Réanimation des patients en début de sepsie sévère: Une étude observationnelle multi-centrique canadienne

Abstract

Background: Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure. Methods:A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure.Results: Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 ± 16.5 yr and 29.0 ± 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval Conclusion:An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.

Renal Outcomes Following Hydroxyethyl Starch Resuscitation: A Meta-Analysis of Randomised Trials

“…Just as persistent and significant pruritus is now recognized as a deleterious consequence of starch administration,49 so too are the potential consequences for the kidney 48,50. Case reports, observational studies and randomized controlled trials involving various patient populations exposed to different HES fluids have inconsistently reported the occurrence of adverse kidney outcomes 4,13,14,16,17,48. Although each HES compound has unique pharmacokinetic properties that depend on the mean molecular weight, the degree of substitution and the C2:C6 ratio,51 it is unclear whether these differences affect clinically important outcomes.…”

“…This population may be especially vulnerable to the effects of resuscitation fluids known to adversely affect kidney function. The evidence about adverse renal outcomes associated with administration of HES from observational studies13-16 and randomized controlled trials7,17-19 is conflicting.…”

Crystalloids and colloids in critical patient resuscitation

“…52 In contraposition to these results, a Canadian study found a lesser incidence of renal failure in patients with sepsis resuscitated with crystalloids plus colloids (HES 200/0.5) than in those who received only crystalloids---though without differences in relation to mortality. 53 More recently, two clinical trials have evaluated HES of lesser molecular weight and lower molar substitution ratio (HES 130/0.4) in the resuscitation of critical patients or patients with severe sepsis and septic shock ( Table 2). The incidence of renal failure and the need for renal replacement therapy were greater in the patients who received HES than in those administered saline solution, though with no differences in mortality after 90 days (primary endpoint).…”

Cristaloides y coloides en la reanimación del paciente crítico

“…Este efecto fue más acusado entre los pacientes que recibieron más de 20 ml/kg, si bien la tasa de fracaso renal y la necesidad de reemplazo renal fue también significativamente superior en los que recibieron < 20 ml/kg al compararlos con el grupo de Ringer Lactato 52 . En contraposición a estos resultados, un estudio canadiense halló una menor tasa de insuficiencia renal en pacientes con sepsis reanimados con cristaloides más coloides (HES 200/0,5) respecto a los que solo recibieron cristaloides, pero sin diferencias en la mortalidad 53 .…”