When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring

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• 作者：Glenn Hernandez ; Cecilia Luengo ; Alejandro Bruhn…
• 关键词：Septic shock ; Perfusion ; Resuscitation ; Lactate ; Microcirculation
• 刊名：Annals of Intensive Care
• 出版年：2014
• 出版时间：December 2014
• 年：2014
• 卷：4
• 期：1
• 全文大小：505 KB
• 参考文献：1. Hernandez, G, Bruhn, A, Castro, R, Pedreros, C, Rovegno, M, Kattan, E, Veas, E, Fuentealba, A, Regueira, T, Ruiz, C, Ince, C (2011) Persistent sepsis-induced hypotension without hyperlactatemia: is it really septic shock?. J Crit Care 26: pp. e9-e14
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  15. Knaus, WA, D
• 刊物主题：Intensive / Critical Care Medicine; Emergency Medicine; Anesthesiology;
• 出版者：Springer Paris
• ISSN：2110-5820

文摘

Background The decision of when to stop septic shock resuscitation is a critical but yet a relatively unexplored aspect of care. This is especially relevant since the risks of over-resuscitation with fluid overload or inotropes have been highlighted in recent years. A recent guideline has proposed normalization of central venous oxygen saturation and/or lactate as therapeutic end-points, assuming that these variables are equivalent or interchangeable. However, since the physiological determinants of both are totally different, it is legitimate to challenge the rationale of this proposal. We designed this study to gain more insights into the most appropriate resuscitation goal from a dynamic point of view. Our objective was to compare the normalization rates of these and other potential perfusion-related targets in a cohort of septic shock survivors. Methods We designed a prospective, observational clinical study. One hundred and four septic shock patients with hyperlactatemia were included and followed until hospital discharge. The 84 hospital-survivors were kept for final analysis. A multimodal perfusion assessment was performed at baseline, 2, 6, and 24?h of ICU treatment. Results Some variables such as central venous oxygen saturation, central venous-arterial pCO2 gradient, and capillary refill time were already normal in more than 70% of survivors at 6?h. Lactate presented a much slower normalization rate decreasing significantly at 6?h compared to that of baseline (4.0 [3.0 to 4.9] vs. 2.7 [2.2 to 3.9] mmol/L; p--.01) but with only 52% of patients achieving normality at 24?h. Sublingual microcirculatory variables exhibited the slowest recovery rate with persistent derangements still present in almost 80% of patients at 24?h. Conclusions Perfusion-related variables exhibit very different normalization rates in septic shock survivors, most of them exhibiting a biphasic response with an initial rapid improvement, followed by a much slower trend thereafter. This fact should be taken into account to determine the most appropriate criteria to stop resuscitation opportunely and avoid the risk of over-resuscitation.