Monitoring peripheral perfusion in sepsis associated acute kidney injury: Analysis of mortality

Abstract

Microcirculatory disorders have been consistently linked to the pathophysiology of sepsis. One of the major organs affected is the kidneys, resulting in sepsis-associated acute kidney injury (SA-AKI) that correlates considerably with mortality. However, the potential role of clinical assessment of peripheral perfusion as a possible tool for SA-AKI management has not been established. To address this gap, the purpose of this study was to investigate the prevalence of peripheral hypoperfusion in SA-AKI, its association with mortality, and fluid balance. This observational cohort study enrolled consecutive septic patients in the Intensive Care Unit. After fluid resuscitation, peripheral perfusion was evaluated using the capillary filling time (CRT) and peripheral perfusion index (PI) techniques. The AKI was defined based on both serum creatinine and urine output criteria. One hundred and forty-one patients were included, 28 (19%) in the non-SA-AKI group, and 113 (81%) in the SA-AKI group. The study revealed higher peripheral hypoperfusion rates in the SA-AKI group using the CRT (OR 3.6; 95% CI 1.35-9.55; p < 0.05). However, this result lost significance after multivariate adjustment. Perfusion abnormalities in the SA-AKI group diagnosed by both CRT (RR 1.96; 95% CI 1.25-3.08) and PI (RR 1.98; 95% CI 1.37-2.86) methods were associated to higher rates of 28-day mortality (p < 0.01). The PI's temporal analysis showed a high predictive value for death over the first 72 h (p < 0.01). A weak correlation between PI values and the fluid balance was found over the first 24 h (r =-0.20; p < 0.05). In conclusion, peripheral perfusion was not different intrinsically between patients with or without SA-AKI. The presence of peripheral hypoperfusion in the SA-AKI group has appeared to be a prognostic marker for mortality. This evaluation maintained its predictive value over the first 72 hours. The fluid balance possibly negatively influences peripheral perfusion in the SA-AKI.

Role of perfusion index and plethysmography variability index for predicting outcomes in neonatal sepsis

“…However, PI did not show an independent association with in‐hospital mortality on multivariable analysis. Although there are no conclusive studies in neonates, 12–14 some studies in older age groups have found PI to be an independent predictor of mortality in out‐of‐hospital cardiac arrest, 22 sepsis associated acute kidney injury 23 . Lack of an independent association of PI and mortality in our study could be explained by several factors.…”

“…Although there are no conclusive studies in neonates, [12][13][14] some studies in older age groups have found PI to be an independent predictor of mortality in out-of-hospital cardiac arrest, 22 sepsis associated acute kidney injury. 23 Lack TA B L E 2 Perfusion index and plethysmography variability index values in neonates with proven/probable sepsis and no-sepsis. PI values were also significantly different between neonates who developed circulatory insufficiency versus those who did not in the first 36 h of onset of sepsis.…”

Positive fluid balance in sepsis and its effects

“…Significant long mechanical ventilation and weaning failure were detected in patients with high APACHE II scores at the time of intensive care unit admission and it was previously reported to be lower in sepsissurvivors than in sepsis-non-survivors [7][8][9]. Moreover, APACHE, and SOFA scores, within the first 24 hours of intensive care unit admission, were higher in nonsurvivors in a recent study [10]. In order to estimate the mortality rate in patients with sepsis, the APACHE II score is the one that is strongly recommended [11].…”

Correlation Between Mean Arterial Pressure and Capillary Refill Time in Patients with Septic Shock: A Systematic Review and Meta-analysis

“…7,12-20 A complete selection process is depicted in Figure 1. There were 917 patients coming from 8 observational studies 7,12-15,17,18,20 and 2 randomized controlled trials. 16,19 By using an original, adjusted quality tool, we identified 5 studies (542 patients) that scored 4/4 points and were considered “good” in regards to the review's aim (Table 1).…”

“…Additionally, studies with higher norepinephrine doses 16,18‐20 (“higher” doses are defined as those that are above the median of all doses of included studies) and with lower norepinephrine doses were assessed. 7,12,13,16,18 Both subgroup analyses failed to show a statistically significant correlation between CRT and MAP—higher versus lower dose: −0.126 (−0.253 to 0.00430) versus −0.138 (−0.272 to 0.0629) (Supplementary Figure 3).…”