Fluids and vasopressors in septic shock: basic knowledge for a first approach in the emergency department

Submitted: 22 August 2022
Accepted: 14 February 2023
Published: 28 March 2023
Abstract Views: 853
PDF: 506
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Authors

Much research, both pathophysiological and clinical, has been produced about septic shock during the last 20 years. Nevertheless, many aspects of treatment are still controversial, among these the approach to the administration of fluids and vasopressors. After the first clinical trial on Early goal-directed therapy (EGDT) was published, a liberal approach to the use of fluids and conservative use of vasopressors prevailed, but in recent years a more restrictive use of fluids and an earlier introduction of vasopressors seem to be preferred. Although both treatments are based on sound pathophysiological knowledge,  clinical evidence is still inadequate and somehow controversial.  In this non-systematic review, recent research on the hemodynamics of septic shock and its treatment with fluids and inotropes is discussed. As a conclusion, general indications are proposed for a practical approach to patients in septic shock.

Dimensions

Altmetric

PlumX Metrics

Downloads

Download data is not yet available.

Citations

Bauer M, Gerlach H, Vogelmann T, Preissing F, Stiefel J, Adam D. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019- results from a systematic review and meta-analysis. Crit Care 2020;24:239. DOI: https://doi.org/10.1186/s13054-020-02950-2
Lat I, Coopersmith CM, De Backer D. The Surviving Sepsis Campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. Crit Care Med 2021;49:623-35. DOI: https://doi.org/10.1097/CCM.0000000000004864
Magder S. Bench-to-bedside review: An approach to hemodynamic monitoring--Guyton at the bedside. Crit Care 2012;16:236. DOI: https://doi.org/10.1186/cc11395
Persichini R, Lai C, Teboul JL, et al. Venous return and mean systemic filling pressure: physiology and clinical applications. Crit Care 2022;26:150. DOI: https://doi.org/10.1186/s13054-022-04024-x
Sato R, Nasu M. A review of sepsis-induced cardiomyopathy. J Intensive Care 2015;3:48. DOI: https://doi.org/10.1186/s40560-015-0112-5
L’Heureux M, Sternberg M, Brath L, et al. Sepsis-induced cardiomyopathy: a comprehensive review. Curr Cardiol Rep 2020;22:35. DOI: https://doi.org/10.1007/s11886-020-01277-2
Yadav H, Cartin-Ceba R. Balance between hyperinflammation and immunosuppression in sepsis. Semin Respir Crit Care Med 2016;37:42–50. DOI: https://doi.org/10.1055/s-0035-1570356
Lee WL, Slutsky AS. Sepsis and endothelial permeability. N Engl J Med 2010;363:689-91. DOI: https://doi.org/10.1056/NEJMcibr1007320
Bentzer P, Griesdale DE, Boyd J, et al. Will this hemodynamically unstable patient respond to a bolus of Intravenous fluids? JAMA 2016;316:1298-1309.
Eskesen TG, Wetterslev M, Perner A: Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Intensive Care Med 2016;42:324–32. DOI: https://doi.org/10.1007/s00134-015-4168-4
Airapetian N, Maizel J, Alyamani O, et al. Does inferior vena cava respiratory variability predict fluid responsiveness in spontaneously breathing patients? Critical Care 2015;19:400 DOI: https://doi.org/10.1186/s13054-015-1100-9
Assessment of sublingual microcirculation in critically ill patients: consensus and debate. Dilken O, Ergin B, Ince C. Ann Transl Med 2020;8:793 DOI: https://doi.org/10.21037/atm.2020.03.222
Hernandez G, Bellomo R, Bakker J. The ten pitfalls of lactate clearance in sepsis. Intensive Care Med 2019;45:82-85 DOI: https://doi.org/10.1007/s00134-018-5213-x
Textoris J, Fouché L, Wiramus S, et al. High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality. Crit Care 2011;15:R176. DOI: https://doi.org/10.1186/cc10325
Gattinoni L, Vasques F, Camporota L, et al. Understanding lactatemia in human sepsis: potential impact for marly Management. Am J Respir Crit Care Med 2019;200:582-9. DOI: https://doi.org/10.1164/rccm.201812-2342OC
