When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring.
When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring.
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DOI：
10.1186/s13613-014-0030-z
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发表时间：
2014
影响因子：
8.1
通讯作者：
Bakker J
中科院分区：
文献类型：
--
作者：
Hernandez G;Luengo C;Bruhn A;Kattan E;Friedman G;Ospina-Tascon GA;Fuentealba A;Castro R;Regueira T;Romero C;Ince C;Bakker J
决定何时停止败血性休克复苏是一个关键的，但尚未探索的护理方面。这一点尤其重要，因为近年来已经强调了液体过载或强心剂过度复苏的风险。最近的指南建议将中心静脉血氧饱和度和/或乳酸盐正常化作为治疗终点，假设这些变量是等效的或可互换的。然而，由于两者的生理决定因素是完全不同的，这是合法的挑战这一建议的理由。我们设计这项研究是为了从动态的角度更深入地了解最合适的复苏目标。我们的目的是比较这些和其他潜在的灌注相关的目标在一个队列的感染性休克幸存者的正常化率。我们设计了一项前瞻性、观察性临床研究。104例感染性休克伴高乳酸血症患者纳入研究，并随访至出院。84名住院幸存者被保留用于最终分析。在基线、ICU治疗后2、6和24小时进行多模式灌注评估。一些变量，如中心静脉血氧饱和度，中心静脉-动脉pCO2梯度和毛细血管再充盈时间在6h时超过70%的存活者已经正常。与基线水平相比，6小时时乳酸正常化率显著降低（4.0 [3.0 - 4.9] vs. 2.7 [2.2 - 3.9] mmol/L; p <0.01），但仅52%的患者在24小时时恢复正常。舌下微循环变量显示最慢的恢复率，在24 h时几乎80%的患者中仍然存在持续的紊乱。灌注相关变量在感染性休克幸存者中表现出非常不同的正常化率，其中大多数表现出双相反应，最初快速改善，随后呈缓慢趋势。应考虑这一事实，以确定最适当的标准，及时停止复苏，避免过度复苏的风险。
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. 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. 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 < 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. 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.
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影响因子：
120.7
作者：
Jones, Alan E.;Shapiro, Nathan I.;Trzeciak, Stephen;Arnold, Ryan C.;Claremont, Heather A.;Kline, Jeffrey A.
通讯作者：
Kline, Jeffrey A.
影响因子：
158.5
作者：
Rivers, E;Nguyen, B;Tomlanovich, M
通讯作者：
Tomlanovich, M
影响因子：
3.7
作者：
Hernandez, Glenn;Pedreros, Cesar;Ince, Can
通讯作者：
Ince, Can
影响因子：
3.7
作者：
Regueira, Tomas;Bruhn, Alejandro;Hernandez, Glenn
通讯作者：
Hernandez, Glenn
影响因子：
8.8
作者：
Levy, MM;Fink, MP;Ramsay, G
通讯作者：
Ramsay, G