Individualized Hemodynamic Management in Sepsis

Abstract

Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and “restrictive” infusion strategies have been recommended by guidelines over “liberal” approaches for several years. Unfortunately, these “fixed regimen” treatment protocols neglect the patient’s individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.

The Potential Role of Extracorporeal Cytokine Removal in Hemodynamic Stabilization in Hyperinflammatory Shock

“…The different underlying mechanisms of hemodynamic instability also correspond to potential therapeutic options to be targeted, including fluids, inotropes, oxygen supplementation, and vasopressors to increase vascular tone, hence tissue perfusion. The differential diagnosis of hemodynamic instability or shock requires a skilled assessment of the complete clinical picture, which ranges from a simple measurement of vital signs such as heart rate and blood pressure, to complex, advanced hemodynamic monitoring [8]. Only after comprehensive assessment can the clinician determine the underlying pathophysiologic mechanisms and decide upon the best course of action and the right combination of interventions for each individual patient.…”

Precision fluid and vasoactive drug therapy for critically ill patients

“…These concerns have prompted calls for resuscitation based on precision care for individual patients rather than a simple restricted versus liberal dichotomous breakdown. 71 Notably, in a pre-post study of a multi-professional diuretic approach as a component of deresuscitation, the diuresis approach was associated with lower cumulative fluid balance and lower mortality. 72 This focus on optimizing clinical outcomes associated with fluid administration has been termed fluid stewardship, analogous to antimicrobial stewardship when dealing with infectious diseases.…”

“…Although large‐scale randomized investigations have not demonstrated a survival advantage for restricted compared to liberal fluid regimens, there remain concerns regarding excessive fluid administration. These concerns have prompted calls for resuscitation based on precision care for individual patients rather than a simple restricted versus liberal dichotomous breakdown 71 . Notably, in a pre‐post study of a multi‐professional diuretic approach as a component of deresuscitation, the diuresis approach was associated with lower cumulative fluid balance and lower mortality 72 .…”

Utilização Da Linha Arterial Na Monitorização Hemodinâmica Do Doente Crítico

“…A sua utilização pode ser apenas de rotina ou vigilância, onde se procede à avaliação de parâmetros básicos (Ngyuen & Bora, 2022), como a saturação periférica de oxigénio (SpO2), a pressão arterial média (PAM), a eletrocardiografia (ECG) ou o débito urinário (DU), podendo também ser avançada (Ngyuen & Bora, 2022;Quilis et al, 2015;Virág et al, 2021), uma vez que é uma ferramenta muito utilizada nos doentes críticos, já que permite obter informações sobre a sua fisiopatologia e estado hemodinâmico do doente, permitindo ainda, adicionalmente e combinada com outros dispositivos e métodos, como a avaliação gasométrica, analisar a causa, o grau de severidade e as intervenções a implementar (Quilis et al, 2015;Virág et al 2021).…”