Fluid Resuscitation In Septic Shock Research Articles

Focused Cardiac Ultrasound Findings of Fluid Tolerance and Fluid Resuscitation in Septic Shock.

Compliance with the fluid bonus component of the SEP-1 (severe sepsis and septic shock management) bundle remains poor due to concerns for iatrogenic harm from fluid overload. We sought to assess whether patients who received focused cardiac ultrasound (FCU) and were found to be fluid tolerant (FT) were more likely to receive the recommended 30 mL/kg fluid bolus within 3 hours of sepsis identification. Retrospective, observational cohort study. University-affiliated, tertiary-care hospital in the United States. Emergency department patients presenting with septic shock from 2018 to 2021. The primary exposure was receipt of FCU with identification of fluid tolerance 3 hours from onset of septic shock. None. Two hundred ninety-two of 1,024 patients with septic shock received FCU within 3 hours of sepsis onset. One hundred seventy-seven were determined to be FT. One hundred fifteen patients were determined to have poor fluid tolerance (pFT). FT patients were more likely to reach the recommended 30 mL/kg fluid bolus amount compared with pFT (FT 52.0% vs. pFT 31.3%, risk difference: 20.7%, [95% CI, 9.4-31.9]). Patients who did not receive FCU met the bolus requirement 34.3% of the time. FT patients received more fluid within 3 hours (FT 2,271 mL vs. pFT 1,646 mL, mean difference 625 mL [95% CI, 330-919]). Multivariable logistic regression was used to estimate the association between fluid tolerance FCU findings and compliance with 30 mL/kg bolus after adjustment for patient characteristics and markers of hemodynamic instability. FT with associated with a higher likelihood of meeting bolus requirement (odds ratio 2.17 [1.52-3.12]). Patients found to be FT by FCU were more likely to receive the recommended 30 mL/kg bolus in the SEP-1 bundle when compared with patients found with pFT or those that did not receive FCU. There was no difference between groups in 28-day mortality, vasopressor requirement, or need for mechanical ventilation.

RESTRICTIVE FLUID RESUSCITATION IN SEPTIC SHOCK PATIENTS HAS LOWER MORTALITY AND ORGAN DYSFUNCTION RATES THAN STANDARD THERAPY.

Background : The influence of restrictive fluid resuscitation and the early administration of vasopressors on the clinical outcomes in patients with septic shock are not fully understood. The purpose of this study was to evaluate the effects of restrictive fluid management on mortality and organ dysfunction in patients with septic shock. Methods : This study included consecutive patients with septic shock in need of fluid resuscitation. Based on the fluid management provided in the initial resuscitation phase, a comparison was made between a restrictive group and a standard fluid management group. The primary outcome was in-hospital death, whereas secondary outcomes included organ dysfunction and other adverse events. Results : A total of 238 patients were included in this study. Restrictive fluid management was administered to 59.2% of patients, whereas 40.8% received standard fluid management. Restrictive resuscitation was associated with a lower in-hospital mortality rate (24.8% vs. 52.6%), as well as a shorter median intensive care unit stay (8.0 vs. 11.0 days). The restrictive strategy was associated with a significantly lower prevalence of new-onset acute kidney injury (25.5% vs. 51.5%) and a decrease in the incidence of renal replacement therapy (20.6% vs. 40.2%). The standard group had a higher risk of the need for mechanical ventilation and a significantly lower median number of days without a ventilator than the restrictive group. The median duration of vasopressor-free days in the restrictive group was significantly longer than that in the standard group (25.0 vs. 18.0). The administration rate of inotropes in the restrictive group was significantly lower than that in the standard group. A multivariate logistic regression model showed that restrictive fluid management (odds ratio [OR], 0.312; 95% confidence interval [CI], 0.098-0.994) and vasopressor-free days (OR, 0.807; 95% CI, 0.765-0.851) protect against in-hospital death, whereas Acute Physiology and Chronic Health Evaluation II scores (OR, 1.121; 95% CI, 1.018-1.234) were independent risk factors for in-hospital death. Conclusions : Restrictive fluid resuscitation and early vasopressor protocol in patients with septic shock are associated with better outcomes, indicating that this regimen is feasible and safe.

