Extracellular Water to Total Body Water Ratio in Septic Shock Patients Receiving Protocol-Driven Resuscitation Bundle Therapy.
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ABSTRACT:
SUBMITTER: Chae B
PROVIDER: S-EPMC8269068 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:To evaluate the prognostic value of the time-to-positivity in patients with culture-positive septic shock. Retrospective study using a prospective data registry was performed at the emergency department of a tertiary hospital. Consecutive adult patients with septic shock (N = 2499) were enrolled between 2014 and 2018. Bacteremia was defined using blood cultures, and viral and fungal pathogens were excluded. The primary outcome was the 28-day mortality. In 803 (46.7%) septic shock patients with bacteremia, median TTP was 10.1 h. The most prevalent isolated bacterial pathogens were Escherichia coli (40.8%) and Klebsiella (23.4%). Although the TTP correlated with a higher sequential organ failure assessment score (Spearman's rho = -0.12, p < 0.01), it showed no significant difference between the 28-day survivors and non-survivors (10.2 vs. 9.4 days, p = 0.35). In subgroup analysis of the Escherichia coli and Klebsiella bacteremia cases, a shorter TTP showed prognostic value for predicting the 28-day mortality. The optimal TTP cut-off for Escherichia coli and Klebsiella was 10 h and 8 h, respectively. The prognostic value of the TTP in septic shock patients receiving bundle therapy may be limited and its clinical interpretation should only be made on a pathogen-specific basis.
| S-EPMC8228862 | biostudies-literature
Project description:Background/aimsMaintaining a mean arterial pressure (MAP) ≥ 65 mmHg during septic shock should be based on individual circumstances, but specific target is poorly understood. We investigated associations between time-weighted average (TWA) hemodynamic parameters during the initial resuscitative period and 28-day mortality.MethodsProspectively collected data were obtained from a septic shock patient registry, according to the Sepsis-3 definition, between 2016 and 2018. The TWA systolic blood pressure, diastolic blood pressure, MAP, shock index, and pulse pressure (PP) during the first 6 hours after shock recognition were compared. Multivariable regression analysis was performed to assess associations between these parameters and 28-day mortality.ResultsOf 340 patients with septic shock, 92 died. Only the median TWA PP differed between the survivors and non-survivors (39.2 mmHg vs. 43.0 mmHg, p = 0.020), whereas the other indexes did not. When PP was divided into quartiles (< 34, 34 to 40, 40 to 48, and > 48 mmHg), the mortality rate was higher in the highest quartile (41.2%). Multivariable logistic analysis revealed that PP (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.012 to 1.622; p = 0.039) and PP of > 48 mmHg (OR, 2.25; 95% CI, 1.272 to 3.981; p = 0.005) were independently associated with 28-day mortality.ConclusionPP was significantly associated with 28-day mortality in patients with septic shock and MAP maintained at > 65 mmHg during the first 6 hours. Further studies are warranted to optimize strategies for maintaining PP and MAP at > 65 mmHg during the early resuscitative period.
| S-EPMC8273825 | biostudies-literature
Project description:The pediatric sepsis syndrome remains a common cause of morbidity, mortality, and health care utilization costs worldwide. The initial resuscitation and management of pediatric sepsis is focused on 1) rapid recognition of abnormal tissue perfusion and restoration of adequate cardiovascular function; 2) eradication of the inciting invasive infection, including prompt administration of empiric broad-spectrum antimicrobial medications; and 3) supportive care of organ system dysfunction. Efforts to improve early and aggressive initial resuscitation and ongoing management strategies have improved outcomes in pediatric severe sepsis and septic shock, though many questions still remain as to the optimal therapeutic strategies for many patients. In this article, we will briefly review the definitions, epidemiology, clinical manifestations, and pathophysiology of sepsis and provide an extensive overview of both current and novel therapeutic strategies used to resuscitate and manage pediatric patients with severe sepsis and septic shock.
| S-EPMC4395852 | biostudies-literature
Project description:This study aimed to address the impact of 1-hr bundle achievement on outcomes in septic shock patients. Secondary analysis of multicenter prospectively collected data on septic shock patients who had undergone protocolized resuscitation bundle therapy at emergency departments was conducted. In-hospital mortality according to 1-h bundle achievement was compared using multivariable logistic regression analysis. Patients were also divided into 3 groups according to the time of bundle achievement and outcomes were compared to examine the difference in outcome for each group over time: group 1 (≤1 h reference), group 2 (1-3 h) and group 3 (3-6 h). In total, 1612 patients with septic shock were included. The 1-h bundle was achieved in 461 (28.6%) patients. The group that achieved the 1-h bundle did not show a significant difference in in-hospital mortality compared to the group that did not achieve the 1-h bundle on multivariable logistic regression analysis (<1 vs. >1 h) (odds ratio = 0.74, p = 0.091). However, 3- and 6- h bundle achievements showed significantly lower odds ratios of in-hospital mortality compared to the group that did not achieve the bundle (<3 vs. >3 h, <6 vs. >6 h, odds ratio = 0.604 and 0.458, respectively). There was no significant difference in in-hospital mortality over time for group 2 and 3 compared to that of group 1. One-hour bundle achievement was not associated with improved outcomes in septic shock patients. These data suggest that further investigation into the clinical implications of 1-h bundle achievement in patients with septic shock is warranted.
