Care 2022; 72:154166. [PMID: 36244256 PMCID: PMC9557772 DOI: 10.1016/j.jcrc.2022.154166] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/29/2022] [Accepted: 09/18/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To evaluate cardiac function in mechanically ventilated patients with COVID-19. MATERIALS AND METHODS Prospective, cross-sectional multicenter study in four university-affiliated hospitals in Chile. All consecutive patients with COVID-19 ARDS requiring mechanical ventilation admitted between April and July 2020 were included. We performed systematic transthoracic echocardiography assessing right and left ventricular function within 24 h of intubation. RESULTS 140 patients aged 57 ± 11, 29% female were included. Cardiac output was 5.1 L/min [IQR 4.5-6.2] and 86% of the patients required norepinephrine. ICU mortality was 29% (40 patients). Fifty-four patients (39%) exhibited right ventricle dilation out of whom 20 patients (14%) exhibited acute cor pulmonale (ACP). Eight out of the twenty patients with ACP exhibited pulmonary embolism (40%). Thirteen patients (9%) exhibited left ventricular systolic dysfunction (ejection fraction <45%). In the multivariate analysis acute cor pulmonale and PaO2/FiO2 ratio were independent predictors of ICU mortality. CONCLUSIONS Right ventricular dilation is highly prevalent in mechanically ventilated patients with COVID-19 ARDS. Acute cor pulmonale was associated with reduced pulmonary function and, in only 40% of patients, with co-existing pulmonary embolism. Acute cor pulmonale is an independent risk factor for ICU mortality.
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Affiliation(s)
- Emilio Daniel Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Pablo Mercado
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Ronald Pairumani
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Juan Nicolás Medel
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Edward Petruska
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Diego Ugalde
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Felipe Morales
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Daniela Eisen
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Carla Araya
- Unidad de Cuidados Intensivos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Jorge Montoya
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Alejandra Gonzalez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Ramirez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javiera Aguilera
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Michel Slama
- Medical Intensive Care Unit, CHU Sud Amiens, Amiens, France
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,Department of intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands,Department of Pulmonary and Critical Care, New York University, NYU Langone Health, New York, USA,Department of Pulmonary and Critical Care, Columbia University Medical Center, New York, USA
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15
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Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, Pichamuthu K, Jog SA, Divatia JV, Myatra SN. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022; 26:S66-S76. [PMID: 36896359 PMCID: PMC9989872 DOI: 10.5005/jp-journals-10071-24301] [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: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. How to cite this article Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.
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Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta - The Medicity, Gurugram, Haryana, India
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India
| | | | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Sameer Arvind Jog
- Department of Critical Care Medicine, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Sheila Nainan Myatra
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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16
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Jessen MK, Andersen LW, Thomsen MH, Kristensen P, Hayeri W, Hassel RE, Messerschmidt TG, Sølling CG, Perner A, Petersen JAK, Kirkegaard H. Restrictive fluids versus standard care in adults with sepsis in the emergency department (REFACED): A multicenter, randomized feasibility trial. Acad Emerg Med 2022; 29:1172-1184. [PMID: 35652491 PMCID: PMC9804491 DOI: 10.1111/acem.14546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fluid treatment in sepsis is a challenge and clinical equipoise exists regarding intravenous (IV) volumes. We aimed to determine whether a 24-h protocol restricting IV fluid was feasible in adult patients with sepsis without shock presenting to the emergency department (ED). METHODS The REFACED Sepsis trial is an investigator-initiated, multicenter, randomized, open-label, feasibility trial, assigning sepsis patients without shock to 24 h of restrictive, crystal IV fluid administration or standard care. In the IV fluid restriction group fluid boluses were only permitted if predefined criteria for hypoperfusion occurred. Standard care was at the discretion of the treating team. The primary outcome was total IV crystalloid fluid volumes at 24 h after randomization. Secondary outcomes included total fluid volumes, feasibility measures, and patient-centered outcomes. RESULTS We included 123 patients (restrictive 61 patients and standard care 62 patients) in the primary analysis. A total of 32% (95% confidence interval [CI] 28%-37%) of eligible patients meeting all inclusion criteria and no exclusion criteria were included. At 24 h, the mean (±SD) IV crystalloid fluid volumes were 562 (±1076) ml versus 1370 (±1438) ml in the restrictive versus standard care group (mean difference -801 ml, 95% CI -1257 to -345 ml, p = 0.001). Protocol violations occurred in 21 (34%) patients in the fluid-restrictive group. There were no differences between groups in adverse events, use of mechanical ventilation or vasopressors, acute kidney failure, length of stay, or mortality. CONCLUSIONS A protocol restricting IV crystalloid fluids in ED patients with sepsis reduced 24-h fluid volumes compared to standard care. A future trial powered toward patient-centered outcomes appears feasible.