What is new and different in the 2021 Surviving Sepsis Campaign guidelines.

The Surviving Sepsis Campaign (SSC) International Guidelines for the Management of Sepsis and Septic Shock provide recommendations on the care of hospitalized adult patients with (or at risk for) sepsis. This review discusses what is new or different in the 2021 SSC adult sepsis guidelines compared to 2016. The guidelines include new weak recommendations for use of balanced fluid over saline 0.9%, use of intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement, and peripheral initiation of intravenous vasopressors over delaying initiation in order to obtain central venous access. As before, there is astrong recommendation to initiate antimicrobials within 1 h of sepsis and septic shock, but there are now additional recommendations when the diagnosis is uncertain. The recommendation for initial fluid resuscitation in septic shock of 30 mL/kg crystalloid has been downgraded from strong to weak. Finally, there are 12 new recommendations addressing long-term outcomes from sepsis, including strong recommendations to screen for economic and social support and to make referrals for follow-up where available; use shared decision-making in post-intensive care unit (ICU) and hospital discharge planning; reconcile medications at both ICU and hospital discharge; provide information about sepsis and its sequelae in written and verbal hospital discharge summary; and to provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.

Fluid Resuscitation in Patients Presenting with Sepsis: Current Insights.

Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid. The rationale is to restore circulating fluid volume and optimise stroke volume. It is acknowledged that there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design. In the past decade, evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation. Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation, however, translating these findings to other settings is not possible. This uncertainty has led to variation in practice with some advocating a more conservative fluid strategy coupled with the earlier introduction of vasopressors for haemodynamic support. This question is the subject of several ongoing clinical trials. This article summarises the current state of the evidence for IV fluid resuscitation in septic shock and provides guidance for practitioners in the face of our evolving understanding of this important area.

Comparison between Crystalloid Versus Colloid in Septic Shock

Abstract Background Fluid resuscitation is a critical component to the emergency department (ED) management of patients with sepsis and septic shock. Fluids are administered to patients with sepsis in order to augment cardiac output and improve tissue perfusion and oxygenation. Recent evidence has suggested that the composition of fluids used in sepsis resuscitation may affect patient-centered outcomes. Objective To systematically review the effects of colloids compared with crystalloids in fluid resuscitation for septic shock. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2017. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion In contrast to 0.9% NS, balanced crystalloid solutions contain significantly lower concentrations of chloride. Instead of large amounts of chloride, balanced solutions contain organic anions (i.e., lactate, gluconate, citrate, acetate) which act as physiologic buffers and are rapidly converted to bicarbonate upon administration. In addition, balanced solutions have less of an adverse effect on acid-base equilibrium than 0.9% NS. Balanced solutions also contain varying amounts of cations (i.e., potassium, calcium). Many critically ill patients across the world receive HES solutions for resuscitation. HES solutions are defined by their molecular weight and degree of hydroxyethylation. Recent evidence has demonstrated significant harm with the use of HES solutions. The administration of albumin in the critical patient is not associated to demonstrated adverse effects, though it should be reserved for specific patient groups in which it has been shown to offer benefit.

The effectiveness and feasibility of fluid resuscitation directed by microcirculation monitoring in patients with septic shock: a randomized controlled trial.

This study sought to examine fluid resuscitation in septic shock patients by monitoring their sublabial point of care microcirculation score (POEM) scores (a 3.5 cut-off value was used as the end point of recovery). It also sought to explore the effectiveness and safety of using the POEM score in the fluid resuscitation of septic shock. Patients were randomly allocated to the experimental group or the control group. In the experimental group, a POEM score >3 was used as the end point of fluid resuscitation. In the control group, the doctor just monitor, don't know the data. Patients' heart rates, mean arterial pressure (MAP), Acute Physiology and Chronic Health Disease Classification System II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores, and oxygenation index scores were recorded at 2, 24, 48, 72 h, and on the 7th day after admission to the study. Statistically significant differences between the 2 groups were examined. Thirty-one septic shock patients (comprising 14 patients in the experimental group and 17 patients in the control group) participated in our study. Patients' parameters upon admission to the study, including MAP, blood lactate and APACHE score, SOFA score, POEM score, cardiac output (CO), and central venous pressure (CVP), were recorded at 2 h; There was no significant difference in the APACHE II scores, SOFA scores, and oxygenation index scores at 48 h between the 2 groups; however, at 72 h, the scores of the experimental group were significantly better than those of the control group (P<0.05). Under the guidance of POEM scores, limited fluid resuscitation reduced the intake of fluid any unnecessary amounts of fluids. POEM scores also offered certain protective effects to organ function at the early stage of septic shock, and did not affect patients' circulation. Chinese Clinical Trial Registry (ChiCTR2100049510).

