Influence of arterial pressure on tissue perfusion in septic shock

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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Lactate Clearance Versus Base Deficit Correction in Monotoring of Septic Shock

QJM ◽

10.1093/qjmed/hcab086.015 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Adel Mikhail Fahmy ◽

Ahmed Kamal ◽

Wael Abd Elmonem Mohamed Abdelwahab ◽

Ameer Shokry Ahmed

Keyword(s):

Septic Shock ◽

Clinical Utility ◽

Tissue Perfusion ◽

Lactate Clearance ◽

Serum Lactate ◽

Base Deficit ◽

Mortality And Morbidity ◽

Survivor Group ◽

Prediction Of Mortality ◽

Group I

Abstract Background Tissue perfusion and oxygenation monitoring is the fundamental of management to immediately identify and properly manage (impending) organ dysfunction in septic shock. This is a study of a prospective randomized trial that aims to comparing the prognostic value of lactate clearance versus base deficit correction as an indicator of tissue perfusion in septic shock, trying to prove the superiority of one over the other. Objective To assess the clinical utility of lactate clearance and arterial base deficit correction in predicting mortality in septic shock. Patients and Methods This is a Prospective randomized observational study that was conducted to assess the clinical utility of lactate clearance and arterial base deficit in predicting mortality in septic shock. This study included forty patients who were divided into two equal groups; each of twenty patients, group I (non-survivors), and group II (survivors). Results In this study, the base deficit values revealed statistically notable difference between the two groups at admission, 18 hours, 24 hours and 2 days of admission. The values revealed no notable difference at the 3rd. 4th, and 5th day of admission. At the 6th and 7th day of admission, the base deficit started to increase again in the non-survivor group with statistically notable increase in the values as compared to the survivor group. The cutoff point of base deficit to differentiate between nonsurvivors from survivors was > 11.43 with 62% sensitivity and 100% specificity. In this study, initial serum lactate levels at admission revealed higher accuracy in prediction of mortality as compared with initial base deficit. Conclusion Lactate clearance is a better predictor of mortality and morbidity than base deficit correction.

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Norepinephrine Dosing in Obese and Nonobese Patients With Septic Shock

American Journal of Critical Care ◽

10.4037/ajcc2016667 ◽

2016 ◽

Vol 25 (1) ◽

pp. 27-32 ◽

Cited By ~ 10

Author(s):

John J. Radosevich ◽

Asad E. Patanwala ◽

Brian L. Erstad

Keyword(s):

Body Mass Index ◽

Septic Shock ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Body Mass ◽

Secondary Outcome ◽

Obese Patients ◽

Hemodynamic Status ◽

Norepinephrine Infusion ◽

Nonobese Patients

Background Whether or not norepinephrine infusions for support of hemodynamic status in patients with septic shock should be weight based is unknown. This situation is particularly pertinent in patients who are extremely overweight or obese. Objective To compare dosing requirements and effect of norepinephrine on blood pressure in obese and nonobese patients with septic shock. Methods In a retrospective cohort study, data on adult patients with septic shock who received norepinephrine infusion for support of hemodynamic status in a tertiary care, academic medical center were analyzed. Patients were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). The primary outcome was dosing requirements of norepinephrine at 60 minutes after the start of the infusion. The secondary outcome was the log-transformed ratio of mean arterial pressure to norepinephrine. Results The final cohort consisted of 100 obese and 100 nonobese patients. Mean norepinephrine infusion rate at 60 minutes was 0.09 (SD, 0.08) μg/kg per minute in the obese group and 0.13 (SD, 0.14) μg/kg per minute in the nonobese group (P = .006). The non–weight-based dose at 60 minutes was 9 μg/min in obese patients and 8 μg/min in nonobese patients (P = .72). The log transformed mean arterial pressure to norepinephrine ratio at 60 minutes was 2.5 (SD, 0.9) in obese patients and 2.5 (SD, 0.8) in nonobese patients (P = .54) Conclusions Compared with nonobese patients, obese patients with septic shock require lower weight-based doses of norepinephrine and similar total norepinephrine doses.