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Affiliation(s)
- Marie K. Jessen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Lars W. Andersen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
| | - Marie‐Louise H. Thomsen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Peter Kristensen
- Department of Emergency MedicineRegional Hospital ViborgViborgDenmark
| | - Wazhma Hayeri
- Department of Emergency MedicineRegional Hospital RandersRandersDenmark
| | - Ranva E. Hassel
- Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | | | | | - Anders Perner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Jens Aage K. Petersen
- Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
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17
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Pinsky MR, Cecconi M, Chew MS, De Backer D, Douglas I, Edwards M, Hamzaoui O, Hernandez G, Martin G, Monnet X, Saugel B, Scheeren TWL, Teboul JL, Vincent JL. Effective hemodynamic monitoring. Crit Care 2022; 26:294. [PMID: 36171594 PMCID: PMC9520790 DOI: 10.1186/s13054-022-04173-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractHemodynamic monitoring is the centerpiece of patient monitoring in acute care settings. Its effectiveness in terms of improved patient outcomes is difficult to quantify. This review focused on effectiveness of monitoring-linked resuscitation strategies from: (1) process-specific monitoring that allows for non-specific prevention of new onset cardiovascular insufficiency (CVI) in perioperative care. Such goal-directed therapy is associated with decreased perioperative complications and length of stay in high-risk surgery patients. (2) Patient-specific personalized resuscitation approaches for CVI. These approaches including dynamic measures to define volume responsiveness and vasomotor tone, limiting less fluid administration and vasopressor duration, reduced length of care. (3) Hemodynamic monitoring to predict future CVI using machine learning approaches. These approaches presently focus on predicting hypotension. Future clinical trials assessing hemodynamic monitoring need to focus on process-specific monitoring based on modifying therapeutic interventions known to improve patient-centered outcomes.
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18
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Jacquet-Lagrèze M, Wiart C, Schweizer R, Didier L, Ruste M, Coutrot M, Legrand M, Baudin F, Javouhey E, Dépret F, Fellahi JL. Capillary refill time for the management of acute circulatory failure: a survey among pediatric and adult intensivists. BMC Emerg Med 2022; 22:131. [PMID: 35850662 PMCID: PMC9290243 DOI: 10.1186/s12873-022-00681-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Recent studies have shown the prognostic value of capillary refill time (CRT) and suggested that resuscitation management guided by CRT may reduce morbidity and mortality in patients with septic shock. However, little is known about the current use of CRT in routine clinical practice. This study aimed to assess the modalities of CRT use among French adult and pediatric intensivists. METHODS A cross-sectional survey exploring CRT practices in acute circulatory failure was performed. The targeted population was French adult and pediatric intensivists (SFAR and GFRUP networks). An individual invitation letter including a survey of 32 questions was emailed twice. Descriptive and analytical statistics were performed. RESULTS Among the 6071 physicians who received the letter, 418 (7%) completed the survey. Among all respondents, 82% reported using CRT in routine clinical practice, mainly to diagnose acute circulatory failure, but 45% did not think CRT had any prognostic value. Perfusion goal-directed therapy based on CRT was viewed as likely to improve patient outcome by 37% of respondents. The measurement of CRT was not standardized as the use of a chronometer was rare (3%) and the average of multiple measurements rarely performed (46%). Compared to adult intensivists, pediatric intensivists used CRT more frequently (99% versus 76%) and were more confident in its diagnostic value and its ability to guide treatment. CONCLUSION CRT measurement is widely used by intensivists in patients with acute circulatory failure but most often in a non-standardized way. This may lead to a misunderstanding of CRT reliability and clinical usefulness.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France.