Management of Dengue in Children: An Update

Dengue viruses cause symptomatic infections or asymptomatic seroconversion. Symptomatic dengue infection is a systemic and dynamic disease. It has a wide clinical spectrum that includes both severe and non-severe clinical manifestations. Due to its dynamic nature, the severity of the disease will usually only be apparent around defervescence which often coincides with the onset of the critical phase. For a disease that is complex in its manifestations, management is relatively simple, inexpensive and very effective in saving lives, so long as correct and timely interventions are instituted. The main hemodynamic elements of dengue shock is hypovolemia with decreased vascular capacitance resulting from plasma leakage. Thus, the strategy of aggressive fluid resuscitation of septic shock is not applicable to severe dengue with plasma leakage. Volume replacement in children with dengue shock is a challenging management problem. Aggressive fluid resuscitation may indeed be harmful and should be limited to dengue shock with hypotension. There is a “narrow therapeutic index”; therefore, fluids have to be given timely, at the appropriate volume, rate, of the appropriate type (crystalloids, colloid and/or blood) and for the appropriate duration. Therein lies the challenge to physicians who are not familiar with the important practice of fluid titration through frequent and meticulous assessment. Progression of the disease through the critical phase should be tracked in hours of plasma leakage. Recognizing the cues to discontinue intravenous fluid therapy is just as important as knowing when to start it. Given time and hemodynamic stability, other issues such as thrombocytopenia, coagulopathy and raised liver enzymes will recover spontaneously or with supportive care.&#x0D; DS (Child) H J 2019; 35(2) : 162-178

Evaluation and prognostic value of Cv-aCO2/Da-vO2 in patients with septic shock receiving fluid resuscitation Cv-aCO2/Ca-vO2.

The present study aimed to evaluate the prognostic value of venous-arterial CO2 to arterial-venous O2 (Cv-aCO2/Da-vO2) for patients with septic shock treated by fluid resuscitation. A total of 108 cases who received fluid resuscitation for septic shock at the Intensive Care Unit were retrospectively screened according to the 2012 surviving sepsis campaign guidelines. Patients were divided into 2 groups according to the Cv-aCO2/Da-vO2 ratio at 6 h after fluid resuscitation: Group A, Cv-aCO2/Da-vO2 >1; group B, Cv-aCO2/Da-vO2 ≤1. The resuscitation target rate and transfused resuscitation volume at 6 h exhibited no significant difference between the 2 groups. The cardiac output at 6 and 24 h, as well as the ratio of patients who reached the target of resuscitation within 24 h, the 24-h lactic acid clearance rate and the number of cases with central venous oxygen saturation >70% were significantly decreased in group A compared with those in group B (all P<0.05). The Sequential Organ Failure Assessment score at day 3 in group A was higher compared with that in group B (7.94±1.6 vs. 6.82±1.9; P=0.0013). The mortality rate at day 7 and 35 was higher in group A compared with that in group B (29/52 vs. 6/56, P<0.001; 48/52 vs. 36/56; P<0.001). In conclusion, the Cv-aCO2/Da-vO2 was able to effectively evaluate the success rate of resuscitation and, regarding prognosis, it was able to identify patients at high risk of adverse outcomes.

Prediction of Fluid Responsiveness in Mechanically Ventilated Critically Ill Patients with the Affection of Positive End-expiratory Pressure

Previous studies have shown that in the process of fluid resuscitation of septic shock and other critically ill patients, fluid resuscitation deficiency and excess liquid load are related to poor prognosis in patients [1,2].