| S-EPMC7867161 | biostudies-literature
Project description:To stratify hydrocortisone application in septic shock, we investigated an immune sub-study of the CORTICUS trial (Sprung et.al 2008, NEJM) employing machine learning to a panel of 120 parameters of 84 patients (n=24 non-survived, n=60 survived, 28 days) with special emphasis on potentially disadvantageous corticosteroids effects in the context of sepsis including clinical parameters, organ failure scores, lymphocyte counts and plasma protein concentrations of cytokines. We identified the ratio of IFNγ/IL10 in serum before randomization to serve as a valid biomarker for treatment stratification. This was validated with cytokine serum levels of patients (n=49) from the SISPCT study (Bloos et.al 2016, JAMA) and the early arm (n=20) of a hydrocortisone cross-over study (Keh et.al. 2003, Am J Respir Crit Care Med). Integrating these three studies, we yielded an odds ratio of 2.1 and a 95% confidence interval of 0.99-4.52 (P=0.03).In vitro assays revealed IFNγ/Il10 to reflect the burden or severity of systemic infection. Severity was evidencedbyserum levels of these cy-tokines in the patients with septic shock we observed, and also in patients with less severe sepsis. Elucidating the molecular regulation of leukocytes during treatment and placebo by a transcriptomics analysis pointed to induced recovery of immune cell function due to hydro-cortisone treatment, particularly in the predicted hydrocortisone responders. IFNγ/IL10 is a molecular marker with high potential for support of hydrocortisone therapy decision. IFNγ/IL10 is reasonable for this as it reflects the burden and recovery of the immune system which seems to be indicative for corticosteroids treatment of septic shock.
2019-10-01 | GSE106878 | GEO
Project description:BackgroundWe hypothesized that the cardiovascular responses to Surviving Sepsis Guidelines (SSG)-defined resuscitation are predictable based on the cardiovascular state.MethodsFifty-five septic patients treated by SSG were studied before and after volume expansion (VE), and if needed norepinephrine (NE) and dobutamine. We measured mean arterial pressure (MAP), cardiac index (CI), and right atrial pressure (Pra) and calculated pulse pressure and stroke volume variation (PPV and SVV), dynamic arterial elastance (Eadyn), arterial elastance (Ea) and left ventricular (LV) end-systolic elastance (Ees), Ees/Ea (VAC), LV ejection efficiency (LVeff), mean systemic pressure analogue (Pmsa), venous return pressure gradient (Pvr), and cardiac performance (Eh), using standard formulae.ResultsAll patients were hypotensive (MAP 56.8 ± 3.1 mmHg) and tachycardic (113.1 ± 7.5 beat min-1), with increased lactate levels (lactate = 5.0 ± 4.2 mmol L-1) with a worsened VAC. CI was variable but > 2 L min-1 M-2 in 74%. Twenty-eight-day mortality was 48% and associated with admission lactate, blood urea nitrogen (BUN), and creatinine levels but not cardiovascular state. In all patients, both MAP and CI improved following VE, as well as cardiac contractility (Ees). Fluid administration improved Pra, Pmsa, and Pvr in all patients, whereas both HR and Ea decreased after VE, thus normalizing VAC. CI increases were proportional to baseline PPV and SVV. CI increases proportionally decreased PPV and SVV. VE increased MAP > 65 mmHg in 35/55 patients. MAP responders had higher PPV, SVV, and Eadyn than non-responders. NE was given to 20/55 patients in septic shock, but increased MAP > 65 mmHg in only 12. NE increased Ea, Eadyn, Pra, Pmsa, and VAC while decreasing HR, PPV, SVV, and LVeff. MAP responders had higher pre-NE Ees and lower VAC. Dobutamine was given to 6/8 patients who remained hypotensive following NE. It increased Ees, MAP, CI, and LVeff, while decreasing HR, Pra, and VAC. At all times and all steps of the protocol, CI changes were proportional to Pvr changes independent of treatment.ConclusionsThe cardiovascular response to SSG-based resuscitation is highly heterogeneous but predictable from pre-treatment measures of cardiovascular state.
| S-EPMC6466803 | biostudies-literature
Project description:Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.