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France.
- CarMeN Laboratory, INSERM UMR 1060, University Claude Bernard Lyon 1, Lyon, France.
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69394, Lyon, Cedex, France.
| | - Cléo Wiart
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
| | - Rémi Schweizer
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
| | - Léa Didier
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
| | - Martin Ruste
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
| | - Maxime Coutrot
- FHU PROMICE, DMU Parabol, Département d'anesthésie-réanimation, Hôpital Saint Louis, Assistance publique des Hôpitaux de Paris, Paris, France
- Faculté de médecine Paris, Université Paris France, Paris, France
| | - Matthieu Legrand
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco & F-CRIN-INI-CRCT Network, Nancy, France
| | - Florent Baudin
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
- Service de Réanimation et Urgences Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, F-69500, Bron, France
| | - Etienne Javouhey
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
- Service de Réanimation et Urgences Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, F-69500, Bron, France
| | - François Dépret
- FHU PROMICE, DMU Parabol, Département d'anesthésie-réanimation, Hôpital Saint Louis, Assistance publique des Hôpitaux de Paris, Paris, France
- Faculté de médecine Paris, Université Paris France, Paris, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-réanimation, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon, Cedex 08, France
- CarMeN Laboratory, INSERM UMR 1060, University Claude Bernard Lyon 1, Lyon, France
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19
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Bockholt R, Paschke S, Heubner L, Ibarlucea B, Laupp A, Janićijević Ž, Klinghammer S, Balakin S, Maitz MF, Werner C, Cuniberti G, Baraban L, Spieth PM. Real-Time Monitoring of Blood Parameters in the Intensive Care Unit: State-of-the-Art and Perspectives. J Clin Med 2022; 11:jcm11092408. [PMID: 35566534 PMCID: PMC9100654 DOI: 10.3390/jcm11092408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
The number of patients in intensive care units has increased over the past years. Critically ill patients are treated with a real time support of the instruments that offer monitoring of relevant blood parameters. These parameters include blood gases, lactate, and glucose, as well as pH and temperature. Considering the COVID-19 pandemic, continuous management of dynamic deteriorating parameters in patients is more relevant than ever before. This narrative review aims to summarize the currently available literature regarding real-time monitoring of blood parameters in intensive care. Both, invasive and non-invasive methods are described in detail and discussed in terms of general advantages and disadvantages particularly in context of their use in different medical fields but especially in critical care. The objective is to explicate both, well-known and frequently used as well as relatively unknown devices. Furtehrmore, potential future direction in research and development of realtime sensor systems are discussed. Therefore, the discussion section provides a brief description of current developments in biosensing with special emphasis on their technical implementation. In connection with these developments, the authors focus on different electrochemical approaches to invasive and non-invasive measurements in vivo.
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Affiliation(s)
- Rebecca Bockholt
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, 01309 Dresden, Germany; (R.B.); (S.P.); (L.H.); (A.L.)
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
| | - Shaleen Paschke
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, 01309 Dresden, Germany; (R.B.); (S.P.); (L.H.); (A.L.)
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
| | - Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, 01309 Dresden, Germany; (R.B.); (S.P.); (L.H.); (A.L.)
