Goal-directed Therapy In Patients Research Articles

Systematic review of ultrasound-guided fluid resuscitation vs. early goal-directed therapy in patients with septic shock

To systematically review the efficacy of ultrasound-guided fluid resuscitation and early goal-directed therapy (EGDT) in patients with septic shock. Multiple databases including Wanfang, CNKI, SinoMed, VIP, PubMed, Embase, Cochrane Library and Web of Science were searched from initial to August 2019 for randomized controlled trial (RCT) studies about the comparison of ultrasound-guided fluid resuscitation and EGDT on resuscitation effect in patients with septic shock. Language, country and region were unlimited. Data extraction and quality evaluation were carried out by means of independent review and cross check results by two researchers. Finally, only two English RCT studies were enrolled. In the two RCT studies, the ultrasound groups used inferior vena cava collapse index (VCCI) and ultrasound score to guide fluid resuscitation, which resulted in clinical heterogeneity. Because the results could not be pooled, only systematic review, not meta-analysis, could be done. There were measurement bias and selection bias in the two RCT studies, and the literature quality level was B and C respectively. System review results showed that using ultrasound would reduce 7-day mortality (15.0% vs. 35.0%, P = 0.039) and prescribe less of 24-hour intravenous fluids (mL: 900 vs. 1 850, P < 0.01) for patients with septic shock as compared with EGDT. Ultrasound was easy to assess the reactive capacity and cardiac function of patients with septic shock, so as to decrease the incidence of pulmonary edema, which was significantly lower than EGDT (15.0% vs. 37.5%, P = 0.022). However, there was no statistically significant difference in 28-day mortality, duration of mechanical ventilation or length of intensive care unit (ICU) stay between the two groups. The ultrasound-guided fluid resuscitation may be useful and practical for septic shock patients within 7 days after admission as compared with EGDT, but it cannot reduce the 28-day mortality, duration of mechanical ventilation or length of ICU stay.

Goal-directed therapy in patients with early acute kidney injury: a multicenter randomized controlled trial

OBJECTIVES:Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goal-directed therapy conducted during the early stages of acute kidney injury could change the course of the disease.METHODS:This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906.RESULTS:A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p=0.001) compared to the control group (p=0.572). No significant differences in the change in serum creatinine level (p=0.96), persistence of acute kidney injury beyond 72h (p=0.064) or the need for renal replacement therapy (p=0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5).CONCLUSIONS:Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.

Evaluation of the effect of early goal-directed therapy in patients with paraquat poisoning

目的： 回顾分析将尿液百草枯浓度通过血液净化治疗降低至1 mg/L作为百草枯中毒患者的早期目标治疗的治疗效果。 方法： 收集中国医科大学附属第一医院急诊科重症监护室收治的187名百草枯中毒患者的临床资料，根据经过数次血液灌流将患者尿中百草枯浓度降至1 mg/L而停止血液灌流治疗的患者设为目标治疗组，将其他符合纳入标准的患者设为对照组，比较两组患者的72 h内早期病死率、28 d病死率、服毒剂量、灌流次数、灌流前后尿液百草枯浓度等指标；按结束灌流后尿液百草枯浓度是否小于1 mg/L分组，比较两组患者的灌流次数、28 d病死率、72 h病死率； 结果： 目标治疗组60人，72 h早期死亡14人，病死率23.3%，对照组127人，72 h早期死亡31人，病死率24.4%；目标治疗组28 d死亡28人，病死率46.7%，对照组28 d死亡77人，病死率60.6%，差异无统计学意义（P>0.05）；按结束灌流后尿液百草枯浓度是否小于1 mg/L分组比较，尿百草枯浓度<1 mg/L组灌流为（2.67±0.752）次，28 d病死率为50.4%，小于尿百草枯浓度≥1 mg/L组灌流[（3.81±0.753）次，病死率为69.6%]，差异有统计学意义（P<0.05）。 结论： 将百草枯中毒患者的尿百草枯浓度小于1 mg/L，设定为百草枯中毒患者血液灌流治疗早期目标，有降低患者28 d病死率，改善患者预后的趋势。.

Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial.

Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N=23; optimized group, N=20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45% optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95%) versus 10 (40%) in the control group, P<0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2±2.5 versus 6.6±2.2 in the control group, P=0.001), POD2 (8.4±2.6 vs 5.0±2.4 in the control group, P=0.002) and POD 3 (5.2±3.6 and 2.2±1.3 in the control group, P=0.01). There was no significant difference in hospital mortality (13% in the control group and 25% in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.

Current perioperative outcomes for patients with disseminated cancer

BackgroundSurgical morbidity and mortality (M&M) for patients with disseminated malignancy (DMa) is high, and some have questioned the role of surgery. Therefore, we sought to characterize temporal trends in M&M among DMa patients, hypothesizing that surgical intervention would remain prevalent. MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program from 2006–2010. Excluding patients undergoing a primary hepatic operation, we identified 21,755 patients with DMa. Parametric and/or nonparametric statistics and logistic regression were used to evaluate temporal trends and predictors of M&M. ResultsThe prevalence of surgical intervention for DMa declined slightly over the time period, from 1.9%–1.6% of all procedures (P < 0.01). Among DMa patients, the most frequent operations performed were bowel resection, other gastrointestinal procedures, and multivisceral resections, these all showed small statistically significant decreases over time (P < 0.01). The rate of emergency operations also decreased (P < 0.01). In contrast, the rate of preoperative independent functional status rose, whereas the rate of preoperative weight loss and sepsis decreased (P < 0.01). Rates of 30-d morbidity (33.7 versus 26.6%), serious morbidity (19.8 versus 14.2%), and mortality (10.4 versus 9.3%) all decreased over the study period (P < 0.05). Multivariate analysis identified standard predictors (e.g., impaired functional status, preoperative weight loss, preoperative sepsis, and hypoalbuminemia) of worse 30-d M&M. ConclusionsThirty-day morbidity, serious morbidity, and mortality have decreased incrementally for patients with DMa undergoing surgical intervention, but surgical intervention remains prevalent. These data further highlight the importance of careful patient selection and goal-directed therapy in patients with incurable malignancy.

Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury

ObjectiveThe purpose of this study was to assess the effect of goal-directed therapy (GDT), after cardiac surgery, on the incidence of acute kidney injury (AKI). DesignThis is a prospective observational study designed to achieve and maintain maximum stroke volume for 8 hours, in patients after cardiac surgery. SettingThis is a single-center study in a 15-bedded cardiothoracic intensive care unit (ICU). ParticipantsParticipants are patients after coronary artery bypass grafting and/or aortic valve surgery. InterventionsPatients in the GDT group received cardiac output monitoring and fluid challenges targeting an increase in stroke volume by at least 10%. Stroke volume maximization was maintained for a period of 8 hours from admission to the ICU. All other aspects of care were dictated by the clinical team. Patients in the standard therapy (ST) group had intravenous fluids in accordance with the routine practice of the unit. Patients were divided into the GDT and ST group dependant on availability of cardiac output monitors and allocation of nursing staff with training in GDT. Patients’ data were collected prospectively in both groups. Measurements and main resultsOne hundred twenty-three patients received GDT compared with 141 patients in the ST group. Both groups received similar volumes of fluid (GDT, 2905 [1367] mL vs 2704 [1393] mL; P = .09). Incidence of AKI was reduced in the GDT group (n = 8 [6.5%] vs n = 28 [19.9%]; P = .002). The median duration of hospital stay was 6 (4) days in the GDT group vs 7 (8) days in the ST, P = .004. ConclusionPostoperative GDT in patients after cardiac surgery was associated with reduction in the incidence of AKI and a reduction in ICU and hospital duration of stay.

