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.

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Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial

Annals of Intensive Care ◽

10.1186/s13613-020-00767-4 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Ricardo Castro ◽

Eduardo Kattan ◽

Giorgio Ferri ◽

Ronald Pairumani ◽

Emilio Daniel Valenzuela ◽

...

Keyword(s):

Septic Shock ◽

Randomized Controlled Trial ◽

Fluid Resuscitation ◽

Controlled Trial ◽

Tissue Perfusion ◽

Capillary Refill Time ◽

Capillary Refill ◽

Randomized Controlled ◽

Microcirculatory Flow ◽

The Impact

Abstract Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)

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Mortality Benefit From the Passive Leg Raise Maneuver in Guiding Resuscitation of Septic Shock Patients: A Systematic Review and Meta-Analysis of Randomized Trials

Journal of Intensive Care Medicine ◽

10.1177/08850666211019713 ◽

2021 ◽

pp. 088506662110197

Author(s):

Moosa Azadian ◽

Suyee Win ◽

Amir Abdipour ◽

Carolyn Krystal Kim ◽

H. Bryant Nguyen

Keyword(s):

Systematic Review ◽

Septic Shock ◽

Fluid Resuscitation ◽

Standard Care ◽

Meta Analysis ◽

Risk Of Bias ◽

Time Interval ◽

Eligibility Criteria ◽

Significant Difference ◽

Passive Leg Raise

Background: Fluid therapy plays a major role in the management of critically ill patients. Yet assessment of intravascular volume in these patients is challenging. Different invasive and non-invasive methods have been used with variable results. The passive leg raise (PLR) maneuver has been recommended by international guidelines as a means to determine appropriate fluid resuscitation. We performed this systematic review and meta-analysis to determine if using this method of volume assessment has an impact on mortality outcome in patients with septic shock. Methods: This study is a systematic review and meta-analysis. We searched available data in the MEDLINE, CINAHL, EMBASE, and CENTRAL databases from inception until October 2020 for prospective, randomized, controlled trials that compared PLR-guided fluid resuscitation to standard care in adult patients with septic shock. Our primary outcome was mortality at the longest duration of follow-up. Results: We screened 1,425 article titles and abstracts. Of the 23 full-text articles reviewed, 5 studies with 462 patients met our eligibility criteria. Odds ratios (ORs) and associated 95% confidence intervals (CIs) for mortality at the longest reported time interval were calculated for each study. Using random effects modeling, the pooled OR (95% CI) for mortality with a PLR-guided resuscitation strategy was 0.82 (0.52 -1.30). The included studies were not blinded and they ranged from having low to high risk of bias using the Cochrane Risk of Bias Tool. Conclusion: Our analysis showed there was no statistically significant difference in mortality among septic shock patients treated with PLR-guided resuscitation vs. those with standard care.

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Sepsis

10.2310/fm.1147 ◽

2020 ◽

Author(s):

Steven P LaRosa ◽

Steven M. Opal

Keyword(s):

Intensive Care Unit ◽

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Organ Dysfunction ◽

Fluid Resuscitation ◽

Multiorgan Failure ◽

Sepsis Management ◽

The Past ◽

Sepsis And Septic Shock

Sepsis, along with the multiorgan failure that often accompanies this condition, is a leading cause of mortality in the intensive care unit. Although modest improvements in the prognosis have been made over the past two decades and promising new therapies continue to be investigated, innovations in the management of septic shock are still required. This chapter discusses the definitions, epidemiology, and pathogenesis (including microbial factors, host-derived mediators, and organ dysfunction) relating to sepsis. Management of severe sepsis and septic shock is also described. This review contains 5 figures, 11 tables, and 99 references. Keywords:Organ dysfunction, sepsis, septic shock, infection, bacteremia, fluid resuscitation, vasopressor

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Sepsis and septic shock

Current Surgical Guidelines ◽

10.1093/med/9780198794769.003.0018 ◽

2018 ◽

pp. 161-168

Author(s):

Abdullah Jibawi ◽

Mohamed Baguneid ◽

Arnab Bhowmick

Keyword(s):

Septic Shock ◽

Mortality Rate ◽

Blood Culture ◽

Antibiotic Therapy ◽

Fluid Resuscitation ◽

High Flow ◽

Empirical Antibiotic Therapy ◽

Goal Directed Therapy ◽

Reduce Mortality Rate ◽

Sepsis And Septic Shock

Sepsis is very common; however, goal–directed therapy significantly helps to reduce mortality rate following septic shock. Sepsis Six should be delivered within one hour of initial diagnosis of sepsis. The sepsis resuscitation and management bundle includes delivery of high flow O2, blood culture, measurement of lactate, empirical antibiotic therapy, and IV fluid resuscitation and renal support.