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
| | - Bergoi Ibarlucea
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
- Institute for Materials Science and Max Bergmann Center of Biomaterials, Center for Advancing Electronics Dresden, Technische Universität Dresden, 01069 Dresden, Germany;
| | - Alexander Laupp
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, 01309 Dresden, Germany; (R.B.); (S.P.); (L.H.); (A.L.)
| | - Željko Janićijević
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
- Institute of Radiopharmaceutical Cancer Research, Helmholtz Center Dresden Rossendorf e.V., Bautzner Landstrasse 400, 01328 Dresden, Germany
| | - Stephanie Klinghammer
- Institute for Materials Science and Max Bergmann Center of Biomaterials, Center for Advancing Electronics Dresden, Technische Universität Dresden, 01069 Dresden, Germany;
| | - Sascha Balakin
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
- Institute for Materials Science and Max Bergmann Center of Biomaterials, Center for Advancing Electronics Dresden, Technische Universität Dresden, 01069 Dresden, Germany;
| | - Manfred F. Maitz
- Leibniz-Institut für Polymerforschung Dresden e.V., 01069 Dresden, Germany; (M.F.M.); (C.W.)
| | - Carsten Werner
- Leibniz-Institut für Polymerforschung Dresden e.V., 01069 Dresden, Germany; (M.F.M.); (C.W.)
| | - Gianaurelio Cuniberti
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
- Institute for Materials Science and Max Bergmann Center of Biomaterials, Center for Advancing Electronics Dresden, Technische Universität Dresden, 01069 Dresden, Germany;
| | - Larysa Baraban
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
- Institute of Radiopharmaceutical Cancer Research, Helmholtz Center Dresden Rossendorf e.V., Bautzner Landstrasse 400, 01328 Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, 01309 Dresden, Germany; (R.B.); (S.P.); (L.H.); (A.L.)
- Else Kröner-Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden (TU Dresden), 01309 Dresden, Germany; (B.I.); (Ž.J.); (S.B.); (G.C.); (L.B.)
- Correspondence: ; Tel.: +49-351-4581-6006
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20
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Gillespie J, Hansen M, Samatham R, Baker SD, Filer S, Sheridan DC. Capillary Refill Technology to Enhance the Accuracy of Peripheral Perfusion Evaluation in Sepsis. J Intensive Care Med 2022; 37:1159-1164. [DOI: 10.1177/08850666221087685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Monitoring of capillary refill time (CRT) is a common bedside assessment used to ascertain peripheral perfusion in a patient for a vast array of conditions. The literature has shown that a change in CRT can be used to recognize life-threatening conditions that cause decreased perfusion, such as sepsis, and aid in resuscitation. The current practice for calculating CRT invites subjectivity and produces a highly variable result. Innovative technology may be able to standardize this process and provide a reliable and accurate value for use in diagnostics and treatment. This study aimed to assess a new technology (DCR by ProMedix Inc.) for rapid, bedside, and noninvasive detection of CRT. Methods: This was a secondary analysis of a prospective observational study evaluating the accuracy of new technology towards CRT-guided diagnosis of sepsis. It was carried out in the adult emergency departments (ED) of an academic tertiary care medical center. Patients seeking care in the ED were determined eligible if they were > 18 years in age and exhibited chief complaints suggestive of possible sepsis. The CRT produced by the technology was compared to the gold standard manual waveform assessment. Results: 218 consecutive subject enrollments were included and multiple measurements were made on each patient. Data with irregular waveforms were excluded. A total of 692 waveforms were evaluated for CRT values by a pair of trained PhD biomedical engineers. The average age of the cohort was 50.62 and 51.4% female. Results showed a Pearson correlation coefficient of 0.91 for the device CRT compared to the CRT gold standard. The Pearson correlation coefficient for the two independent engineering review of the waveform data was 0.98. This device produces accurate, consistent results and eliminates the subjectivity of CRT measurements that is in practice currently.
