Over recent decades many recommendations for the management of patients with sepsis and septic shock have been published, mainly as the Surviving Sepsis Campaign (SSC) guidelines. In order to use these recommendations at the bedside one must fully understand their limitations, especially with regard to preload assessment, fluid responsiveness and cardiac output. In this review we will discuss the evidence behind the bundles presented by the Surviving Sepsis Campaign and will try to explain why some recommendations may need to be updated. Barometric preload indicators, such as central venous pressure (CVP) or pulmonary artery occlusion pressure, can be persistently low or erroneously increased, as is the case in situations of increased intrathoracic pressure, as seen with the application of high positive end-expiratory pressure, or in situations with increased intra-abdominal pressure. Chasing a CVP of 8 to 12 mm Hg may lead to under-resuscitation in these situations. On the other hand, a low CVP does not always correspond to fluid responsiveness and may lead to over-resuscitation and all the deleterious effects on end-organ function associated with fluid overload. We will suggest the introduction of new variables and more dynamic measurements. During the initial resuscitation phase, it is equally important to assess fluid responsiveness, either with a passive leg raising manoeuvre or an end-expiratory occlusion test. The use of functional hemodynamics with stroke volume variation or pulse pressure variation may further help to identify patients who will respond to fluid administration or not. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock, one should consider (active) de-resuscitation guided by extravascular lung water index measurements.

This survey showed that although most responding clinicians claim to be familiar with IAH and ACS, knowledge of published consensus definitions, measurement techniques, and clinical management are inadequate.

Background: Burn patients are at high risk for secondary intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) due to capillary leak and large volume fluid resuscitation. Our objective was to examine the incidence the incidence of IAH and ACS and their relation to outcome in mechanically ventilated (MV) burn patients. Methods: This observational study included all MV burn patients admitted between April 2007 and December 2009. Various physiological parameters, intra-abdominal pressure (IAP) measurements and severity scoring indices were recorded on admission and/or each day in ICU. Transpulmonary thermodilution parameters were also obtained in 23 patients. The mean and maximum IAP during admission was calculated. The primary endpoint was ICU (burn unit) mortality. Results: Fifty-six patients were included. The average Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores were 43.4 ± 15.1 and 6.4 ± 3.4, respectively. The average total body surface area (TBSA) affected by burns was 24.9% ( ± 24.9), with 33 patients suffering inhalational injuries. Forty-four (78.6%) patients developed IAH and 16 (28.6%) suffered ACS. Patients with ACS had higher TBSAs burned (35.8 ± 30 vs 20.6 ± 21.4%, P = 0.04) and higher cumulative fluid balances after 48 hours (13.6 ± 16L vs 7.6 ± 4.1L, P = 0.03). The TBSA burned correlated well with the mean IAP (R = 0.34, P = 0.01). Mortality was notably high (26.8%) and significantly higher in patients with IAH (34.1%, P = 0.014) and ACS (62.5%, P < 0.0001). Most patients received more fluids than calculated by the Parkland Consensus Formula while, interestingly, non-survivors received less. However, when patients with pure inhalation injury were excluded there were no differences. Non-surgical interventions (n = 24) were successful in removing body fluids and were related to a significant decrease in IAP, central venous pressure (CVP) and an improvement in oxygenation and urine output. Non-resolution of IAH was associated with a significantly worse outcome (P < 0.0001). Conclusion: Based on our preliminary results we conclude that IAH and ACS have a relatively high incidence in MV burn patients compared to other groups of critically ill patients. The percentage of TBSA burned correlates with the mean IAP. The combination of high CLI, positive (daily and cumulative) fluid balance, high IAP, high EVLWI and low APP suggest a poor outcome. Non-surgical interventions appear to improve end-organ function. Non-resolution of IAH is related to a worse outcome.

An improved understanding of burn shock pathophysiology and subsequent development of fluid resuscitation strategies has led to dramatic outcome improvements in burn care during the 20th century. While organ hypoperfusion caused by inadequate resuscitation has become rare in clinical practice, there is growing concern that increased morbidity and mortality related to over-resuscitation is occurring more frequently in burn care. In order to reduce complications related to this concept of "fluid creep", such as respiratory failure and compartment syndromes, efforts should be made to resuscitate with the least amount of fluid in order to provide adequate organ perfusion. In this first part of a concise review, historic and current evidence regarding the available fluids is discussed, as well as some adjunctive treatments modulating the inflammatory response. In the second part, special reference will be made to the role of abdominal hypertension in burn care and the endpoints used to guide fluid resuscitation will be discussed. Finally, as urine output has been recognized as a poor resuscitation target, a resuscitation protocol is suggested in part two which includes new targets and endpoints that can be obtained with modern, less invasive hemodynamic monitoring devices.

Background Sepsis is a potentially life-threatening condition characterized by a deregulated body’s response to infection causing injury to its own tissues and organs. Sepsis is the primary cause of death from infection. If not recognized and treated timely, it can evolve within minutes/hours to septic shock. Sepsis is associated with an acute deficiency of Vitamin C. Despite the proof-of-concept of the benefit of administering Vitamin C in patients with sepsis or septic shock, Vitamin C administration is not yet current practice. Objective To investigate the potential benefit of early administration of high doses of Vitamin C in addition to standard of care in patients with sepsis or septic shock. Methods This phase 3b multi-center trial is conducted in 8 hospitals throughout Belgium. In total 300 patients will be randomly assigned to one of two groups in a 1:1 allocation ratio. The intervention group will receive 1.5 g Vitamin C 4 times a day during 4 days, started within 6 hours after admission. The primary outcome is the average post-baseline patient SOFA score. Conclusion This trial will determine whether the early administration of Vitamin C in patients with sepsis or septic shock can lead to a more rapid solution of shock and less deterioration from sepsis to septic shock, hereby reducing morbidity and mortality as well as the length of hospital stay in this patient population. Trial registration The C-EASIE trial has been registered on the ClinicalTrials.gov website on 10 February 2021 with registration number NCT04747795. Trial Sponsor UZ Leuven (sponsor’s reference S63213)