Association Between Mortality and Vasoactive Agent Initiation Time During Fluid Resuscitation in Septic Shock

Association Between Mortality and Vasoactive Agent Initiation Time During Fluid Resuscitation in Septic Shock

Fluid resuscitation in pre-hospital management of septic shock

BackgroundSeptic shock is associated with hypovolemia resulting in organs failure and poor prognosis. The first step in hemodynamic resuscitation relies on early fluid expansion. In this study, we describe qualitative and quantitative fluid resuscitation of septic shock initially managed in a pre-hospital setting by a mobile intensive care unit. MethodsPatients with septic shock who received pre-hospital medical care were retrospectively analysed. Qualitative and quantitative fluid resuscitation performed in the pre-hospital setting were analysed. Applying the "grey zone" concept, we define 3 categories of fluid expansion indexed on ideal body weight (IBW): >20ml/kg, 10-20ml/kg and < 10ml/kg. The relationship between the pre-specified categories and mortality at day 28 were analyzed. ResultsNinety-five patients were included. The origin of sepsis was mainly pulmonary (68%). Mortality reached 34%. Pre-hospital fluid expansion was performed using serum saline (98%) with a mean of 1158±559ml. An inversed linear relationship between pre-specified categories and mortality was observed. Using logistic regression model, significant association with mortality remained for fluid expansion indexed on IBW: p=0.02, ORa [CI95] = 0.93 [0.89-0.98]. For fluid expansion indexed on IBW < 10ml/kg, the OR [CI95] was 4.03 [1.78-9.41] (p=0.005) whereas for fluid expansion indexed on IBW > 20ml/kg, the OR [CI95] was 0.30 [0.13-0.66] (p=0.01). DiscussionPre-hospital fluid resuscitation in septic shock is mainly performed using crystalloids with quantitative fluid expansion lower than recommended. Low pre-hospital fluid expansion was associated with increased mortality. Further prospective studies are needed to evaluate the impact of optimized early fluid expansion on mortality in the prehospital management of septic shock.

383 A Novel Technique for Improving Fluid Resuscitation in Septic Shock

Rapid fluid delivery is commonly required in sepsis and other conditions leading to shock and hypotension. Since gravity flow and infusion pumps are unable to deliver a fluid bolus rapidly, pressure bags are commonly used to increase flow rates. Disadvantages of this technique include progressive decrease in flow rate without continuous re-inflation of the bag, difficulty administering accurate doses, particularly with smaller volumes, and the risk of inadvertent air embolism. LifeFlow is an intuitive single-use device that provides rapid and controlled infusion, enabling a health care provider to administer a measured fluid bolus and quickly assess clinical response. This study will compare the LifeFlow to pressure bag in simulated out-of-hospital and hospital settings. Registered nurses and paramedics participated in a simulated septic shock resuscitation and were randomly assigned to administer repeated fluid boluses with the LifeFlow or pressure bag. Training was provided if the participant was not familiar with either method. Participants were given a clinical sepsis scenario that required administration of three, 500 ml boluses (totaling 1500 ml) through a 20G IV catheter into simulated patient. The scenario involved a variety of clinical tasks including a physical exam, vitals assessment, delivery of oxygen via nasal cannula, medication administration, manual charting, and fluid administration. Total scenario time and fluid infusion times were determined by video recording of the scenario. Fluid volume was measured by weight to determine the accuracy of each bolus. Variance was defined as difference between actual and desired fluid bolus volume. Fourteen providers (8 RNs, 6 Paramedics) delivered three 500 ml normal saline boluses during the septic shock scenario. Average time to completion of each bolus was 2.5 minutes for LifeFlow vs. 7.6 minutes for pressure bag. Total infusion time for 1500 ml was almost 3 times as fast for LifeFlow vs pressure bag (7.8 vs 22.8 minutes). Total time to completion of the sepsis scenario was 1.8 times as fast for LifeFlow compared pressure bag (20 vs. 36.3 minutes). Total fluid amount variance, above or below 1500ml, was greater for pressure bag infusion (1500 + 39.1 vs 184 ml, p=0.04). When compared to pressure bag, use of the LifeFlow device resulted in significantly faster time to completion of the septic shock resuscitation scenario. Times to completion of each bolus, and infusion time for the total 1500 ml, were significantly faster. The LifeFlow also reduced variance in the size of fluid bolus administered, indicating that clinicians can more accurately deliver the correct fluid volume and avoid inadvertently providing more fluid than is needed. This technique may offer a faster and more efficient method of fluid resuscitation in sepsis and septic shock.