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Affiliation(s)
- Jordan Gillespie
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew Hansen
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ravi Samatham
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | - David C. Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
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21
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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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22
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Accuracy of pulse pressure variations for fluid responsiveness prediction in mechanically ventilated patients with biphasic positive airway pressure mode. J Clin Monit Comput 2021; 36:1479-1487. [PMID: 34865181 DOI: 10.1007/s10877-021-00789-8] [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: 09/07/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
The accuracy of pulse pressure variation (PPV) to predict fluid responsiveness using pressure-controlled (PC) instead of volume-controlled modes is under debate. To specifically address this issue, we designed a study to evaluate the accuracy of PPV to predict fluid responsiveness in severe septic patients who were mechanically ventilated with biphasic positive airway pressure (BIPAP) PC-ventilation mode. 45 patients with sepsis or septic shock and who were mechanically ventilated with BIPAP mode and a target tidal volume of 7-8 ml/kg were included. PPV was automatically assessed at baseline and after a standard fluid challenge (Ringer's lactate 500 ml). A 15% increase in stroke volume (SV) defined fluid responsiveness. The predictive value of PPV was evaluated through a receiver operating characteristic (ROC) curve analysis and "gray zone" statistical approach. 20 (44%) patients were considered fluid responders. We identified a significant relationship between PPV decrease after volume expansion and SV increase (spearman ρ = - 0.5, p < 0.001). The area under ROC curve for PPV was 0.71 (95%CI 0.56-0.87, p = 0.007). The best cut-off (based on Youden's index) was 8%, with a sensitivity of 80% and specificity of 60%. Using a gray zone approach, we identified that PPV values comprised between 5 and 15% do not allow a reliable fluid responsiveness prediction. In critically ill septic patients ventilated under BIPAP mode, PPV appears to be an accurate method for fluid responsiveness prediction. However, PPV values comprised between 5 and 15% constitute a gray zone that does not allow a reliable fluid responsiveness prediction.
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23
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Wentowski C, Ingles DP, Nielsen ND. Sepsis 2021: a review. ANAESTHESIA & INTENSIVE CARE MEDICINE 2021. [DOI: 10.1016/j.mpaic.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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24
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Gavelli F, Castello LM, Avanzi GC. Management of sepsis and septic shock in the emergency department. Intern Emerg Med 2021; 16:1649-1661. [PMID: 33890208 PMCID: PMC8354945 DOI: 10.1007/s11739-021-02735-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/30/2021] [Indexed: 12/19/2022]
Abstract
Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.
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Affiliation(s)
- Francesco Gavelli
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Via Solaroli 17, Novara, Italy.
- Emergency Medicine Department, AOU Maggiore Della Carità, Corso Mazzini 18, Novara, Italy.
| | - Luigi Mario Castello
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Via Solaroli 17, Novara, Italy
- Emergency Medicine Department, AOU Maggiore Della Carità, Corso Mazzini 18, Novara, Italy
| | - Gian Carlo Avanzi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Via Solaroli 17, Novara, Italy
- Emergency Medicine Department, AOU Maggiore Della Carità, Corso Mazzini 18, Novara, Italy
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25
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Sivakorn C, Schultz MJ, Dondorp AM. How to monitor cardiovascular function in critical illness in resource-limited settings. Curr Opin Crit Care 2021; 27:274-281. [PMID: 33899817 PMCID: PMC8240644 DOI: 10.1097/mcc.0000000000000830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hemodynamic monitoring is an essential component in the care for critically ill patients. A range of tools are available and new approaches have been developed. This review summarizes their availability, affordability and feasibility for hospital settings in resource-limited settings. RECENT FINDINGS Evidence for the performance of specific hemodynamic monitoring tools or strategies in low-income and middle-income countries (LMICs) is limited. Repeated physical examination and basic observations remain a cornerstone for patient monitoring and have a high sensitivity for detecting organ hypoperfusion, but with a low specificity. Additional feasible approaches for hemodynamic monitoring in LMICs include: for tissue perfusion monitoring: urine output, skin mottling score, capillary refill time, skin temperature gradients, and blood lactate measurements; for cardiovascular monitoring: echocardiography and noninvasive or minimally invasive cardiac output measurements; and for fluid status monitoring: inferior vena cava distensibility index, mini-fluid challenge test, passive leg raising test, end-expiratory occlusion test and lung ultrasound. Tools with currently limited applicability in LMICs include microcirculatory monitoring devices and pulmonary artery catheterization, because of costs and limited added value. Especially ultrasound is a promising and affordable monitoring device for LMICs, and is increasingly available. SUMMARY A set of basic tools and approaches is available for adequate hemodynamic monitoring in resource-limited settings. Future research should focus on the development and trialing of robust and context-appropriate monitoring technologies.