Vincent JL, Quintairos ESA, Couto L Jr, Taccone FS. The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care 2016;20:257 DOI: https://doi.org/10.1186/s13054-016-1403-5
Yasufumi O, Morimura N, Shirasawa A, et al. Quantitative capillary refill time predicts sepsis in patients with suspected infection in the emergency department: an observational study. J Intensive Care 2019;7:29 DOI: https://doi.org/10.1186/s40560-019-0382-4
Castro R, Kattan E, Ferri G, et al. Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial. Ann Intensive Care 2020;10:150. DOI: https://doi.org/10.1186/s13613-020-00767-4
Zampieri FG, Damiani LP, Bakker J, et al: Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: A Bayesian reanalysis of the ANDROMEDA-SHOCK trial. Am J Respir Crit Care Med 2020;201:423–29. DOI: https://doi.org/10.1164/rccm.201905-0968OC
Magder S, Brengelmann GL. Point: Counterpoint: the classic Guyton view that mean systemic pressure, right atrial pressure, and venous resistance govern venous return is/is not correct. J Appl Physiol 2006;101:1523–27. DOI: https://doi.org/10.1152/japplphysiol.00698.2006
Spiegel R. Stressed vs. unstressed volume and its relevance to critical care practitioners. Clin Exp Emerg Med 2016;3:52-4. DOI: https://doi.org/10.15441/ceem.16.128
Magder SA. The highs and lows of blood pressure: toward meaningful clinical targets in patients with shock. Crit Care Med 2014;42:1241–51. DOI: https://doi.org/10.1097/CCM.0000000000000324
Carrara M, Herpain A, Baselli G, Ferrario M. Vascular decoupling in septic shock: the combined role of autonomic nervous system, arterial stiffness, and peripheral vascular tone. Front Physiol 2020;11:594. DOI: https://doi.org/10.3389/fphys.2020.00594
Bayer O, Reinhart K, Sakr Y, et al. Renal effects of synthetic colloids and crystalloids in patients with severe sepsis: a prospective sequential comparison. Crit Care Med 2011;39:1335–42. DOI: https://doi.org/10.1097/CCM.0b013e318212096a
Hammond DA, Lam SW, Rech MA, et al. Balanced crystalloids versus saline in critically ill adults: A systematic review and meta-analysis. Ann Pharmacother 2020;54:5–13
Xue M, Zhang X, Liu F, et al: Effects of chloride content of intravenous crystalloid solutions in critically ill adult patients: a meta-analysis with trial sequential analysis of randomized trials. Ann Intensive Care 2019;9:30 DOI: https://doi.org/10.1186/s13613-019-0506-y
Hammond DA, Lam SW, Rech MA, et al. Balanced crystalloids versus saline in critically ill adults: a systematic review and meta-analysis. Ann Pharmacother 2020;54:5-13. DOI: https://doi.org/10.1177/1060028019866420
Nunes TS, Ladeira RT, Bafi AT, et al. Duration of hemodynamic effects of crystalloids in patients with circulatory shock after initial resuscitation. Ann Intensive Care 2014;4:25 DOI: https://doi.org/10.1186/s13613-014-0025-9
Bentzer P, Griesdale DE, Boyd, J, et al. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA 2016;316:1298-1309. DOI: https://doi.org/10.1001/jama.2016.12310
Preau S, Bortolotti P, Colling D, et al.Diagnostic accuracy of the inferior vena cava collapsibility to predict fluid responsiveness in spontaneously breathing patients with sepsis and acute circulatory failure. Crit Care Med 2017;45:e290–7. DOI: https://doi.org/10.1097/CCM.0000000000002090
Hernandez G, Teboul JL, Bakker J. Norepinephrine in septic shock. Intensive Care Med 2019;45:687–9. DOI: https://doi.org/10.1007/s00134-018-5499-8
Avni T, Lador A, Lev S, et al. Vasopressors for the treatment of septic shock: systematic review and meta-analysis. PLoS One 2015;10:e0129305.
Vasu TS, Cavallazzi R, Hirani A, et al . Norepinephrine or dopamine for septic shock: systematic review of randomized clinical trials. J Intensive Care Med 2012;27:172-8 . DOI: https://doi.org/10.1177/0885066610396312
