By
Fabio Guarracino, Pietro Bertini and Michael R. Pinsky
Critical Care: 201923:118
Background: We hypothesized that the cardiovascular
responses to Surviving Sepsis Guidelines (SSG)-defined resuscitation are
predictable based on the cardiovascular state.
Methods: Fifty-five septic patients treated by SSG
were studied before and after volume expansion (VE), and if needed
norepinephrine (NE) and dobutamine. We measured mean arterial pressure (MAP),
cardiac index (CI), and right atrial pressure (Pra) and calculated pulse
pressure and stroke volume variation (PPV and SVV), dynamic arterial elastance
(Eadyn), arterial elastance (Ea)
and left ventricular (LV) end-systolic elastance (Ees), Ees/Ea (VAC), LV
ejection efficiency (LVeff), mean systemic pressure analogue (Pmsa), venous
return pressure gradient (Pvr), and cardiac performance (Eh), using standard formulae.
Results: All patients were hypotensive (MAP
56.8 ± 3.1 mmHg) and tachycardic (113.1 ± 7.5 beat min−1),
with increased lactate levels (lactate = 5.0 ± 4.2 mmol L−1)
with a worsened VAC. CI was variable but > 2 L min−1 M−2 in
74%. Twenty-eight-day mortality was 48% and associated with admission lactate,
blood urea nitrogen (BUN), and creatinine levels but not cardiovascular state.
In all patients, both MAP and CI improved following VE, as well as cardiac
contractility (Ees). Fluid administration improved Pra, Pmsa, and Pvr in all
patients, whereas both HR and Ea decreased after VE, thus normalizing VAC. CI
increases were proportional to baseline PPV and SVV. CI increases
proportionally decreased PPV and SVV. VE increased MAP > 65 mmHg in 35/55
patients. MAP responders had higher PPV, SVV, and Eadyn than non-responders.
NE was given to 20/55 patients in septic shock, but increased MAP
> 65 mmHg in only 12. NE increased Ea, Eadyn, Pra, Pmsa, and VAC while
decreasing HR, PPV, SVV, and LVeff. MAP responders had higher pre-NE Ees and
lower VAC. Dobutamine was given to 6/8 patients who remained hypotensive
following NE. It increased Ees, MAP, CI, and LVeff, while decreasing HR, Pra,
and VAC. At all times and all steps of the protocol, CI changes were
proportional to Pvr changes independent of treatment.
Conclusions: The cardiovascular response to SSG-based
resuscitation is highly heterogeneous but predictable from pre-treatment
measures of cardiovascular state.
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