Individualized Hemodynamic Management in Sepsis

Abstract

Hemodynamic optimization remains the cornerstone of resuscitation in the treatment of sepsis and septic shock. Delay or inadequate management will inevitably lead to hypoperfusion, tissue hypoxia or edema, and fluid overload, leading eventually to multiple organ failure, seriously affecting outcomes. According to a large international survey (FENICE study), physicians frequently use inadequate indices to guide fluid management in intensive care units. Goal-directed and "restrictive" infusion strategies have been recommended by guidelines over "liberal" approaches for several years. Unfortunately, these "fixed regimen" treatment protocols neglect the patient's individual needs, and what is shown to be beneficial for a given population may not be so for the individual patient. However, applying multimodal, contextualized, and personalized management could potentially overcome this problem. The aim of this review was to give an insight into the pathophysiological rationale and clinical application of this relatively new approach in the hemodynamic management of septic patients.

Keywords: early goal-directed therapy; fluid therapy; hemodynamic monitoring; lactate; septic shock.

Figure 1

The “bricks” of individualized hemodynamic management. SpO₂, pulse oximetry driven oxygen saturation; MAP, mean arterial pressure; CRT, capillary refill time; UO, urine output; Clin. S, clinical signs; PaO_2, partial pressure of oxygen; Hb, hemoglobin; HCO_3, bicarbonate; S_cvO₂, central venous oxygen saturation; P_a-vCO₂, arterial-to-venous carbon dioxide gap; CO, cardiac output; SV, stroke volume; PPV, pulse pressure variability; SVR, systemic vascular resistance; ITBV, intrathoracic blood volume; GEDV, global end-diastolic volume; dPmax, left ventricle contractility index; CPI, cardiac power index; ELWI, extravascular lung water index; * indicates that CO can be determined by invasive hemodynamic measurements or by echo-cardiography. For explanation, please see text.

Figure 2

Management algorithm. Rhythm dist., cardiac rhythm disturbances; Clin, clinical; MV, mechanical ventilation. *, extracorporeal renal replacement therapies, immunomodulation, other adjuvant therapies. Whenever an “Alarming signal” is detected or suspected, the first step is to evaluate its “Severity”. If the signal is regarded as “Severe” (such as profound hypotension, extreme tachycardia, hypoxemia, etc.) then immediate resuscitation is needed in the form of the appropriate “Interventions”, after which the situation should be “Reassessed”, by checking the change in the alarming parameters and starting the loop again if necessary. If the alarm signal is regarded as “Mild”, then further observation and reassessment is enough. In cases of “Moderate” disturbances, when decisions cannot be made easily, the multimodal contextualized concept could become useful. This includes components listed in Figure 1, and putting these parameters in context can help us to determine whether the moderate alarm signal was indeed “True” or “False”. In cases of the presence of true pathology, the measures listed in the “Interventions” domain can be implemented, after which reassessment is again necessary.