When to stop septic shock resuscitation: clues from a dynamic perfusion monitoringReport as inadecuate




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Annals of Intensive Care

, 4:30

First Online: 11 October 2014Received: 10 April 2014Accepted: 06 August 2014

Abstract

BackgroundThe 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.

MethodsWe 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.

ResultsSome 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 < 0.01 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.

ConclusionsPerfusion-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.

KeywordsSeptic shock Perfusion Resuscitation Lactate Microcirculation AbbreviationsAPACHEAcute physiology and chronic health evaluation

CVPcentral venous pressure

CRTcapillary refill time

DO2oxygen transport

IAPintra-abdominal pressure

ICUintensive care unit

MAPmean arterial pressure

MFImicrocirculatory flow index

NEnorepinephrine

NIRSnear-infrared spectroscopy

Pv-aCO2mixed venous to arterial pCO2 gradient

PPVproportion of perfused vessels

PVDperfused vascular density

SOFASequential Organ Failure Assessment

ScvO2central venous oxygen saturation

StO2tissue oxygen saturation

SvO2mixed venous oxygen saturation

VOTvascular occlusion test

Electronic supplementary materialThe online version of this article doi:10.1186-s13613-014-0030-z contains supplementary material, which is available to authorized users.

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