Uhel F, van der Poll T. Norepinephrine in septic shock: a mixed blessing. Am J Respir Crit Care Med 2020;202:788–9. DOI: https://doi.org/10.1164/rccm.202006-2301ED
Levy B, Collin S, Sennoun N, et al. Vascular hyporesponsiveness to vasopressors in septic shock: From bench to bedside. Intensive Care Med 2010;36:2019–29. DOI: https://doi.org/10.1007/s00134-010-2045-8
Hernandez G, Bruhn A, Luengo C, et al. Effects of dobutamine on systemic, regional and microcirculatory perfusion parameters. Intensive Care Med 2013;39:1435–43. DOI: https://doi.org/10.1007/s00134-013-2982-0
Sato R, Nasu M. Time to re-think the use of dobutamine in sepsis. J Intensive Care 2017;5:65. DOI: https://doi.org/10.1186/s40560-017-0264-6
Singer M, Inada-Kim M, Shankar-Hari M. Sepsis hysteria: excess hype and unrealistic expectations. Lancet 2019;394:1513-14. DOI: https://doi.org/10.1016/S0140-6736(19)32483-3
Rhee C, Klompas M. Sepsis trends: increasing incidence and decreasing mortality, or changing denominator? J Thorac Dis 2020;12:S89-S100. DOI: https://doi.org/10.21037/jtd.2019.12.51
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77. DOI: https://doi.org/10.1056/NEJMoa010307
Gao F, Melody T, Daniels DF, et al. The impact of compliance with 6-hour and24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care 2005;9:R764-R770.
Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010;38:367-74. DOI: https://doi.org/10.1097/CCM.0b013e3181cb0cdc
Rivers E. Implementation of an evidence-based “standard operating procedure” and outcome in septic shock: what a sepsis pilot must consider before taking flight with your next patient. Crit Care Med 2006;34:1247. DOI: https://doi.org/10.1097/01.CCM.0000208324.00379.AD
Prasad PA, Shea ER, Shiboski S, et al. Relationship between a sepsis intervention bundle and in-hospital mortality among hospitalized patients: a retrospective analysis of real-world data. Anesth Analg 2017;125:507-13. DOI: https://doi.org/10.1213/ANE.0000000000002085
Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013;41:1774–81. DOI: https://doi.org/10.1097/CCM.0b013e31828a25fd
Kumar A, Anel R, Bunnell E, et al. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 2004;32:691–9. DOI: https://doi.org/10.1097/01.CCM.0000114996.68110.C9
Delaney A. Protocolized sepsis care is not helpful for patients. Crit Care Med 2017;45:473-5. DOI: https://doi.org/10.1097/CCM.0000000000001990
Jones AE. Unbundling early sepsis resuscitation. Ann Emerg Med 2014;63:654-5. DOI: https://doi.org/10.1016/j.annemergmed.2013.10.034
Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: International guidelines for the management of sepsis and septic shock: 2016. Crit Care Med 2017;43:304–77. DOI: https://doi.org/10.1007/s00134-017-4683-6
Kalil AC, Johnson DV, Lisco SJ, Su JN. Early goal-directed therapy for sepsis: a novel solution for discordant survival outcomes in clinical trials. Crit Care Med 2017;45:607–14. DOI: https://doi.org/10.1097/CCM.0000000000002235
Sakr Y, Rubatto Birri PN, Kotfis K, et al. Intensive Care Over Nations Investigators: higher fluid balance increases the risk of death from sepsis: Results from a large international audit. Crit Care Med 2017;45:386–94. DOI: https://doi.org/10.1097/CCM.0000000000002189
Boyd JH, Forbes J, Nakada TA, et al. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–265. DOI: https://doi.org/10.1097/CCM.0b013e3181feeb15
Kellum JA, Chawla LS, Keener C, et al. ProCESS and ProGReSS-AKI Investigators.The effects of alternative resuscitation strategies on acute kidney injury in patients with septic Shock. Am J Respir Crit Care Med 2016;193:281-7. DOI: https://doi.org/10.1164/rccm.201505-0995OC
Mele A, Cerminara E, Häbel H, et al. Fluid accumulation and major adverse kidney events in sepsis: a multicenter observational study. Ann Intensive Care 2022;12:62. DOI: https://doi.org/10.1186/s13613-022-01040-6
ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506. DOI: https://doi.org/10.1056/NEJMoa1404380
