Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study

Chen, Jen-Ting; Roberts, Russel J.; Fazzari, Melissa; Kashani, Kianoush; Qadir, Nida; Cairns, Charles B.; Mathews, Kusum S.; Park, Pauline; Khan, Akram; Gilmore, James F.; Brown, Anne Rain; Handzel, Michele; Chang, Alfredo Lee; Duggal, Abhijit; Lanspa, Michael J.; Herbert, James T.; Martinez, Anthony; Tonna, Joseph E.; Ammar, Mahmoud; Hammond, Drayton A.; Nazer, Lama; Heavner, Mojdeh; Pender, Erin; Chambers, Lauren; Kenes, Michael; Kaufman, David A.; Downey, April; Brown, Brent; Chaykosky, Darlene; Wolff, Armand; Smith, Michael; Nault, Katie; Sevransky, Jonathan; Gong, Michelle N.

doi:10.1097/ccm.0000000000004429

Cited by 9 publications

(6 citation statements)

References 27 publications

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“…Observation of variation in fluids administered and characterization of vasopressor requirements in shock (VOLUME-CHASERS) was a multicenter prospective cohort study conducted through the Discovery Network, the Society of Critical Care Medicine’s research network (ClinicalTrials.gov NCT03190408) ( 9 ). The VOLUME-CHASERS study included adult patients with shock intended for ICU admissions between September 1, 2017, and February 1, 2018.…”

Section: Methodsmentioning

confidence: 99%

“…The use of physiologic assessment in the 24 hours following hypotension onset, total fluid administered, vasopressors, and mechanical ventilator was included in the model. We included the use of dynamic (stroke volume variation, pulse pressure variation), static (central venous pressure, pulmonary arterial occlusion pressure), and point-of-care ultrasound to determine fluid responsiveness as a physiologic assessment ( 9 ). We tested for interactions between SSC compliance, fluid, and vasopressor administration 24 hours following sepsis-induced hypotension onset.…”

Section: Methodsmentioning

confidence: 99%

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Resuscitation in the First 3 Hours of Sepsis-Induced Hypotension Varies by Patient and Hospital Factors

Chen

Roberts

Sevransky³

et al. 2023

Critical Care Explorations

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IMPORTANCE: Patient and hospital factors affects how we resuscitate patients in the first 3 hours of sepsis-induced hypotension. OBJECTIVES: To evaluate variability in compliance to the 3-hour surviving sepsis campaign (SSC) bundle and explore the association of early compliance with subsequent shock and in-hospital mortality. DESIGN: Retrospective cohort study between September 2017 and February 2018. SETTING: Thirty-four academic medical centers. PARTICIPANTS: A subgroup sepsis-induced hypotensive patients from a larger shock cohort study. MAIN OUTCOMES AND MEASURES: Compliance to SSC bundle that was defined as receiving appropriate antibiotics, 30 mL/kg of crystalloid or initiation of vasopressors, and lactate, obtained in the first 3 hours following sepsis-induced hypotension. RESULTS: We included 977 patients with septic-induced hypotension. Bundle compliance was 43.8%, with the lowest compliance to fluid or vasopressor components (56%). Patients with high Sequential Organ Failure Assessment scores and physiologic assessments were more likely to receive compliant care, as were patients with sepsis-induced hypotension onset in the emergency department (ED) or admitted to mixed medical-surgical ICUs. SSC compliance was not associated with in-hospital mortality (adjusted odds ratio, 0.72; 95% CI, 0.47–1.10). The site-to-site variability contributed to SSC compliance (intraclass correlation coefficient [ICC], 0.15; 95% CI, 0.07–0.3) but not in-hospital mortality (ICC, 0.02; 95% CI, 0.001–0.24). Most patients remained in shock after 3 hours of resuscitation (SSC compliant 81.1% and noncompliant 53.7%). Mortality was higher among patients who were persistently hypotensive after 3 hours of resuscitation for both the SSC compliant (persistent hypotension 37% vs not hypotensive 27.2%; p = 0.094) and noncompliant (30.1% vs 18.2%; p = 0.001, respectively). CONCLUSIONS AND RELEVANCE: Patients with a higher severity of illness and sepsis-induced hypotension identified in the ED were more likely to receive SSC-compliant care. SSC compliance was not associated with in-hospital mortality after adjusting for patient- and hospital-level differences. Higher mortality is seen among those who remain in shock after initial resuscitation, regardless of SSC compliance.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Resuscitation in the First 3 Hours of Sepsis-Induced Hypotension Varies by Patient and Hospital Factors