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FLUID RESUSCITATION IN SEVERE SEPSIS AND SEPTIC SHOCK

Shock ◽

10.1097/01.shk.0000248583.33270.12 ◽

2007 ◽

Vol 27 (5) ◽

pp. 520-526 ◽

Cited By ~ 33

Author(s):

Fuhong Su ◽

Zhen Wang ◽

Ying Cai ◽

Peter Rogiers ◽

Jean-Louis Vincent

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Fluid Resuscitation ◽

Sepsis And Septic Shock

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Assessment and Management of Hypoperfusion in Sepsis and Septic Shock

10.5772/intechopen.98876 ◽

2021 ◽

Author(s):

Zohair Al Aseri

Keyword(s):

Blood Pressure ◽

Septic Shock ◽

Fluid Resuscitation ◽

Early Treatment ◽

Daily Practice ◽

Normal Blood ◽

Organ Perfusion ◽

Emergency Physicians ◽

Normal Blood Pressure ◽

Sepsis And Septic Shock

Diagnosis of organ hypoperfusion in patient with sepsis is not always straightforward which makes septic shock definition, diagnosis, and early treatment are major challenges that emergency physicians and intensivist must deal with in their daily practice. Normal blood pressure does not always mean good organ perfusion, which means patient might develop septic shock, yet they are not hypotensive. There are several indices that could be used in combination to diagnose and manage hypoperfusion in patients with septic shock. Fluid resuscitation and vasopressor administration along with infection sources control are the cornerstones in septic shock management. This chapter will cover indices that can be used to diagnose hypoperfusion, type and amount of fluid and vasopressor that can be used in resuscitating septic shock patients.

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Sepsis

10.2310/im.1147 ◽

2020 ◽

Author(s):

Steven P LaRosa ◽

Steven M. Opal

Keyword(s):

Intensive Care Unit ◽

Septic Shock ◽

Severe Sepsis ◽

Intensive Care ◽

Organ Dysfunction ◽

Fluid Resuscitation ◽

Multiorgan Failure ◽

Sepsis Management ◽

The Past ◽

Sepsis And Septic Shock

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How to choose the therapeutic goals to improve tissue perfusion in septic shock

Einstein (São Paulo) ◽

10.1590/s1679-45082015rw3148 ◽

2015 ◽

Vol 13 (3) ◽

pp. 441-447 ◽

Cited By ~ 4

Author(s):

Murillo Santucci Cesar de Assuncao ◽

Thiago Domingos Corrêa ◽

Bruno de Arruda Bravim ◽

Eliézer Silva

Keyword(s):

Septic Shock ◽

New Technologies ◽

Early Recognition ◽

Tissue Perfusion ◽

Successful Outcome ◽

Tissue Blood Flow ◽

Metabolic Demand ◽

Therapeutic Goals ◽

Sepsis And Septic Shock ◽

The Impact

The early recognition and treatment of severe sepsis and septic shock is the key to a successful outcome. The longer the delay in starting treatment, the worse the prognosis due to persistent tissue hypoperfusion and consequent development and worsening of organ dysfunction. One of the main mechanisms responsible for the development of cellular dysfunction is tissue hypoxia. The adjustments necessary for adequate tissue blood flow and therefore of oxygen supply to metabolic demand according to the assessment of the cardiac index and oxygen extraction rate should be performed during resuscitation period, especially in high complexity patients. New technologies, easily handled at the bedside, and new studies that directly assess the impact of macro-hemodynamic parameter optimization on microcirculation and in the clinical outcome of septic patients, are needed.

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Correlation between Arterial Lactate and Central Venous Lactate in Children with Sepsis

Critical Care Research and Practice ◽

10.1155/2016/7839739 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Jaime Fernández Sarmiento ◽

Paula Araque ◽

María Yepes ◽

Hernando Mulett ◽

Ximena Tovar ◽

...

Keyword(s):

Septic Shock ◽

Blood Sample ◽

Pediatric Patients ◽

Venous Blood ◽

Tissue Perfusion ◽

Central Venous ◽

Important Indicator ◽

Arterial Lactate ◽

Arterial Blood ◽

Sepsis And Septic Shock

Introduction. Lactate is an important indicator of tissue perfusion. The objective of this study is to evaluate if there are significant differences between the arterial and central venous measurement of lactate in pediatric patients with sepsis and/or septic shock.Methods. Longitudinal retrospective observational study. Forty-two patients were included between the age of 1 month and 17 years, with a diagnosis of sepsis and septic shock, who were admitted to the intensive care unit of a university referral hospital. The lactate value obtained from an arterial blood sample and a central venous blood sample drawn simultaneously, and within 24 hours of admission to the unit, was recorded.Results. The median age was 2.3 years (RIC 0,3–15), with a predominance of males (71.4%), having a 2.5 : 1 ratio to females. Most of the patients had septic shock (78.5%) of pulmonary origin (50.0%), followed by those of gastrointestinal origin (26.1%). Using Spearman’s Rho, a 0.872 (p<0.001) correlation was found between arterial and venous lactate, which did not vary when adjusted for age (p<0.05) and the use of vasoactive drugs (p<0.05).Conclusion. There is a good correlation between arterial and venous lactate in pediatric patients with sepsis and septic shock, which is not affected by demographic variables or type of vasoactive support.

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Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock

The Journal of Critical Care Medicine ◽

10.2478/jccm-2019-0025 ◽

2019 ◽

Vol 5 (4) ◽

pp. 130-135

Author(s):

Oana Antal ◽

Elena Ștefănescu ◽

Monica Mleșnițe ◽

Andrei Mihai Bălan ◽

Natalia Hagău

Keyword(s):

Septic Shock ◽

Body Weight ◽

Fluid Resuscitation ◽

Ideal Body Weight ◽

Mortality Rates ◽

Haemodynamic Monitoring ◽

Fluid Load ◽

Ideal Body ◽

Sepsis And Septic Shock ◽

The Ideal

Abstract Introduction Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality. Aim of the study The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW). Methods Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by transpulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours. Results 68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid. Conclusions Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.

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