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Affiliation(s)
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Arjen M. Dondorp
- Mahidol–Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine Mahidol University, Bangkok, Thailand
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
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26
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Iepsen UW, Plovsing RR, Tjelle K, Foss NB, Meyhoff CS, Ryrsø CK, Berg RMG, Secher NH. The role of lactate in sepsis and COVID-19: Perspective from contracting skeletal muscle metabolism. Exp Physiol 2021; 107:665-673. [PMID: 34058787 PMCID: PMC8239768 DOI: 10.1113/ep089474] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022]
Abstract
NEW FINDINGS What is the topic of this review? Lactate is considered an important substrate for mitochondria in the muscles, heart and brain during exercise and is the main gluconeogenetic precursor in the liver and kidneys. In this light, we review the (patho)physiology of lactate metabolism in sepsis and coronavirus disease 2019 (COVID-19). What advances does it highlight? Elevated blood lactate is strongly associated with mortality in septic patients. Lactate seems unrelated to tissue hypoxia but is likely to reflect mitochondrial dysfunction and high adrenergic stimulation. Patients with severe COVID-19 exhibit near-normal blood lactate, indicating preserved mitochondrial function, despite a systemic hyperinflammatory state similar to sepsis. ABSTRACT In critically ill patients, elevated plasma lactate is often interpreted as a sign of organ hypoperfusion and/or tissue hypoxia. This view on lactate is likely to have been influenced by the pioneering exercise physiologists around 1920. August Krogh identified an oxygen deficit at the onset of exercise that was later related to an oxygen 'debt' and lactate accumulation by A. V. Hill. Lactate is considered to be the main gluconeogenetic precursor in the liver and kidneys during submaximal exercise, but hepatic elimination is attenuated by splanchnic vasoconstriction during high-intensity exercise, causing an exponential increase in blood lactate. With the development of stable isotope tracers, lactate has become established as an important energy source for muscle, brain and heart tissue, where it is used for mitochondrial respiration. Plasma lactate > 4 mM is strongly associated with mortality in septic shock, with no direct link between lactate release and tissue hypoxia. Herein, we provide evidence for mitochondrial dysfunction and adrenergic stimulation as explanations for the sepsis-induced hyperlactataemia. Despite profound hypoxaemia and intense work of breathing, patients with severe coronavirus disease 2019 (COVID-19) rarely exhibit hyperlactataemia (> 2.5 mM), while presenting a systemic hyperinflammatory state much like sepsis. However, lactate dehydrogenase, which controls the formation of lactate, is markedly elevated in plasma and strongly associated with mortality in severe COVID-19. We briefly review the potential mechanisms of the lactate dehydrogenase elevation in COVID-19 and its relationship to lactate metabolism based on mechanisms established in contracting skeletal muscle and the acute respiratory distress syndrome.