Impact of a goal-directed therapy protocol on postoperative fluid balance in patients undergoing liver transplantation: A retrospective study

ObjectiveLiver transplantation carries major risks during the perioperative period. Few studies focused on the hemodynamics of patients undergoing liver transplantation. The present study was aimed to evaluate the impact of the implementation of a protocol including goal-directed therapy in patients undergoing liver transplantation. Our first goal was to determine its impact on the fluid balance. Secondarily, we evaluated possible improvements in the patient outcomes. Study designA before and after study. Patients and methodsFifty patients undergoing liver transplantation were included during two successive six-month periods. During the first period, the management of the patients was left at the discretion of the senior physicians (control group, n=25). During the second period, the patients were treated according to a predetermined protocol including a specific hemodynamic monitoring (protocol group, n=25). ResultsThe fluid balance was negative in the protocol group and positive in the control group at 24h (−606mL vs. +3445mL, P<0.01) and 48h (−2315mL vs. +1170mL, P<0.01) after liver transplantation. The volume of the crystalloid administration was lower in the protocol group than in the control group (5000mL vs. 8000mL, P<0.01, and 1500mL vs. 6000mL, P<0.01, during surgery and 48h after liver transplantation, respectively). The duration of mechanical ventilation and postoperative ileus were significantly reduced in the protocol group, as compared with the control group, 20h vs. 94h (P<0.01) and 4days vs. 6days (P<0.01), respectively. ConclusionFor patients undergoing liver transplantation, the implementation of a protocol aiming to optimize hemodynamics was associated with reduced fluid balance and decreased requirement for mechanical ventilation and postoperative ileus duration.

In Response

In Response

Effect of ICU interventions on gastrointestinal motility

Early detection of gastrointestinal motility disturbances is a major goal to reduce the incidence of this potentially disastrous event by prophylactic managements and early goal-directed therapy in patients at risk. Gastroparesis frequently results in the inability to feed critically ill patients, aggravating problems such as bacterial translocation and stress-induced intestinal damage. Recently published data have advanced our understanding of the pathophysiologic background of gastroparesis, intestinal stress damage and the effect of early enteral nutrition on gastrointestinal function. New techniques, such as ultrasound and the capsule techniques, might help to assess intestinal function beyond the aspiration of gastric residual volumes and the passage of stool. Therapeutic options such as opioid antagonists and the 5-hydroxytryptamine receptor 4 agonist prucalopride might help to restore intestinal function. Gastrointestinal motility disturbances are caused by a myriad of pathological processes. Moreover, bowel integrity is governed by comorbidity, impaired metabolic function and pharmacological interventions in critically ill patients. Restoring gastrointestinal function, therefore, requires a multimodal approach including prophylactic management strategies and the sensible use of substances with inhibitory effects on intestinal motility.

Evaluation of early goal directed therapy in patients with septic shock

Objective To probe into the treatment effect and the influencing factors of early goal directed therapy(ECDT)in patients with septic shock.Method One hundred and twenty-six patients with septic shock were assigned into the treatment group(n=62)and the control group(n=64).The treatment group was administrated with EGDT,while the control group used conventional therapy for cycle and capacity support.Then sequential organ failure assessment(SOFA)score,APACHE Ⅱ score before treatment and 28-dav-mortality were respectively recorded before the above-mentioned treatment and at 24 hours after the therapy in the two groups.The treatment group was again subdivided into two groups after 6 hours recovery according to the resuscitation results:the sufficiently resuscitated group(n=40)and insufficiently resuscitated group(n=22).Age,genders,correlated haemodynamic parameter,SOFA score,APACHE Ⅱ score and serum lactic acid concentration before resuscitation and 28 d mortality were compared between the two groups.Results There was no significant difference in SOFA score and APACHE Ⅱ score before resuscitation between the treatment group and the control group[SOFA:(12.26±4.37)vs.(12.54±5.21);APACHE Ⅱ:(21.26±6.03)vs.(21.64±6.80)].The two scores at 24 hours after resuscitation[SOFA:(9.18±3.63)vs.(10.62±4.27);APACHEⅡ:(14.92±3.81)vs.(18.21±4.25);P＜0.05]and 28-day-mortality rate(48.39%vs.76.56%,P＜0.05)of the treatment group were significantly lower than those in the control group.There was significant difference in the age,mean arterial pressure (MAP),APACHEⅡ score between the sufficiently restoring group and the insufficiental resuscitated group.The 28-day-mortality of the sufficiently restoring group was significantly lower than that in the insufficiently restoring group.Conclusions EGDT can improve the prognosis in patients with septic shock.Ages,MAP and APPCHE Ⅱ score before resuscitation can be the important factors of EGDT. Key words: Septic shock; Early goal directed therapy SOFA; APACHE Ⅱ; Mortality rate

