Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock

Abstract

Introduction: The ultrasound measurement of inferior vena cava (IVC) diameter change during respiratory phase to guide fluid resuscitation in shock patients is widely performed, but the benefit on reducing the mortality of sepsis patients is questionable. The study objective was to evaluate the 30-day mortality rate of patients with sepsis-induced tissue hypoperfusion (SITH) and septic shock (SS) treated with ultrasound-guided fluid management (UGFM) using ultrasonographic change of the IVC diameter during respiration compared with those treated with the usual-care strategy. Methods: This was a randomized controlled trial conducted in an urban, university-affiliated tertiary-care hospital. Adult patients with SITH/SS were randomized to receive treatment with UGFM using respiratory change of the IVC (UGFM strategy) or with the usual-care strategy during the first six hours after emergency department (ED) arrival. We compared the 30-day mortality rate and other clinical outcomes between the two groups. Results: A total of 202 patients were enrolled, 101 in each group (UGFM vs usual-care strategy) for intention-to-treat analysis. There was no significant difference in 30-day overall mortality between the two groups (18.8% and 19.8% in the usual-care and UGFM strategy, respectively; p > 0.05 by log rank test). Neither was there a difference in six-hour lactate clearance, a change in the sequential organ failure assessment score, or length of hospital stay. However, the cumulative fluid amount given in 24 hours was significantly lower in the UGFM arm. Conclusion: In our ED setting, the use of respiratory change of IVC diameter determined by point-of-care ultrasound to guide initial fluid resuscitation in SITH/SS ED patients did not improve the 30-day survival probability or other clinical parameters compared to the usual-care strategy. However, the IVC ultrasound-guided resuscitation was associated with less amount of fluid used. [West J Emerg Med. 2021;22(2):369-378.] tissue hypoperfusion (SITH) and septic shock (SS). 4-7 The initial treatment emphasizes early recognition, prompt administration of antibiotics, and the restoration of hemodynamic status with fluid resuscitation and

A Study to Compare Ultrasound-guided and Clinically-guided Fluid Management in Children with Septic Shock

“…Binomial logistic regression demonstrated a nearly 11-fold reduction in odds ratio for developing fluid overload on day 3. Though there were a few RCTs done on the adult population, 20 – 23 there was only one such study done in the pediatric age group, conducted in Egypt by El-Nawawy et al This particular study serially measured echocardiographic parameters and showed significantly reduced incidence of fluid overload on day 3 of admission (11% vs 44%, p <0.05), similar to our study. 12 Kelm et al revealed that clinical evidence of fluid overload could reach up to 67% in adults with septic shock treated with early goal-directed therapy.…”

“…Comparable to our study cohort, Musikatavorn et al found no difference in ventilator usage at 72 hours in an adult cohort through ultrasound-guided resuscitation (23% vs 30%, p = 0.26). 20 Diuretics usage and AKI were slightly lesser in the USG arm of this study, though it was not statistically significant. Lower cumulative fluid balance in the treatment arm may have been the reason.…”

“…The adult study by Musikatavorn et al also found lesser fluid bolus requirement in the USG-guided arm [79 (51–102) vs 88 (67–123) mL/kg, p = 0.005] at 24 hours. 20 El-Nawawy et al revealed that by the end of the 24 hours, children in the echocardiography group received significantly lower fluid (86 vs 98 mL/kg, p = 0.027), probably due to early and successful titration of fluid volume. 12 The additional help of lung ultrasound may have resulted in an overall lesser fluid bolus in our treatment arm, and a larger proportion of malnourished children in our control arm (though nonsignificant) had led to overall lesser amount of fluid bolus.…”

POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence

“…Only patients with truly undifferentiated shock were included, patients with a high suspicion of acute abdominal aneurysm and a clear mechanism of shock were excluded. Musikatavorn et al [85] found no positive effect on 30-day mortality of patients with sepsis who received an inferior vena cava assessment to guide intravenous fluid management. They were involved in patient management.…”

Đánh Giá Tĩnh Mạch Chủ Dưới Trong Liệu Pháp Dịch Truyền Trong Đơn Vị Hồi Sức Tích Cực: Tiếp Cận Thực Hành

“…Việc sử dụng biến đổi IVC được ưa chuộng trong số các phương pháp động học đánh giá khả năng đáp ứng dịch truyền trong ICU vì nó không xâm lấn, rẻ tiền, dễ dàng và không đòi hỏi kỹ thuật cao [7]. Ngoài ra, đánh giá siêu âm tim bổ sung, cả định lượng và định tính, góp phần đánh giá lâm sàng tổng thể tốt hơn [4].…”