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Affiliation(s)
- Ulrik Winning Iepsen
- Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Ronni R Plovsing
- Department of Anaesthesiology, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Tjelle
- Department of Anaesthesiology, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla K Ryrsø
- Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ronan M G Berg
- Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Physiology, Nuclear Medicine & PET, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Niels H Secher
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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27
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Abstract
PURPOSE OF REVIEW Current goals of resuscitation in septic shock are mainly a fixed volume of fluids and vasopressors to correct hypotension and improve tissue perfusion indicated by decreasing lactate levels. RECENT FINDINGS Abnormal peripheral perfusion by objective and subjective parameters are associated with increased mortality in various phases of the treatment of critically ill patients including patients with septic shock. Ongoing resuscitation in septic shock patients with normal peripheral perfusion is not associated with improved outcome, rather with increased mortality. Mitigation of fluid resuscitation by using parameters of peripheral perfusion in septic shock seems to be safe. SUMMARY Septic shock patients with normal peripheral perfusion represent a different clinical phenotype of patients that might benefit from limited resuscitation efforts. Parameters of peripheral perfusion could be used to guide the individualization of patients with septic shock.
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28
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Virág M, Leiner T, Rottler M, Ocskay K, Molnar Z. Individualized Hemodynamic Management in Sepsis. J Pers Med 2021; 11:157. [PMID: 33672267 PMCID: PMC7926902 DOI: 10.3390/jpm11020157] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and "restrictive" infusion strategies have been recommended by guidelines over "liberal" approaches for several years. Unfortunately, these "fixed regimen" treatment protocols neglect the patient's individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.
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Affiliation(s)
- Marcell Virág
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Tamas Leiner
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Anaesthetic Department, North West Anglia NHS Foundation Trust, Hinchingbrooke Hospital, Huntingdon PE29 6NT, UK
| | - Mate Rottler
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Szent György University Teaching Hospital of Fejér County, 8000 Székesfehérvár, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
| | - Zsolt Molnar
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary; (M.V.); (T.L.); (M.R.); (K.O.)
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland
- Department of Anesthesiology and Intensive Therapy, Markusovszky Teaching Hospital, 9700 Szombathely, Hungary
- Multidisciplinary Doctoral School, University of Szeged, 6720 Szeged, Hungary
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29
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Hasanin A, Karam N, Mukhtar AM, Habib SF. The ability of pulse oximetry-derived peripheral perfusion index to detect fluid responsiveness in patients with septic shock. J Anesth 2021; 35:254-261. [PMID: 33616758 DOI: 10.1007/s00540-021-02908-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fluid challenge test is a widely used method for the detection of fluid responsiveness in acute circulatory failure. However, detection of the patient's response to the fluid challenge requires monitoring of cardiac output which is not feasible in many settings. We investigated whether the changes in the pulse oximetry-derived peripheral perfusion index (PPI), as a non-invasive surrogate of cardiac output, can detect fluid responsiveness using the fluid challenge test or not. METHODS We prospectively enrolled 58 patients with septic shock on norepinephrine infusion. Fluid challenge test, using 200 mL crystalloid solution, was performed in all study subjects. All patients received an additional 300 mL crystalloid infusion to confirm fluid responsiveness. Velocity time integral (VTI) (using transthoracic echocardiography), and PPI were measured at the baseline, after 200 mL fluid challenge, and after completion of 500 mL crystalloids. Fluid responsiveness was defined by 10% increase in the VTI after completion of the 500 mL. The predictive ability of ∆PPI [Calculated as (PPI after 200 mL - baseline PPI)/baseline PPI] to detect fluid responders was obtained using the receiver operating characteristic curve. RESULTS Forty-two patients (74%) were fluid responders; in whom, the mean arterial pressure, the central venous pressure, the VTI, and the PPI increased after fluid administration compared to the baseline values. ∆PPI showed moderate ability to detect fluid responders [area under receiver operating characteristic curve (95% confidence interval) 0.82 (0.70-0.91), sensitivity 76%, specificity 80%, positive predictive value 92%, negative predictive value 54%, cutoff value ≥ 5%]. There was a significant correlation between ∆PPI and ∆VTI induced by the fluid challenge. CONCLUSION ∆PPI showed moderate ability to detect fluid responsiveness in patients with septic shock on norepinephrine infusion. Increased PPI after 200 mL crystalloid challenge can detect fluid responsiveness with a positive predictive value of 92%; however, failure of the PPI to increase does not exclude fluid responsiveness. CLINICAL TRIAL IDENTIFIER NCT03805321. Date of registration: 15 January 2019. Clinical trial registration URL: https://clinicaltrials.gov/ct2/show/NCT03805321?term=ahmed+hasanin&rank=9 .
