Comparison of Fluid Compartments and Fluid Responsiveness in Septic and Non-Septic Patients

Sánchez, Manuel Sánchez; Jiménez-Lendínez, M; Cidoncha, Manuel; Asensio, M.J.; Herrerot, E; Collado, A.; Santacruz, M

doi:10.1177/0310057x1103900607

Cited by 55 publications

(42 citation statements)

References 33 publications

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“…In an animal model of sepsis and fluid bolus resuscitation, only 0.6% of the fluid bolus remained in the circulation after 20 min [61]. Similar results have been demonstrated in humans with sepsis, with rapid redistribution of a fluid bolus out of the vascular compartment [62–64]. Clinically this translates into very small and short-lived effects of fluid bolus therapy on haemodynamic parameters such as blood pressure, heart rate, cardiac output and urine output [52, 65].…”

Section: Changing Understanding Of Sepsis and Resuscitationmentioning

confidence: 64%

Fluid resuscitation in human sepsis: Time to rewrite history?

Byrne

Haren

2017

Ann. Intensive Care

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Fluid resuscitation continues to be recommended as the first-line resuscitative therapy for all patients with severe sepsis and septic shock. The current acceptance of the therapy is based in part on long history and familiarity with its use in the resuscitation of other forms of shock, as well as on an incomplete and incorrect understanding of the pathophysiology of sepsis. Recently, the safety of intravenous fluids in patients with sepsis has been called into question with both prospective and observational data suggesting improved outcomes with less fluid or no fluid. The current evidence for the continued use of fluid resuscitation for sepsis remains contentious with no prospective evidence demonstrating benefit to fluid resuscitation as a therapy in isolation. This article reviews the historical and physiological rationale for the introduction of fluid resuscitation as treatment for sepsis and highlights a number of significant concerns based on current experimental and clinical evidence. The research agenda should focus on the development of hyperdynamic animal sepsis models which more closely mimic human sepsis and on experimental and clinical studies designed to evaluate minimal or no fluid strategies in the resuscitation phase of sepsis.

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Section: Changing Understanding Of Sepsis and Resuscitationmentioning

confidence: 64%

Fluid resuscitation in human sepsis: Time to rewrite history?

Byrne

Haren

2017

Ann. Intensive Care

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“…Of note, piperacillin V d was also significantly larger overall. Changes in V d have been observed with other β-lactams in critical illness [26] and likely reflect the substantial fluid shifts frequently encountered [27]. Use of unbound piperacillin concentrations in the PK model may also have contributed to the higher V d observed, although use of free concentrations is essential to describe the pharmacologically active fraction of piperacillin.…”

Section: Discussionmentioning

confidence: 99%

Are standard doses of piperacillin sufficient for critically ill patients with augmented creatinine clearance?

et al. 2015

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IntroductionThe aim of this study was to explore the impact of augmented creatinine clearance and differing minimum inhibitory concentrations (MIC) on piperacillin pharmacokinetic/pharmacodynamic (PK/PD) target attainment (time above MIC (fT>MIC)) in critically ill patients with sepsis receiving intermittent dosing.MethodsTo be eligible for enrolment, critically ill patients with sepsis had to be receiving piperacillin-tazobactam 4.5 g intravenously (IV) by intermittent infusion every 6 hours for presumed or confirmed nosocomial infection without significant renal impairment (defined by a plasma creatinine concentration greater than 171 μmol/L or the need for renal replacement therapy). Over a single dosing interval, blood samples were drawn to determine unbound plasma piperacillin concentrations. Renal function was assessed by measuring creatinine clearance (CLCR). A population PK model was constructed, and the probability of target attainment (PTA) for 50% and 100% fT>MIC was calculated for varying MIC and CLCR values.ResultsIn total, 48 patients provided data. Increasing CLCR values were associated with lower trough plasma piperacillin concentrations (P < 0.01), such that with an MIC of 16 mg/L, 100% fT>MIC would be achieved in only one-third (n = 16) of patients. Mean piperacillin clearance was approximately 1.5-fold higher than in healthy volunteers and correlated with CLCR (r = 0.58, P < 0.01). A reduced PTA for all MIC values, when targeting either 50% or 100% fT>MIC, was noted with increasing CLCR measures.ConclusionsStandard intermittent piperacillin-tazobactam dosing is unlikely to achieve optimal piperacillin exposures in a significant proportion of critically ill patients with sepsis, owing to elevated drug clearance. These data suggest that CLCR can be employed as a useful tool to determine whether piperacillin PK/PD target attainment is likely with a range of MIC values.

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“…However, most of the EVLWI values in excess of 10 mL/kg were observed on the third day. Other factors that may have influenced these findings include lymphatic drainage, which can prevent an initial increase in the EVLWI and allow its elevation when saturated [31,32]. Therefore, EVLW increases to provide volume during resuscitation and may provide useful data for limiting volume input during this stage.…”

Section: Discussionmentioning

confidence: 99%

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study

et al. 2013

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IntroductionThe use of urinary output and vital signs to guide initial burn resuscitation may lead to suboptimal resuscitation. Invasive hemodynamic monitoring may result in over-resuscitation. This study aimed to evaluate the results of a goal-directed burn resuscitation protocol that used standard measures of mean arterial pressure (MAP) and urine output, plus transpulmonary thermodilution (TPTD) and lactate levels to adjust fluid therapy to achieve a minimum level of preload to allow for sufficient vital organ perfusion.MethodsWe conducted a three-year prospective cohort study of 132 consecutive critically burned patients. These patients underwent resuscitation guided by MAP (>65 mmHg), urinary output (0.5 to 1 ml/kg), TPTD and lactate levels. Fluid therapy was adjusted to achieve a cardiac index (CI) >2.5 L/minute/m2 and an intrathoracic blood volume index (ITBVI) >600 ml/m2, and to optimize lactate levels. Statistical analysis was performed using mixed models. We also used Pearson or Spearman methods and the Mann-Whitney U-test.ResultsA total of 98 men and 34 women (mean age, 48 ± 18 years) was studied. The mean total body surface area (TBSA) burned was 35% ± 22%. During the early resuscitation phase, lactate levels were elevated (2.58 ± 2.05 mmol/L) and TPTD showed initial hypovolemia by the CI (2.68 ± 1.06 L/minute/m2) and the ITBVI (709 ± 254 mL/m2). At 24 to 32 hours, the CI and lactic levels were normalized, although the ITBVI remained below the normal range (744 ± 276 ml/m2). The mean fluid rate required to achieve protocol targets in the first 8 hours was 4.05 ml/kg/TBSA burned, which slightly increased in the next 16 hours. Patients with a urine output greater than or less than 0.5 ml/kg/hour did not show differences in heart rate, mean arterial pressure, CI, ITBVI or lactate levels.ConclusionsInitial hypovolemia may be detected by TPTD monitoring during the early resuscitation phase. This hypovolemia might not be reflected by blood pressure and hourly urine output. An adequate CI and tissue perfusion can be achieved with below-normal levels of preload. Early resuscitation guided by lactate levels and below-normal preload volume targets appears safe and avoids unnecessary fluid input.

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Comparison of Fluid Compartments and Fluid Responsiveness in Septic and Non-Septic Patients

Cited by 55 publications

References 33 publications

Fluid resuscitation in human sepsis: Time to rewrite history?

Fluid resuscitation in human sepsis: Time to rewrite history?

Are standard doses of piperacillin sufficient for critically ill patients with augmented creatinine clearance?

A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study

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