| S-EPMC9729725 | biostudies-literature
Project description:Septic shock is the leading cause of cardiovascular failure in the intensive care unit (ICU). Cardiac output is a primary component of global oxygen delivery to organs and a sensitive parameter of cardiovascular failure. Any mismatch between oxygen delivery and rapidly varying metabolic demand may result in tissue dysoxia, hence organ dysfunction. Since the intricate alterations of both vascular and cardiac function may rapidly and widely change over time, cardiac output should be measured repeatedly to characterize the type of shock, select the appropriate therapeutic intervention, and evaluate patient's response to therapy. Among the numerous techniques commercially available for measuring cardiac output, transpulmonary thermodilution (TPT) provides a continuous monitoring with external calibration capability, whereas critical care echocardiography (CCE) offers serial hemodynamic assessments. CCE allows early identification of potential sources of inaccuracy of TPT, including right ventricular failure, severe tricuspid or left-sided regurgitations, intracardiac shunt, very low flow states, or dynamic left ventricular outflow tract obstruction. In addition, CCE has the unique advantage of depicting the distinct components generating left ventricular stroke volume (large cavity size vs. preserved contractility), providing information on left ventricular diastolic properties and filling pressures, and assessing pulmonary artery pressure. Since inotropes may have deleterious effects if misused, their initiation should be based on the documentation of a cardiac dysfunction at the origin of the low flow state by CCE. Experts widely advocate using CCE as a first-line modality to initially evaluate the hemodynamic profile associated with shock, as opposed to more invasive techniques. Repeated assessments of both the efficacy (amplitude of the positive response) and tolerance (absence of side-effect) of therapeutic interventions are required to best guide patient management. Overall, TPT allowing continuous tracking of cardiac output variations and CCE appear complementary rather than mutually exclusive in patients with septic shock who require advanced hemodynamic monitoring.
| S-EPMC7333154 | biostudies-literature
Project description:IntroductionRecent evidence suggests that early, aggressive resuscitation in patients with septic shock reduces mortality. The objective of this survey was to characterize reported resuscitation practices of Canadian physicians caring for adult critically ill patients with early septic shock.MethodsA scenario-based self-administered national survey was sent out to Canadian critical care physicians. One hypothetical scenario was developed to obtain information on several aspects of resuscitation in early septic shock, including monitoring and resuscitation end-points, fluid administration, red blood cell transfusion triggers, and use of inotropes. The sampling frame was physician members of Canadian national and provincial critical care societies.ResultsThe survey response rate was 232 out of 355 (65.3%). Medicine was the most common primary specialty (60.0%), most respondents had practiced for 6 to 10 years (30.0%), and 82.0% were male. The following monitoring devices/parameters were reported as used/measured 'often' or 'always' by at least 89% of respondents: oxygen saturation (100%), Foley catheters (100%), arterial blood pressure lines (96.6%), telemetry (94.3%), and central venous pressure (89.2%). Continuous monitoring of central venous oxygen saturation was employed 'often' or 'always' by 9.8% of respondents. The two most commonly cited resuscitation end-points were urine output (96.5%) and blood pressure (91.8%). Over half of respondents used normal saline (84.5%), Ringers lactate (52.2%), and pentastarch (51.3%) 'often' or 'always' for early fluid resuscitation. In contrast, 5% and 25% albumin solutions were cited as used 'often' or 'always' by 3.9% and 1.3% of respondents, respectively. Compared with internists, surgeons and anesthesiologists (odds ratio (95% confidence interval): 9.8 (2.9 to 32.7) and 3.8 (1.7 to 8.7), respectively) reported greater use of Ringers lactate. In the setting of a low central venous oxygen saturation, 52.5% of respondents reported use of inotropic support 'often' or 'always'. Only 7.6% of physicians stated they would use a red blood cell transfusion trigger of 100 g/l to optimize oxygen delivery further.ConclusionOur survey results suggest that there is substantial practice variation in the resuscitation of adult patients with early septic shock. More randomized trials are needed to determine the optimal approach.
| S-EPMC2206518 | biostudies-literature
Project description:BackgroundThe decision of when to stop septic shock resuscitation is a critical but yet a relatively unexplored aspect of care. This is especially relevant since the risks of over-resuscitation with fluid overload or inotropes have been highlighted in recent years. A recent guideline has proposed normalization of central venous oxygen saturation and/or lactate as therapeutic end-points, assuming that these variables are equivalent or interchangeable. However, since the physiological determinants of both are totally different, it is legitimate to challenge the rationale of this proposal. We designed this study to gain more insights into the most appropriate resuscitation goal from a dynamic point of view. Our objective was to compare the normalization rates of these and other potential perfusion-related targets in a cohort of septic shock survivors.MethodsWe designed a prospective, observational clinical study. One hundred and four septic shock patients with hyperlactatemia were included and followed until hospital discharge. The 84 hospital-survivors were kept for final analysis. A multimodal perfusion assessment was performed at baseline, 2, 6, and 24 h of ICU treatment.ResultsSome variables such as central venous oxygen saturation, central venous-arterial pCO2 gradient, and capillary refill time were already normal in more than 70% of survivors at 6 h. Lactate presented a much slower normalization rate decreasing significantly at 6 h compared to that of baseline (4.0 [3.0 to 4.9] vs. 2.7 [2.2 to 3.9] mmol/L; p?<?0.01) but with only 52% of patients achieving normality at 24 h. Sublingual microcirculatory variables exhibited the slowest recovery rate with persistent derangements still present in almost 80% of patients at 24 h.ConclusionsPerfusion-related variables exhibit very different normalization rates in septic shock survivors, most of them exhibiting a biphasic response with an initial rapid improvement, followed by a much slower trend thereafter. This fact should be taken into account to determine the most appropriate criteria to stop resuscitation opportunely and avoid the risk of over-resuscitation.
| S-EPMC4273696 | biostudies-literature