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Affiliation(s)
- Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Nadia Karam
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed M Mukhtar
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Sara F Habib
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Joffre J, Legrand M. Microcirculation-targeted resuscitation in septic shock: can complex problems have simple answers? Ann Intensive Care 2021; 11:1. [PMID: 33409748 PMCID: PMC7788131 DOI: 10.1186/s13613-020-00796-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/26/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Jérémie Joffre
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, UCSF School of Medicine, University of California, 500 Parnassus Av, San Francisco, CA, 94143, USA
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, UCSF School of Medicine, University of California, 500 Parnassus Av, San Francisco, CA, 94143, USA. .,INI-CRCT Network, Nancy, France.
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Trivedi S, Sharma A, Baghel KS, Karna ST, Thaware P, Trivedi G, Tejpal M. The Effect of Normal Saline and Plasmalyte on Acid-Base Status in Patients Undergoing Head-and-Neck Surgery with Free Flap Reconstruction: A Prospective, Observational Cohort Study. Anesth Essays Res 2021; 15:227-232. [PMID: 35281354 PMCID: PMC8916140 DOI: 10.4103/aer.aer_133_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 11/04/2022] Open
Abstract
Background Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeries with free flap reconstruction (HNS-FFR). Studies to guide regarding association of intraoperative fluid with metabolic parameters during such surgeries are infrequent. Aim This study aimed to compare plasmalyte (PL) and normal saline (NS) (0.9%) in terms of acid-base balance and electrolytes in the peri-operative period along with graft viability during above-mentioned surgeries. Settings and Design Prospective, observational cohort study was conducted in patients, 18-65 years, undergoing HNS-FFR at a tertiary care center. Materials and Methods The cohort was categorized into two groups based on the intraoperative fluid used, i.e., PL (Group A) and NS (Group B) group. The primary objective was to compare arterial blood gas parameters at seven time points till the 3rd postoperative day. We studied the effect on graft viability and length of hospital stay. Statistical Analysis Used The independent t-tests, Chi-square, or Fisher's exact test were used to evaluate the categorical variables with a repeated measures analysis of variance for inter-group comparison with P < 0.05 as significant. Results Seventy-one (36 in Group A and 35 in Group B) patients were included in the study with comparable baseline characteristics. Group A had a better acid-base status, especially after the conclusion of vascular anastomosis (pH 7.37 ± 0.06 vs. 7.33 ± 0.04, P = 0.014) and in the postoperative period (pH 7.35 ± 0.07 vs. 7.31 ± 0.05, P = 0.013). No statistically significant difference was observed in outcome parameters between the groups. Conclusions PL may be preferred over NS due to better metabolic milieu during HNS-FFR surgery.
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Affiliation(s)
- Saurabh Trivedi
- Department of Anaesthesia and Critical Care Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Anand Sharma
- Department of Anaesthesia, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Kaushal Singh Baghel
- Department of Anaesthesia and Critical Care Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Sunaina Tejpal Karna
- Department of Anaesthesia and Critical Care Medicine, AIIMS, Bhopal, Madhya Pradesh, India,Address for correspondence: Dr. Sunaina Tejpal Karna, Department of Anaesthesia and Critical Care Medicine, AIIMS, Bhopal, Madhya Pradesh, India. E-mail:
| | - Pooja Thaware
- Department of Anaesthesia and Critical Care Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Gaurav Trivedi
- Department of Radiation Oncology, Command Hospital, Lucknow, Uttar Pradesh, India
| | - Manvinder Tejpal
- Department of Community and Family Medicine, AFMC, Pune, Maharashtra, India
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