Chen

Roberts

Sevransky³

et al. 2023

Critical Care Explorations

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show abstract

“…This is a secondary analysis of the Observation of variation in fluids administered and characterization of vasopressor requirements in shock (VOLUME–CHASERS) study, 8 an observational, multicenter, prospective cohort of all consecutive adult patients (≥ 18 years) considered for ICU admission who had shock, defined as a systolic blood pressure < 90 mm Hg, mean arterial blood pressure < 65 mm Hg, or vasopressor initiation. The study sites included academic and community hospitals across the United States and one site in Amman, Jordan.…”

Section: Methodsmentioning

confidence: 99%

“…In the IMV subgroup, "early" IMV patients had a high severity of illness in the peri-shock period and more often had liver disease or cirrhosis (Table 1.). The total number of days on the ventilator was similar between both "early" versus "delayed" groups (median [IQR], 3 [2][3][4][5][6][7] vs. 3 [1][2][3][4][5][6][7][8] days, p = 0.34). In this cohort, noninvasive positive pressure ventilation use varied from 0.5%-23.3% by site, and high flow nasal oxygen use varied 1.3%-14.5% by site.…”

Section: Baseline Characteristicsmentioning

confidence: 98%

Effects of Timing of Invasive Mechanical Ventilation in Patients with Shock. An Analysis of the Multicenter Prospective Observational VOLUME–CHASERS Cohort

Goel

Chen

Roberts

et al. 2022

J Intensive Care Med

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Objectives: Describe the variation in practice and identify predictors of invasive mechanical ventilation (IMV) use in shock. Explore the association between the timing of IMV initiation (“Early” vs. “Delayed”) on shock duration. Design: Multicenter, prospective, observational cohort study between September 2017 and February 2018 Setting: 34 hospitals in the United States and Jordan. Patients: Consecutive, adult, critically ill patients with shock, defined as a systolic blood pressure less than or equal to 90mm Hg, mean arterial pressure less than or equal to 65mm Hg, or need for a vasopressor medication. Interventions: None. Measurements and Main Results: “Early” IMV was defined as starting IMV 0–6 hours of shock onset and “Delayed” IMV was defined as starting IMV between 6 and 48 hours of shock onset. The primary outcome was shock–free days, defined as the number of days without shock after the first 48 hours of shock onset. Variation and predictors of IMV use were examined within the whole cohort as well as the subgroup of those intubated within 0–48 hours of shock onset. Mixed effects modeling with hospital site as a random effect showed that there was 7% variation by site in the use and timing of IMV in this shock cohort. In a propensity–matched model for the timing of IMV, “Early” IMV after shock onset was associated with more shock–free days when compared to “Delayed” IMV in those intubated within 0–48 hours of shock onset (Beta coefficient 0.65 days, 95% CI 0.14-1.16 days). Conclusions: Timing of IMV initiation for patients in shock has potentially important implications for patient outcomes and merits further study.

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“…Hence, the implicit, intended-effect of IV fluid is to raise blood flow and the mechanism of this intended-effect is the Frank-Starling principle [ 1 ]. The rub is that we uncommonly measure how blood flow changes in response to IV fluid [ 3 ]. As a consequence, we rely on the aforementioned clinical surrogates as imperfect guides [ 1 ].…”

mentioning

confidence: 99%

Ask not liberal or conservative intravenous fluids in septic shock: ask rather why and when

Kenny

2022

Scand J Trauma Resusc Emerg Med

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Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study

Cited by 9 publications

References 27 publications

Resuscitation in the First 3 Hours of Sepsis-Induced Hypotension Varies by Patient and Hospital Factors

Resuscitation in the First 3 Hours of Sepsis-Induced Hypotension Varies by Patient and Hospital Factors

Effects of Timing of Invasive Mechanical Ventilation in Patients with Shock. An Analysis of the Multicenter Prospective Observational VOLUME–CHASERS Cohort

Ask not liberal or conservative intravenous fluids in septic shock: ask rather why and when

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