Effects of fluid restriction on measures of circulatory efficacy in adults with septic shock

The haemodynamic consequences of fluid resuscitation in septic shock have not been fully elucidated. Therefore, we assessed circulatory effects in the first 24 h of restriction of resuscitation fluid as compared to standard care in intensive care unit (ICU) patients with septic shock. This was a post-hoc analysis of the multicentre CLASSIC randomised trial in which patients with septic shock, who had received the initial fluid resuscitation, were randomised to a protocol restricting resuscitation fluid or a standard care protocol in nine ICUs. The highest plasma lactate, highest dose of noradrenaline, and the urinary output were recorded in five time frames in the first 24 h after randomisation. We used multiple linear mixed effects models to compare the two groups. We included all 151 randomised patients; the cumulated fluid resuscitation volume in the first 24 h after randomisation was median 500 ml (Interquartile range (IQR) 0-1500) and 1250 ml (500-2500) in the fluid restriction group and standard care group, respectively. The estimated differences in the fluid restriction group vs. the standard care group were 0.1 mM (95% confidence interval -0.7 to 0.9; P = 0.86) for lactate, 0.01 μg/kg/min (-0.02 to 0.05; P = 0.48) for dose of noradrenaline, and -0.1 ml/kg/h (-0.3 to 0.2; P = 0.70) for urinary output during the first 24 h after randomisation. We observed no indications of worsening of measures of circulatory efficacy in the first 24 h of restriction of resuscitation fluid as compared with standard care in adults with septic shock who had received initial resuscitation.

P.2.d.024 - Adherence to antipsychotic medication in bipolar disorder and schizophrenia patients: a systematic review

Septic shock is associated with hypovolemia resulting in organs failure and poor prognosis. The first step in hemodynamic resuscitation relies on early fluid expansion. In this study, we describe qualitative and quantitative fluid resuscitation of septic shock initially managed in a pre-hospital setting by a mobile intensive care unit.Patients with septic shock who received pre-hospital medical care were retrospectively analysed. Qualitative and quantitative fluid resuscitation performed in the pre-hospital setting were analysed. Applying the "grey zone" concept, we define 3 categories of fluid expansion indexed on ideal body weight (IBW): >20ml/kg, 10-20ml/kg and < 10ml/kg. The relationship between the pre-specified categories and mortality at day 28 were analyzed.Ninety-five patients were included. The origin of sepsis was mainly pulmonary (68%). Mortality reached 34%. Pre-hospital fluid expansion was performed using serum saline (98%) with a mean of 1158±559ml. An inversed linear relationship between pre-specified categories and mortality was observed. Using logistic regression model, significant association with mortality remained for fluid expansion indexed on IBW: p=0.02, ORa [CI95] = 0.93 [0.89-0.98]. For fluid expansion indexed on IBW < 10ml/kg, the OR [CI95] was 4.03 [1.78-9.41] (p=0.005) whereas for fluid expansion indexed on IBW > 20ml/kg, the OR [CI95] was 0.30 [0.13-0.66] (p=0.01).Pre-hospital fluid resuscitation in septic shock is mainly performed using crystalloids with quantitative fluid expansion lower than recommended. Low pre-hospital fluid expansion was associated with increased mortality. Further prospective studies are needed to evaluate the impact of optimized early fluid expansion on mortality in the prehospital management of septic shock.

