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. 2020 Apr 15;10(1):40.
doi: 10.1186/s13613-020-00659-7.

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

Arnaldo Dubin  1 , Cecilia Loudet  2 , Vanina S Kanoore Edul  3 , Javier Osatnik  4 , Fernando Ríos  5 , Daniela Vásquez  6 , Mario Pozo  7 , Bernardo Lattanzio  8 , Fernando Pálizas  7 , Francisco Klein  9 , Damián Piezny  5 , Paolo N Rubatto Birri  10 , Graciela Tuhay  9 , Analía García  11 , Analía Santamaría  12 , Graciela Zakalik  13 , Cecilia González  14 , Elisa Estenssoro  2 ; investigators of the SATISEPSIS group
Collaborators, Affiliations

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

Arnaldo Dubin et al. Ann Intensive Care. .

Abstract

Background: Resuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. Our aim was to characterize cardiovascular and fluid management of sepsis in Argentina, a low and middle-income country (LMIC). Furthermore, we sought to test whether the utilization of dynamic tests of fluid responsiveness, as a guide for fluid therapy after initial resuscitation in patients with persistent or recurrent hypoperfusion, was associated with decreased mortality.

Methods: Secondary analysis of a national, multicenter prospective cohort study (n = 787) fulfilling Sepsis-3 definitions. Epidemiological characteristics, hemodynamic management data, type of fluids and vasopressors administered, physiological variables denoting hypoperfusion, use of tests of fluid responsiveness, and outcomes, were registered. Independent predictors of mortality were identified with logistic regression analysis.

Results: Initially, 584 of 787 patients (74%) had mean arterial pressure (MAP) < 65 mm Hg and/or signs of hypoperfusion and received 30 mL/kg of fluids, mostly normal saline (53%) and Ringer lactate (35%). Vasopressors and/or inotropes were administered in 514 (65%) patients, mainly norepinephrine (100%) and dobutamine (9%); in 22%, vasopressors were administered before ending the fluid load. After this, 413 patients (53%) presented persisting or recurrent hypotension and/or hypoperfusion, which prompted administration of additional fluid, based on: lactate levels (66%), urine output (62%), heart rate (54%), central venous O2 saturation (39%), central venous-arterial PCO2 difference (38%), MAP (31%), dynamic tests of fluid responsiveness (30%), capillary-refill time (28%), mottling (26%), central venous pressure (24%), cardiac index (13%) and/or pulmonary wedge pressure (3%). Independent predictors of mortality were SOFA and Charlson scores, lactate, requirement of mechanical ventilation, and utilization of dynamic tests of fluid responsiveness.

Conclusions: In this prospective observational study assessing the characteristics of resuscitation of septic patients in Argentina, a LMIC, the prevalent use of initial fluid bolus with normal saline and Ringer lactate and the use of norepinephrine as the most frequent vasopressor, reflect current worldwide practices. After initial resuscitation with 30 mL/kg of fluids and vasopressors, 413 patients developed persistent or recurrent hypoperfusion, which required further volume expansion. In this setting, the assessment of fluid responsiveness with dynamic tests to guide fluid resuscitation was independently associated with decreased mortality.

Keywords: Dynamic tests; Fluid responsiveness; Hypoperfusion; Sepsis; Vasopressors.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of the study
Fig. 2
Fig. 2
Frequency of the variables utilized as criteria of hypoperfusion for the assessment of the response to the initial fluid bolus of 30 mL/kg. MAP, mean arterial pressure; ScvO2, central venous O2 saturation; Pcv-aCO2, central venous–arterial PCO2 difference; CRT, capillary-refill time; CVP, central venous pressure
See this image and copyright information in PMC

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