Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the “one-size-fits-all” approach

Truong, Tuyet-Trinh; Dunn, Andrew; McCardle, Ken; Glasser, Allison; Huprikar, Shirish; Poor, Hooman; Raucher, B.; Poeran, Jashvant

doi:10.1016/j.jcrc.2019.02.006

Cited by 36 publications

(26 citation statements)

References 20 publications

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“…We observed good compliance with the 3 h-recommendation about administration of 30 mL/kg. In large controlled trials, fluid resuscitation followed the 3-h recommendation [17][18][19], but a recent observational study showed that only 47% of patients with septic shock received the initial fluid load [20]. These figures reflect the inconsistencies in implementation of bundles worldwide, regardless of the association with improved outcomes [2].…”

Section: Discussionmentioning

confidence: 99%

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

Dubin

Loudet

Edul

et al. 2020

Ann. Intensive Care

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Background: Resuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. Our aim was to characterize cardiovascular and fluid management of sepsis in Argentina, a low and middle-income country (LMIC). Furthermore, we sought to test whether the utilization of dynamic tests of fluid responsiveness, as a guide for fluid therapy after initial resuscitation in patients with persistent or recurrent hypoperfusion, was associated with decreased mortality.Methods: Secondary analysis of a national, multicenter prospective cohort study (n = 787) fulfilling Sepsis-3 definitions. Epidemiological characteristics, hemodynamic management data, type of fluids and vasopressors administered, physiological variables denoting hypoperfusion, use of tests of fluid responsiveness, and outcomes, were registered. Independent predictors of mortality were identified with logistic regression analysis.Results: Initially, 584 of 787 patients (74%) had mean arterial pressure (MAP) < 65 mm Hg and/or signs of hypoperfusion and received 30 mL/kg of fluids, mostly normal saline (53%) and Ringer lactate (35%). Vasopressors and/ or inotropes were administered in 514 (65%) patients, mainly norepinephrine (100%) and dobutamine (9%); in 22%, vasopressors were administered before ending the fluid load. After this, 413 patients (53%) presented persisting or recurrent hypotension and/or hypoperfusion, which prompted administration of additional fluid, based on: lactate levels (66%), urine output (62%), heart rate (54%), central venous O 2 saturation (39%), central venous-arterial PCO 2 difference (38%), MAP (31%), dynamic tests of fluid responsiveness (30%), capillary-refill time (28%), mottling (26%), central venous pressure (24%), cardiac index (13%) and/or pulmonary wedge pressure (3%). Independent predictors of mortality were SOFA and Charlson scores, lactate, requirement of mechanical ventilation, and utilization of dynamic tests of fluid responsiveness. © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article' s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article'

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Section: Discussionmentioning

confidence: 99%

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

Dubin

Loudet

Edul

et al. 2020

Ann. Intensive Care

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“…From the commonly accepted SEP-1 bundle, stakeholders selected antibiotics, blood cultures, and lactate measurements as the bundle elements that would be monitored and excluded measures related to the volume of intravenous fluids administered. The decision to exclude fluids was made because of the belief that significant practice variation existed due to patient-specific conditions and comorbidities [ 15 , 16 ] and that alerts suggesting that additional fluids should be administered could be clinically inappropriate.…”

Section: Resultsmentioning

confidence: 99%

Design and Implementation of a Real-time Monitoring Platform for Optimal Sepsis Care in an Emergency Department: Observational Cohort Study

Lee¹,

Aaronson²,

Hibbert³

et al. 2021

J Med Internet Res

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Background Sepsis is the leading cause of death in US hospitals. Compliance with bundled care, specifically serial lactates, blood cultures, and antibiotics, improves outcomes but is often delayed or missed altogether in a busy practice environment. Objective This study aims to design, implement, and validate a novel monitoring and alerting platform that provides real-time feedback to frontline emergency department (ED) providers regarding adherence to bundled care. Methods This single-center, prospective, observational study was conducted in three phases: the design and technical development phase to build an initial version of the platform; the pilot phase to test and refine the platform in the clinical setting; and the postpilot rollout phase to fully implement the study intervention. Results During the design and technical development, study team members and stakeholders identified the criteria for patient inclusion, selected bundle measures from the Center for Medicare and Medicaid Sepsis Core Measure for alerting, and defined alert thresholds, message content, delivery mechanisms, and recipients. Additional refinements were made based on 70 provider survey results during the pilot phase, including removing alerts for vasopressor initiation and modifying text in the pages to facilitate patient identification. During the 48 days of the postpilot rollout phase, 15,770 ED encounters were tracked and 711 patient encounters were included in the active monitoring cohort. In total, 634 pages were sent at a rate of 0.98 per attending physician shift. Overall, 38.3% (272/711) patients had at least one page. The missing bundle elements that triggered alerts included: antibiotics 41.6% (136/327), repeat lactate 32.4% (106/327), blood cultures 20.8% (68/327), and initial lactate 5.2% (17/327). Of the missing Sepsis Core Measures elements for which a page was sent, 38.2% (125/327) were successfully completed on time. Conclusions A real-time sepsis care monitoring and alerting platform was created for the ED environment. The high proportion of patients with at least one alert suggested the significant potential for such a platform to improve care, whereas the overall number of alerts per clinician suggested a low risk of alarm fatigue. The study intervention warrants a more rigorous evaluation to ensure that the added alerts lead to better outcomes for patients with sepsis.

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“…Suggesting neutral outcomes, a study of 1027 patients with septic shock recently found failure to administer an initial 30 mL/kg fluid bolus did not affect mortality (OR: 1.03; 95% CI: 0.76-1.41). 82 This finding, along with concern for excess fluids increasing ICU mortality, continued to rebut the “one size fits all” approach of fluid resuscitation, but no subgroups of HF were analyzed. Seymour et al observed an increase in mortality for each hour delay of a 3-hour sepsis bundle among HF patients, but this outcome was not observed for each hour delay in fluid bolus administration.…”

Section: Methodsmentioning

confidence: 99%

“…93 Unsurprisingly, failure to reach fluid resuscitation of 30 mL/kg has been observed in patients with HF. 82,89 –91 Kuttab et al found decreased odds of reaching a goal of 30 mL/kg of fluid by 3 hours in patients with HF (14.3 mL/kg in patients with HF vs 30 mL/kg in patients without HF; OR: 0.42 [0.29-0.60]). 90 Leisman et al associated HF with longer times to initiation of fluids (β = 20 minutes; CI, 14 to 25; P < .001) and a lower volume of fluid resuscitation (β = −14 mL/kg; CI, −17 to −12; P < .001).…”

Section: Methodsmentioning

confidence: 99%

“…Achieving 30 mL/kg of fluid by 3 hours is a reasonable goal in sepsis with preexisting HF, as it has improved outcomes in patients with sepsis. 82 However, caution is advised in patients with advanced HF, and research on these specific subgroups (eg, EF < 15%) is warranted due to the lack of conclusive evidence and risk of disproportionate consequences from volume resuscitation. After acute fluid resuscitation, a conservative fluid strategy is reasonable in HF patients, but more research is needed in protocolizing a conservative fluid strategy.…”

Section: Methodsmentioning

confidence: 99%

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Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

Jones

Smith

Tuyl

et al. 2020

J Intensive Care Med

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Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.

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Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the “one-size-fits-all” approach

Cited by 36 publications

References 20 publications

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

Design and Implementation of a Real-time Monitoring Platform for Optimal Sepsis Care in an Emergency Department: Observational Cohort Study

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

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