Fluid resuscitation for septic shock – a 50-year perspective: from dogma to skepticism

Fluid resuscitation for septic shock – a 50-year perspective: from dogma to skepticism

Comparing transesophageal Doppler corrected systolic flow time versus central venous pressure as a guide for fluid resuscitation in septic shock

BackgroundAortic corrected flow time (FTc) is easily measured by Doppler techniques. Recent data using transesophageal Doppler suggest that it may predict fluid responsiveness in critical care. This use of FTc has not previously been evaluated in septic shock, and only one preliminary study has incorporated transcutaneously measured FTc, denoting its importance in prediction of fluid responsiveness in septic patient. Furthermore, no comparison has been made between transesophageal FTc and central venous pressure (CVP).ObjectiveThe aim of our study was to compare the impact of using FTc versus CVP as a guide for fluid resuscitation in septic shock on stroke volume denoting cardiac responsiveness for fluid administration.MethodsThis was a prospective study of 46 consecutive adult septic shock patients (in sinus rhythm). 44 patients were mechanically ventilated, treated with intravenous fluid challenge (500 mL over 15 min), guided with CVP in control group and guided by FTC in Doppler group assessment incorporating transesophageal aortic Doppler (CardioQ®) measurements in a surgical tertiary intensive care unit. Stroke volume (SV), mechanical ventilation days, length of stay and mortality of both groups were recorded.ResultsFourty one patients demonstrated an increase in stroke volume (SV) by more than 10% (fluid responders) while five patients were non responders. There were statistically significant increases in SV after 1 h post resuscitation in the Doppler group as the values were 63.87 ± 25.87 & 81.39 ± 35.02 in the control group and the Doppler group respectively (p value = 0.034). There were statistically significant differences in FTc values after 1 h [397.00 (390.00–404.00) & 362.00 (351.00–377.00)] between non-responders and responders respectively (p value was 0.003) and after 6 h [377.00 (376.00–378.00) & 330.00 (314.00–353.00)] between non-responders and responders respectively (p value was 0.007).ConclusionTransesophageal aortic Doppler is a simple, non-invasive tool of guiding fluid therapy in patients with severe sepsis and septic shock. FTC change was a better predictor of fluid responsiveness than CVP in septic shock. There was higher significant difference in SV after resuscitation when using FTC as guidance.

Progress in fluid resuscitation of septic shock

Septic shock remains a major cause of morbidity and mortality in intensive care unit (ICU). Abundant fluid resuscitation is one of the most common therapies for septic shock patients; but some fundamental questions about its efficacy and safety remain.In this paper, recent insight derived from clinical trials in terms of fluid type, dose, rate and toxicity are discussed. Key words: Septic shock; Fluid resuscitation; Normal saline; Albumin; Hydroxyethyl starches

