Abstract
ObjectiveEchocardiography is often used to guide septic shock resuscitation, but without evidence for efficacy. We conducted an intensive care unit (ICU)-based randomized controlled feasibility trial comparing echocardiography-guided septic shock resuscitation (ECHO) with early goal-directed therapy (EGDT).MethodsWe conducted a single center, randomized controlled feasibility trial at a 468-bed academic tertiary care center in Utah, USA. Adult patients with early septic shock were assessed and treated at defined intervals over 6 h using an echocardiogram-guided resuscitation protocol or a slightly modified EGDT protocol. Feasibility outcomes were fluid balance, dobutamine administration, and time to lactate clearance. The primary clinical outcome was changed in sequential organ failure assessment score at 48 h (delta SOFA). Secondary outcomes included inpatient mortality, ICU-free days, and ventilator-free days at 28 days.ResultsThirty participants, 15 per group, were randomized and completed the study. Baseline characteristics were similar between groups. Patients were randomized within a median of 3.5 h of meeting inclusion criteria but had received a median of 3 L crystalloid by then. Fluid administration during the study protocol was similar in both groups (median ECHO 0 vs EGDT 1 L, p = 0.61). Eleven (73%) subjects in each arm received ≤ 1 L fluid. Dobutamine administration was also similar (20% vs 13%, p > 0.99). Twenty-one patients (70%) had lactate clearance prior to the first study assessment. No difference was observed in delta SOFA (median − 4 for ECHO vs − 6 for EGDT, p = 0.10) nor mortality (33% ECHO vs 20% EGDT, p = 0.68).ConclusionsNo experimental separation was observed in this randomized, controlled feasibility trial. Early lactate clearance, coupled with substantial fluid administration before randomization, suggests that patients were already resuscitated before arrival in the ICU. Future trials of echocardiogram-guided sepsis resuscitation will likely need to enroll in the emergency department.Trial registrationThis study was retrospectively registered at clinicaltrials.gov (identifier NCT02354742, title Echo vs EGDT in severe sepsis and septic shock) on February 3, 2015. Registration was completed before review or analysis of any data.
Highlights
Septic shock is a common cause of death, with current mortality rates between 20 and 40% in resource-rich settings [1,2,3,4]
Four patients did not meet septic shock criteria until after their intensive care unit (ICU) admission. Patients in both arms received a median of 3 L crystalloid prior to randomization. This was equivalent to a median of 33 mL/kg in the echocardiography-guided septic shock resuscitation (ECHO) group and 38 mL/kg in the early goal-directed therapy (EGDT) arm (p = 0.53, 35 mL/ kg for the overall cohort)
To our knowledge, no prior randomized controlled trials have investigated the use of echocardiogram-guided resuscitation of septic shock in adults
Summary
Septic shock is a common cause of death, with current mortality rates between 20 and 40% in resource-rich settings [1,2,3,4]. Beyond timely antibiotics and control of the source of infection, the early resuscitation of septic shock focuses on optimizing the delivery of oxygen to vital organs using intravenous (IV) fluid administration, vasopressor infusions, and, occasionally, inotrope infusions [5]. Fluid administration improves organ perfusion up to a point. Excess IV fluid administration may be associated with increased organ dysfunction and mortality [6,7,8]. In resource-limited settings, the association between higher volumes of fluid administration and increased mortality appears to be causal [9, 10]. The optimal strategy for the administration of fluid in septic shock in resource-rich settings is unknown
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