Evolving Management Practices for Early Sepsis-induced Hypoperfusion: A Narrative Review

Munroe, Elizabeth; Hyzy, Robert C.; Semler, Matthew W.; Shankar-Hari, Manu; Young, Paul; Zampieri, Fernando Godinho; Prescott, Hallie C.

doi:10.1164/rccm.202209-1831ci

Cited by 11 publications

(12 citation statements)

References 99 publications

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“…These findings have important implications for informed consent and clinical practice because they highlight the need for widespread use of up-to-date insertion protocols and for clinicians to carefully consider risks and benefits of CVC use, particularly for delivery of medications traditionally thought to require CVC that may be safely administered peripherally with appropriate protocols for a short period of time. 4,5 Studies examining vasopressor dose trajectories and implementation of peripheral vasopressor delivery protocols have shown that approximately 50% of patients requiring vasopressors can avoid need for CVC, 13,25,26 with extravasation of peripheral vasopressors being uncommon, and tissue injury being very rare with monitored peripheral administration. 4,[26][27][28][29] A recent international survey of ICUs in the US, Australia, the UK, Canada, and Saudi Arabia found that norepinephrine was delivered peripherally in 113 of 132 centers (86%), reducing need for CVCs.…”

Section: Main Findings and Potential Implicationsmentioning

confidence: 99%

“…4,5 Studies examining vasopressor dose trajectories and implementation of peripheral vasopressor delivery protocols have shown that approximately 50% of patients requiring vasopressors can avoid need for CVC, 13,25,26 with extravasation of peripheral vasopressors being uncommon, and tissue injury being very rare with monitored peripheral administration. 4,[26][27][28][29] A recent international survey of ICUs in the US, Australia, the UK, Canada, and Saudi Arabia found that norepinephrine was delivered peripherally in 113 of 132 centers (86%), reducing need for CVCs. 30…”

Section: Main Findings and Potential Implicationsmentioning

confidence: 99%

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Complication Rates of Central Venous Catheters

Teja,

Bosch,

Diep

et al. 2024

JAMA Intern Med

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ImportanceCentral venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization decisions.ObjectiveTo summarize current rates of CVC-associated complications.Data SourcesMEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023.Study SelectionThis study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest. Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded.Data Extraction and SynthesisTwo reviewers independently extracted data and assessed risk of bias. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated.Main Outcomes and MeasuresTen prespecified complications associated with CVC placement (placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, and delay of ≥1 hour in vasopressor administration) and 5 prespecified complications associated with CVC use (malfunction, infection, deep vein thrombosis [DVT], thrombophlebitis, and venous stenosis) were assessed. The composite of 4 serious complications (arterial cannulation, pneumothorax, infection, or DVT) after CVC exposure for 3 days was also assessed.ResultsOf 11 722 screened studies, 130 were included in the analyses. Seven of 15 prespecified complications were meta-analyzed. Placement failure occurred at 20.4 (95% CrI, 10.9-34.4) events per 1000 catheters placed. Other rates of CVC placement complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5). Rates of CVC use complications (per 1000 catheter-days) were malfunction (5.5; 95% CrI, 0.6-38), infection (4.8; 95% CrI, 3.4-6.6), and DVT (2.7; 95% CrI, 1.0-6.2). It was estimated that 30.2 (95% CrI, 21.8-43.0) in 1000 patients with a CVC for 3 days would develop 1 or more serious complication (arterial cannulation, pneumothorax, infection, or DVT). Use of ultrasonography was associated with lower rates of arterial puncture (risk ratio [RR], 0.20; 95% CrI, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and pneumothorax (RR, 0.25; 95% CrI, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters).Conclusions and RelevanceApproximately 3% of CVC placements were associated with major complications. Use of ultrasonography guidance may reduce specific risks including arterial puncture and pneumothorax.

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Section: Main Findings and Potential Implicationsmentioning

confidence: 99%

Section: Main Findings and Potential Implicationsmentioning

confidence: 99%

Complication Rates of Central Venous Catheters

Teja,

Bosch,

Diep

et al. 2024

JAMA Intern Med

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“…5,[10][11][12][13] As a result, there has been increasing interest in restricting fluid volumes and starting vasopressors earlier. 14,15 To date, clinical trials comparing fluid-restrictive, early vasopressor treatment vs fluid-liberal strategies in patients with sepsis have yielded neutral results. 16,17 However, these trials have used generalized protocols and broad clinical criteria, rather than personalized approaches, to guide resuscitation.…”

Section: Introductionmentioning

confidence: 99%

Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

Munroe,

Weinstein,

Gershengorn

et al. 2024

JAMA Netw Open

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ImportanceRecent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice.ObjectiveTo understand how clinicians personalize decisions about resuscitation in practice.Design, Setting, and ParticipantsThis survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023.ExposureOnline Qualtrics clinical vignette survey.Main Outcomes and MeasuresUsing multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs.ResultsAmong 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with &gt;15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%).Conclusions and RelevanceThese findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.

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“…The dose (mL/kg) of intravenous crystalloid fluid is based on the average volumes of patients received in clinical trials 3–9 . The optimal dose (mL/kg) of intravenous crystalloid and timing of vasopressor initiation in sepsis‐induced hypoperfusion remain an active area of research 3 . Fluid‐sensitive groups (e.g., heart failure) tend to receive less crystalloid fluid volumes, and resuscitation is frequently delayed 5,10 .…”

Section: Introductionmentioning

confidence: 99%

“…[3][4][5][6][7][8][9] The optimal dose (mL/kg) of intravenous crystalloid and timing of vasopressor initiation in sepsis-induced hypoperfusion remain an active area of research. 3…”

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confidence: 99%

Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis

Fronrath,

Hencken,

Martz

et al. 2023

Pharmacotherapy

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PurposeTo compare guideline‐based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH.MethodsThis was a single center, retrospective cohort study (November 2013‐December 2019) of patients with or without PH hospitalized and diagnosed with sepsis. Patients with sepsis were included into two groups based on a previous PH diagnosis or no PH diagnosis. The primary outcome was incidence of respiratory support escalation within 72 hours from sepsis time zero. Respiratory support escalation included high‐flow nasal cannula, bilevel positive airway pressure, or intubation.ResultsOne‐hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non‐PH patients (32.7% vs 11.5%; p=0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 hours of time zero compared with non‐PH patients (3.8% vs 42.3%; p<0.001). Vasopressor initiation was more common in patients with PH compared with the non‐PH group (40.4% vs 19.2%; p=0.018). PH diagnosis was the only independent predictor of respiratory support escalation.ConclusionsDuring initial sepsis management when compared to patients without PH, patients with PH had increased instances of respiratory support escalation within 72 hours of sepsis time zero despite lower fluid resuscitation volumes.

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Evolving Management Practices for Early Sepsis-induced Hypoperfusion: A Narrative Review

Abstract: Word count: 4,584 (main text); citations 90 (main text) + 4 (figures only). Remaining citations are included in the supplement. Tables/Figures: 4 tables, 2 figures Pages of Text: 20

Cited by 11 publications

References 99 publications

Complication Rates of Central Venous Catheters

Complication Rates of Central Venous Catheters

Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis

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