Early Hemoperfusion With a Polymyxin B Column Improves Gastric Intramucosal pH in Sepsis

This study had two purposes. One was to assess gastric intramucosal pH (pHi) after early goal-directed therapy in patients with sepsis and septic shock. The other was to determine whether direct hemoperfusion with a polymyxin B fiber column (DHP-PMX) could improve the pHi if it remained low after early goal-directed therapy. The subjects were 32 patients who underwent early goal-directed therapy within 6 h of a diagnosis of sepsis or septic shock, and who achieved the following conditions: (i) central venous pressure of 8-12 mm Hg; (ii) mean arterial blood pressure >or=65 mm Hg; (iii) urine output >or=0.5 mL/kg/h; and (iv) mixed venous oxygen saturation >or=70%. A gastric tonometer was inserted in each patient and the pHi was measured before DHP-PMX, and at 24, 48, and 72 h after the start of treatment. The pHi was 7.22 +/- 0.04 immediately before DHP-PMX, 7.28 +/- 0.03 (P < 0.05) at 24 h, 7.32 +/- 0.03 (P < 0.01) at 48 h, and 7.34 +/- 0.02 (P < 0.01) at 72 h, showing a significant increase from 24 h onward compared with the pretreatment value. In patients with sepsis and septic shock, the pHi remained low after early goal-directed therapy; however, it was significantly improved from 24 h after the start of DHP-PMX and was normalized from 48 h onwards. These findings suggest that DHP-PMX improves pHi. Because this was a prospective uncontrolled observational study on a limited number of patients, larger multicenter clinical trials are required to more accurately assess the benefits of DHP-PMX.

Critical care response teams: A step forward in patient care, or a step closer to an emergency physician manpower crisis?

In this issue of CJEM, Upadhye and associates discuss the potential roles for emergency physicians (EPs) in the formation and implementation of critical care response teams (CCRTs) in Canadian hospitals. 1 They suggest that EPs could be valuable members of such teams, even playing the role of team leaders in hospitals where there are inadequate numbers of, or no intensivists. The stated purpose of these teams is to “bring critical care expertise to the bedside of patients outside of ICUs [intensive care units],” thereby impacting the “early care of critically ill or deteriorating patients in order to improve outcomes and potentially reduce the rate of, or shorten the duration of, ICU admissions.” As written, this goal of better patient outcomes seems laudable. Certainly, Rivers and colleagues have demonstrated clear benefit of early, goal-directed therapy for patients in shock.

Early goal-directed therapy in patients with end-stage renal disease

Patients with end-stage renal disease (ESRD) on dialysis are at increased risk for infection, yet few studies in sepsis focus on this population. The current study evaluates early goal-directed therapy (EGDT) for ESRD patients with severe sepsis and septic shock.

Utilisation de la SvO 2

Monitoring of O 2 venous saturation (SvO 2) is easily performed with fiberoptic pulmonary artery catheters and is used in circulatory shock to assess global balance between tissue O 2 supply and O 2 demand (VO 2). Simultaneous measurement of SvO 2 and continuous Cardiac Output (CO), as recently allowed by modified artery catheters, improve SvO 2 interpretation. Indeed, a decrease in SvO 2 may result from a decrease in arterial O 2 saturation, a decrease in hemoglobin or CO or from an increase in VO 2. SvO 2 is a surrogate marker of tissue O 2 extraction (EO 2) with SvO 2 = 1 – EO 2. When EO 2 is altered, as observed in septic shock, SvO 2 does not anymore guarantee correct interpretation of tissue oxygenation. Central venous O 2 saturation (ScvO 2) can be monitored with more easiness and a lower risk than mixed venous O 2 saturation with a good correlation between SvO 2 and ScvO 2. ScvO 2 has been recently used for early goal-directed therapy in patients with severe sepsis in order to improve hemodynamics at the emergency room; this was associated with a 16% reduction ( p = 0.009) in in-hospital mortality.