Initial resuscitation guided by the Surviving Sepsis Campaign recommendations and early echocardiographic assessment of hemodynamics in intensive care unit septic patients: A pilot study

Center of Clinical Investigation (JBA, PV), Inserm 0801, University of Limoges, Limoges, France.
Critical care medicine (Impact Factor: 6.31). 08/2012; 40(10):2821-7. DOI: 10.1097/CCM.0b013e31825bc565
Source: PubMed


: To compare therapeutic interventions during initial resuscitation derived from echocardiographic assessment of hemodynamics and from the Surviving Sepsis Campaign guidelines in intensive care unit septic patients.
: Prospective, descriptive study in two intensive care units of teaching hospitals.
: The number of ventilated patients with septic shock who were studied was 46. Transesophageal echocardiography was first performed (T1 < 3 hrs after intensive care unit admission) to adapt therapy according to the following predefined hemodynamic profiles: fluid loading (index of collapsibility of the superior vena cava ≥36%), inotropic support (left ventricular fractional area change <45% without relevant index of collapsibility of the superior vena cava), or increased vasopressor support (right ventricular systolic dysfunction, unremarkable transesophageal echocardiography study consistent with sustained vasoplegia). Agreement for treatment decision between transesophageal echocardiography and Surviving Sepsis Campaign guidelines was evaluated. A second transesophageal echocardiography assessment (T2) was performed to validate therapeutic interventions.
: Although transesophageal echocardiography and Surviving Sepsis Campaign approaches were concordant to manage fluid loading in 32 of 46 patients (70%), echocardiography led to the absence of blood volume expansion in the remaining 14 patients who all had a central venous pressure <12mm Hg. Accordingly, the agreement was weak between transesophageal echocardiography and Surviving Sepsis Campaign for the decision of fluid loading (κ: 0.37 [0.16;0.59]). With a cut-off value <8 mm Hg for central venous pressure, κ was 0.33 [-0.03;0.69]. Inotropes were prescribed based on transesophageal echocardiography assessment in 14 patients but would have been decided in only four patients according to Surviving Sepsis Campaign guidelines. As a result, the agreement between the two approaches for the decision of inotropic support was weak (κ: 0.23 [-0.04;0.50]). No right ventricular dysfunction was observed. No patient had anemia and only three patients with transesophageal echocardiography documented left ventricular systolic dysfunction had a central venous oxygen saturation <70%.
: A weak agreement was found in the prescription of fluid loading and inotropic support derived from early transesophageal echocardiography assessment of hemodynamics and Surviving Sepsis Campaign guidelines in patients presenting with septic shock.

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Available from: Cyril Charron, Sep 30, 2015
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    • "By recruiting unstressed volume and inducing venoconstriction, vasopressors can increase central venous pressure, thus disguising hypovolemia [23]. When compared with an echocardiography-based fluid resuscitation protocol, use of a central venous pressure of 8 to 12 mm Hg as a guide to fluid loading resulted in over-resuscitation in a substantial number of patients with sepsis [24]. "
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    ABSTRACT: Definitions of shock and resuscitation endpoints traditionally focus on blood pressures and cardiac output. This carries a high risk of overemphasizing systemic hemodynamics at the cost of tissue perfusion. In line with novel shock definitions and evidence of the lack of a correlation between macro- and microcirculation in shock, we recommend that macrocirculatory resuscitation endpoints, particularly arterial and central venous pressure as well as cardiac output, be reconsidered. In this viewpoint article, we propose a three-step approach of resuscitation endpoints in shock of all origins. This approach targets only a minimum individual and context-sensitive mean arterial blood pressure (for example, 45 to 50 mm Hg) to preserve heart and brain perfusion. Further resuscitation is exclusively guided by endpoints of tissue perfusion irrespectively of the presence of arterial hypotension ('permissive hypotension'). Finally, optimization of individual tissue (for example, renal) perfusion is targeted. Prospective clinical studies are necessary to confirm the postulated benefits of targeting these resuscitation endpoints.
    Critical care (London, England) 10/2013; 17(5):326. DOI:10.1186/cc12727 · 4.48 Impact Factor
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    • "We have some arguments suggesting that such a treatment may improve prognosis. Bouferrache and colleagues reported recently that dobutamine significantly improves the macrocirculation in patients with a low flow state who show a 40% increase in cardiac output despite normal venous oxygen saturation [5]. This improvement was sustained by a 50% increase in LVEF. "
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    ABSTRACT: The meta-analysis of Huang and coworkers failed to find any evidence for a protective effect of a decreased left ventricular (LV) ejection fraction (EF). These results have to be interpreted with caution since in most studies included in the meta-analysis patients with LV systolic dysfunction received inotropic drugs. We have some arguments suggesting that such a treatment may improve macrocirculation and microcirculation and finally prognosis. This paper allows us to clarify the meaning of LV function in septic shock patients. In all experimental models of septic shock using the load-independent parameter of LV systolic function, LV contractility impairment, called septic cardiomyopathy, has been reported to be constant. However, LVEF reflects the coupling between LV contractility and LV afterload. A normal LVEF may be observed when the arterial tone is severely depressed, as in septic shock, despite seriously impaired intrinsic LV contractility. LV systolic function, evaluated using an echocardiograph or another device, is then more a reflection of arterial tone (and its correction) than of intrinsic LV contractility. As a consequence, the incidence of LV systolic dysfunction greatly depends on the time of the evaluation, reflecting the fact that, during resuscitation and treatment, vasoplegia and then LV afterload are corrected, thus unmasking septic cardiomyopathy. With these points in mind, we can revisit the results of Margaret Parker's original study: it is not that the patients with a low EF survived better, but rather that the other patients had an increased mortality due to persistent profound vasoplegia.
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    ABSTRACT: Echocardiography is a versatile, accurate and noninvasive tool suited to examination of shocked patients. Since the 1980s, intensive care practitioners have used ultrasound widely for hemodynamic evaluation and for cardiac anatomy visualization. This article will describe transthoracic and transesophageal echocardiography, their scope, and the classic windows needed to interpret the examination properly. We will also report the main indications of echocardiography and the corresponding parameters. Finally, we will indicate educational programs and define minimum training that enable self-sufficiency.
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