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Impact of individualized target mean arterial pressure for septic shock resuscitation on the incidence of acute kidney injury: a retrospective cohort study

Annals of Intensive Care ◽

10.1186/s13613-018-0468-5 ◽

2018 ◽

Vol 8 (1) ◽

Cited By ~ 7

Author(s):

Rajat N. Moman ◽

Stuart A. Ostby ◽

Abbasali Akhoundi ◽

Rahul Kashyap ◽

Kianoush Kashani

Keyword(s):

Septic Shock ◽

Acute Kidney Injury ◽

Cohort Study ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Kidney Injury

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Pharmacological modulation of procoagulant microparticles improves haemodynamic dysfunction during septic shock in rats

Thrombosis and Haemostasis ◽

10.1160/th13-04-0313 ◽

2014 ◽

Vol 111 (01) ◽

pp. 154-164 ◽

Cited By ~ 18

Author(s):

Su-Emmanuelle Degirmenci ◽

Fatiha Zobairi ◽

Asael Berger ◽

Grégory Meyer ◽

Mélanie Burban ◽

...

Keyword(s):

Septic Shock ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Vascular Dysfunction ◽

Vascular Inflammation ◽

Activated Protein C ◽

Resistance Arteries ◽

Pharmacological Modulation ◽

Circulating Microparticles ◽

Haemodynamic Improvement

SummaryCirculating microparticles play a pro-inflammatory and procoagulant detrimental role in the vascular dysfunction of septic shock. It was the objective of this study to investigate mechanisms by which a pharmacological modulation of microparticles could affect vascular dysfunction in a rat model of septic shock. Septic or sham rats were treated by activated protein C (aPC) and resuscitated during 4 hours. Their microparticles were harvested and inoculated to another set of healthy recipient rats. Haemodynamic parameters were monitored, circulating total procoagulant microparticles assessed by prothrombinase assay, and their cell origin characterised. Mesenteric resistance arteries, aorta and heart were harvested for western blotting analysis. We found that a) the amount and phenotype of circulating microparticles were altered in septic rats with an enhanced endothelial, leucocyte and platelet contribution; b) aPC treatment significantly reduced the generation of leucocyte microparticles and norepinephrine requirements to reach the mean arterial pressure target in septic rats; c) Microparticles from untreated septic rats, but not from aPC-treated ones, significantly reduced the healthy recipients’ mean arterial pressure; d) Microparticle thromboxane content and aPC activity were significantly increased in aPC-treated septic rats. In inoculated naïve recipients, microparticles from aPC-treated septic rats prompted reduced NF-κB and cyclooxygenase-2 arterial activation, blunted the generation of pro-inflammatory iNOS and secondarily increased platelet and endothelial microparticles. In conclusion, in this septic shock model, increased circulating levels of procoagulant microparticles led to negative haemodynamic outcomes. Pharmacological treatment by aPC modified the cell origin and levels of circulating microparticles, thereby limiting vascular inflammation and favouring haemodynamic improvement.

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Assessment of clinical parameters and immediate outcome of children with shock in a tertiary care hospital ASRAM, Eluru, Andhra Pradesh, India

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20170714 ◽

2017 ◽

Vol 4 (2) ◽

pp. 586

Author(s):

Arigela Vasundhara ◽

Manas Ranjan Sahoo ◽

Sai Silpa Chowdary

Keyword(s):

Septic Shock ◽

Cardiogenic Shock ◽

Tertiary Care ◽

Hypovolemic Shock ◽

Oxygen Demand ◽

Tissue Perfusion ◽

Multiple Organ ◽

Cellular Damage ◽

Care Hospital ◽

A Prospective Study

Background: Shock is a state of impaired tissue perfusion resulting in an imbalance between oxygen demand and supply. This widespread reduction in effective tissue perfusion causes insufficient or improper delivery and distribution of oxygen and nutrients, the end result of which is an altered cellular and sub cellular function leading to anaerobic metabolism and accumulation of lactic acid, and consequently cellular damage, multiple organ dysfunction and finally cardiovascular collapse.Methods: The present study was conducted in the department of Pediatrics at Alluri Sitarama Raju Academy of Medical Sciences hospital, Eluru, between December 2014 and June 2016. It is a prospective study. Children aged 1 month to 12 years with a clinical diagnosis of shock were included after written consent from parents.Results: Out of 75 children admitted with shock, 69.33% had septic shock, 25.33% had hypovolemic shock, 2.66% had distributive shock, 2.66% cardiogenic shock. Most common age group admitted with shock was 1 month-1 year 38.666%. Among 75 children with shock, 74.66% children survived and 25.33% children died. Mortality rate in cardiogenic shock was 100%, in septic shock 28.84%, in hypovolemic shock 10.52%.Conclusions: Septic shock was the most common type of shock. Most common cause for septic shock was pneumonia. Septic shock has got highest mortality in the present study.Need for inotropes and mechanical ventilaton indicates poor prognosis in shock.

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