Adequate fluid resuscitation in septic shock with high catecholamine doses

Appropriate fluid resuscitation is a fundamental aspect for the hemodynamic management of septic shock patients and should ideally be achieved before vasopressors and positive inotropic substances are administered. The development of hemodynamic monitoring has revealed that in some cases patients had been improperly treated with high-dose catecholamines for initially insufficient fluid resuscitation. The aim of this study was to show that in some cases it is possible to actively reduce catecholamines by a volume challenge adapted according to the individual patient needs. In this retrospective observational study 29 patients with septic shock in a surgical intensive care unit (ICU) at a university hospital (17 male, 12 female, mean age 71 ± 10 years) on high-dose catecholamines (median values norepinephrine 0.204µg/kg body weight/min, dobutamine 3.876µg/kg/min and epinephrine 0.025µg/kg/min, ranging up to 0.810µg/kg/min, 22.222µg/kg/min and 0.407µg/kg/min in 28, 20 and 17 patients, respectively) were analyzed. The extremities of the patients were initially cold with a mottled marbled appearance whereas the mean arterial pressure (MAP) was ≥ 65mmHg. The median central venous pressure (CVP) was 17mmHg (range 55-34mmHg) and the mean lactate concentration was 2.78mmol/l (range 0.93-10.67mmol/l). The standard therapy concept consisted of a forced volume challenge combined with active reduction of catecholamines to achieve an adequate fluid loading status, guided by the passive leg raising test (PLR), clinical signs and in 19 cases by hemodynamic monitoring (pulmonary artery catheter Vigilance II(™) n = 10, FloTrac(™), Vigileo(™) n = 9 andPreSep(™) n = 5; Edwards Life Sciences). The forced volume challenge was stopped after clinical improvement with rewarmed extremities, increasing diuresis volumes and lack of improvement by PLR. Catecholamine doses could be significantly reduced in all patients: norepinephrine to 0µg/kg/min, dobutamine to 1.852µg/kg/min and epinephrine to 0µg/kg/min (up to 0.133µg/kg/min, 6.289µg/kg/min and 0.091µg/kg/min, respectively, p < 0.05 Wilcoxon signed rank test). Volume challenge test: + 4,500ml Ringer solution (range 0-24,000ml) and 1,000ml hydroxyethyl starch (range 0-2,500ml) and mean fluid balance + 6,465ml (range + 2,040ml to + 27,255ml). The median weaning time from catecholamineswas 12h (range 4-43h). After treatment all patients showed rewarmed extremities and a decrease in mean lactate levels from 2.78mmol/l (range 0.93-10.67mmol/l) to 2.05mmol/l (range 0.7-5.4mmol/l). The measured hemodynamic constellations showed clear interindividual differences but no cardiac deterioration occurred. The median oxygenation index (paO2/FiO2) showed a statistically insignificant change from 264mmHg (range 75-418mmHg) to 250mmHg (range 120-467mmHg). Of the patients 20 survived and 9 died. It is possible to wean a substantial proportion of septic shock patients from high-dose catecholamines in combination with a needs-adapted forced volume challenge test. The importance of appropriate fluid loading prior to the use of high catecholamine doses should be a main subject of discussion in patients with severe septic shock and was confirmed in this study. This should be oriented to clinical and if possible, hemodynamic parameters and should not be underestimated.

Venous congestion: are we adding insult to kidney injury in sepsis?

In critical illness, septic shock is a contributing factor in nearly half of all cases of acute kidney injury (AKI). Traditional approaches to prevention of organ dysfunction in early sepsis have focused on prevention of hypoperfusion by optimisation of systemic haemodynamics, primarily by fluid resuscitation. Fluid administration to a target central venous pressure (CVP) of 8 to 12 mmHg (12 to 15 mmHg in mechanically ventilated patients) is currently recommended for the early resuscitation of septic shock. However, in the previous issue of Critical Care, Legrand and colleagues report that higher CVP in the first 24 hours of ICU admission with septic shock was associated with increased risk for development or persistence of AKI over the next 5 days. This study highlights a potential association between venous congestion and the development of septic AKI, suggesting that CVP-targeted fluid resuscitation in septic shock might not be beneficial for renal function.

Fluid Resuscitation in Septic Shock

To determine whether progressively increasing fluid balance after initial fluid resuscitation for septic shock is associated with increased mortality. A retrospective review of the use of intravenous fluids in patients with septic shock in a large university affiliated hospital with 56 medical-surgical intensive care unit beds. We analyzed the data of 350 patients with septic shock who were managed according to the Surviving Sepsis Campaign guidelines. Based on net fluid balance at 24 hours, we examined the results of increase in positive fluid balance on the risk of in-hospital mortality. Patients were divided into 4 groups based on the amount of fluid balance by 24 hours, based on 6-L aliquots. At 24 hours, the average fluid balance was +6.5 L. After correcting for age and sequential organ failure assessment score, a more positive fluid balance at 24 hours significantly increased the risk of in-hospital mortality. Using Cox proportional hazard analysis, excess 12-, 18-, and 24-L positive fluid balance had higher risk of mortality than those patients with a neutral to positive 6-L fluid balance (reference group). Adjusted hazard ratios, 1.519 (95% confidence interval [CI], 1.353-1.685), 1.740 (95% CI, 1.467-2.013), and 1.620 (95% CI, 1.197-2.043), respectively, P < .05. In patients with septic shock resuscitated according to current guidelines, a more positive fluid balance at 24 hours is associated with an increase in the risk of mortality. Optimal survival occurred at neutral fluid balance and up to 6-L positive fluid balance at 24 hours after the development of septic shock.