Abstract
BackgroundResuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. Our aim was to characterize cardiovascular and fluid management of sepsis in Argentina, a low and middle-income country (LMIC). Furthermore, we sought to test whether the utilization of dynamic tests of fluid responsiveness, as a guide for fluid therapy after initial resuscitation in patients with persistent or recurrent hypoperfusion, was associated with decreased mortality.MethodsSecondary analysis of a national, multicenter prospective cohort study (n = 787) fulfilling Sepsis-3 definitions. Epidemiological characteristics, hemodynamic management data, type of fluids and vasopressors administered, physiological variables denoting hypoperfusion, use of tests of fluid responsiveness, and outcomes, were registered. Independent predictors of mortality were identified with logistic regression analysis.ResultsInitially, 584 of 787 patients (74%) had mean arterial pressure (MAP) < 65 mm Hg and/or signs of hypoperfusion and received 30 mL/kg of fluids, mostly normal saline (53%) and Ringer lactate (35%). Vasopressors and/or inotropes were administered in 514 (65%) patients, mainly norepinephrine (100%) and dobutamine (9%); in 22%, vasopressors were administered before ending the fluid load. After this, 413 patients (53%) presented persisting or recurrent hypotension and/or hypoperfusion, which prompted administration of additional fluid, based on: lactate levels (66%), urine output (62%), heart rate (54%), central venous O2 saturation (39%), central venous–arterial PCO2 difference (38%), MAP (31%), dynamic tests of fluid responsiveness (30%), capillary-refill time (28%), mottling (26%), central venous pressure (24%), cardiac index (13%) and/or pulmonary wedge pressure (3%). Independent predictors of mortality were SOFA and Charlson scores, lactate, requirement of mechanical ventilation, and utilization of dynamic tests of fluid responsiveness.ConclusionsIn this prospective observational study assessing the characteristics of resuscitation of septic patients in Argentina, a LMIC, the prevalent use of initial fluid bolus with normal saline and Ringer lactate and the use of norepinephrine as the most frequent vasopressor, reflect current worldwide practices. After initial resuscitation with 30 mL/kg of fluids and vasopressors, 413 patients developed persistent or recurrent hypoperfusion, which required further volume expansion. In this setting, the assessment of fluid responsiveness with dynamic tests to guide fluid resuscitation was independently associated with decreased mortality.
Highlights
Resuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable
In this prospective observational study assessing the characteristics of resuscitation of septic patients in Argentina, a low and middle-income country (LMIC), the prevalent use of initial fluid bolus with normal saline and Ringer lactate and the use of norepinephrine as the most frequent vasopressor, reflect current worldwide practices
The assessment of fluid responsiveness with dynamic tests to guide fluid resuscitation was independently associated with decreased mortality
Summary
Resuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. The proper management of these therapeutic tools remains controversial, including the volume and the type of fluid infused, the choice of the vasoconstrictor and the timing of its beginning, as well as the appropriate monitoring for deciding and tracking each intervention. Despite these conflictive standpoints, the resuscitation bundles of the Surviving Sepsis Campaign (SSC) are commonly accepted [1]. SSC recommendations include the infusion of norepinephrine to reach a mean arterial pressure (MAP) of at least 65 mm Hg. If manifestations of hypoperfusion persist after the fluid load, further intravascular volume expansion and eventually vasopressors and inotropes should be considered to optimize cardiovascular performance [1]
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