Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes

Latham, Heath; Bengtson, Charles; Satterwhite, Lewis; Stites, Mindy; Subramaniam, Dipti P.; Chen, G. John; Simpson, Steven Q.

doi:10.1016/j.jcrc.2017.06.028

Cited by 43 publications

(34 citation statements)

References 27 publications

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“…A strategy of PLRguided resuscitation resulted in significantly lower net fluid balance and reduced renal and respiratory dysfunction at 72 hours. This finding supports the hypothesis that physiologically guided fluid administration in patients with sepsis-associated hypotension and shock is associated with lower fluid balance 23 and improvements in vital end-organ function that are associated causally with sepsis-related death when treatment is coupled to the dynamic fluid management protocol. 9,32 Neither systemic hypotension nor static endovascular pressures in the patient who is vasodilated with sepsis are reliable measures of circulatory effectiveness.…”

Section: Discussionsupporting

confidence: 81%

“…36 FRESH provides a prospective validation of earlier observations that optimal real-time physiologic monitoring and individualized assessment of FR may inform treatment decisions and improve patient outcomes. 17,23 In an earlier single center nonrandomized pre-post intervention assessment, a larger fluid difference (3.59 L) was reported between patients who were treated with PLR-guided strategy and usual care. 23 We found a smaller difference in the mITT analysis of the FRESH study, which may be due to more restrictive fluid management in the usual care arm.…”

Section: Discussionmentioning

confidence: 99%

“…16 In contrast, dynamic measurement of stroke volume (SV) after an IV fluid bolus or passive leg raise (PLR) is a safe and feasible method of rapidly assessing the effectiveness of fluidinduced augmentation of SV and cardiac output (CO). 18,20,[22][23][24] This approach has been associated with reduced length of stay, fewer postoperative complications, and earlier return to regular diet in surgical patients. 25 A retrospective study of real-time, noninvasive bioreactance SV and cardiac performance measurements incorporated PLR to assess FR and guide resuscitation in patients with septic shock in an ICU.…”

mentioning

confidence: 99%

“…25 A retrospective study of real-time, noninvasive bioreactance SV and cardiac performance measurements incorporated PLR to assess FR and guide resuscitation in patients with septic shock in an ICU. 23 Bioreactance analyzes the relative phase shift of an oscillating current passing through the thoracic cavity. [26][27][28][29][30] Dynamic SVguided resuscitation was associated with decreased net fluid balance, reduced ICU length of stay, risk of mechanical ventilation, time on vasopressors, and risk of renal replacement therapy (RRT) initiation.…”

mentioning

confidence: 99%

“…[26][27][28][29][30] Dynamic SVguided resuscitation was associated with decreased net fluid balance, reduced ICU length of stay, risk of mechanical ventilation, time on vasopressors, and risk of renal replacement therapy (RRT) initiation. 23 Given the uncertainty surrounding the benefits of dynamic measure-guided fluid resuscitation, we designed the Fluid Responsiveness Evaluation in Sepsisassociated Hypotension (FRESH) Trial (NCT02837731). The primary objective was to determine if SV-guided dynamic assessment could guide the amount of IV fluid administered to patients with septic shock.…”

mentioning

confidence: 99%

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Fluid Response Evaluation in Sepsis Hypotension and Shock

Douglas

Alapat

Corl

et al. 2020

Chest

191

152

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BACKGROUND: Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. RESEARCH QUESTION: Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes? STUDY DESIGN AND METHODS: We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first. RESULTS: In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (À1.37 L favoring the intervention arm; 0.65 AE 2.85 L intervention arm vs 2.02 AE 3.44 L usual care arm; P ¼ .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P ¼ .04) or mechanical ventilation (17.7% vs 34.1%; P ¼ .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals. INTERPRETATION: Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Fluid Response Evaluation in Sepsis Hypotension and Shock

Douglas

Alapat

Corl

et al. 2020

Chest

191

152

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Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission

Yoo

Zhu

et al. 2021

JAMA Netw Open

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IMPORTANCE Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. OBJECTIVE To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. EXPOSURES Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). MAIN OUTCOMES AND MEASURES The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. RESULTS The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). CONCLUSIONS AND RELEVANCEIn this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.

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Early recognition and management of the seriously ill child

Welsby¹,

Andre²

2023

The Great Ormond Street Hospital Manual of Children and Young People's Nursing Practices

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Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes

Cited by 43 publications

References 27 publications

Fluid Response Evaluation in Sepsis Hypotension and Shock

Fluid Response Evaluation in Sepsis Hypotension and Shock

Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission

Early recognition and management of the seriously ill child

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