Mouncey PR, Osborn TM, Power GS Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015;372:1301-11. DOI: https://doi.org/10.1056/NEJMoa1500896
The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683-93. DOI: https://doi.org/10.1056/NEJMoa1401602
Meyhoff TS, Møller MH, Hjortrup PB, et al. Lower vs higher fluid volumes during initial management of sepsis: A systematic review with meta-analysis and trial sequential analysis. Chest 2020;157:1478–96. DOI: https://doi.org/10.1016/j.chest.2019.11.050
Hjortrup PB, Haase N, Bundgaard H, et al. CLASSIC Trial Group; Scandinavian Critical Care Trials Group. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med 2016;42:1695-705. DOI: https://doi.org/10.1007/s00134-016-4500-7
Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of intravenous fluid in ICU patients with septic shock. N Engl J Med 2022;386:2459-70. DOI: https://doi.org/10.1056/NEJMoa2202707
National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network; Shapiro NI, Douglas IS, et al. Early restrictive or liberal fluid management for sepsis-Induced hypotension. N Engl J Med. 2023;388:499-510. DOI: https://doi.org/10.1056/NEJMoa2212663
Hernandez G, Bruhn A, Castro R, Pedreros C, et al. Persistent sepsis-induced hypotension without hyperlactatemia: a distinct clinical and physiological profile within the spectrum of septic shock. Crit Care Res Pract 2012;2012:536852. DOI: https://doi.org/10.1155/2012/536852
Jansen TC, van Bommel J, Schoonderbeek FJ, et al. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med 2010;182:752-61. DOI: https://doi.org/10.1164/rccm.200912-1918OC
Hernandez G, Luengo C, Bruhn A, et al. When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring. Ann Intensive Care 2014,4:30. DOI: https://doi.org/10.1186/s13613-014-0030-z
Hoste EA, Maitland K, Brudney CS, et al. Four phases of intravenous fluid therapy: a conceptual model. Br J Anaesth 2014;113:740-7. DOI: https://doi.org/10.1093/bja/aeu300
Malbrain MLNG, Langer T, Annane D, et al. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA). Ann Intensive Care 2020;10:64. DOI: https://doi.org/10.1186/s13613-020-00679-3
Avni T, Lador A, Lev S, et al. Vasopressors for the treatment of septic shock: Systematic review and meta-analysis. PLoS One 2015;10:e0129305. DOI: https://doi.org/10.1371/journal.pone.0129305
Permpikul C, Tongyoo S, Viarasilpa T, et al. Early use of norepinephrine in septic shock resuscitation (CENSER): a randomized trial. Am J Resp Crit Care Medicine 2019;199:1097-05. DOI: https://doi.org/10.1164/rccm.201806-1034OC
Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. Critical Care 2020;24:488. DOI: https://doi.org/10.1186/s13054-020-03204-x
Waechter J, Kumar A, Lapinsky SE, et al. for the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group. Interaction between fluids and vasoactive agents on mortality in septic shock: a multicenter, observational study. Crit Care Med 2014;42:2158-68. DOI: https://doi.org/10.1097/CCM.0000000000000520
Takala J. Should we target blood pressure in sepsis? Crit Care Med 2010;38:S613–S619. DOI: https://doi.org/10.1097/CCM.0b013e3181f2430c
Martin C, Medam S, Antonini F, et al. Norepinephrine: not too much, too long. Shock 2015;44:305–9. DOI: https://doi.org/10.1097/SHK.0000000000000426
Stolk RF, van der Poll T, Angus DC, et al. Potentially inadvertent immunomodulation: norepinephrine use in sepsis. Am J Respir Crit Care Med 2016;194:550–8. DOI: https://doi.org/10.1164/rccm.201604-0862CP
Morelli A, Ertmer C, Westphal M, et al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. JAMA 2013;310:1683–91. DOI: https://doi.org/10.1001/jama.2013.278477
Kopczynska M, Sharif B, Cleaver S, et al. Sepsis-related deaths in the at-risk population on the wards: attributable fraction of mortality in a large point-prevalence study. BMC Res Notes 2018;11:720. DOI: https://doi.org/10.1186/s13104-018-3819-2
Rhee C, Jones TM, Hamad Y, et al. Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Netw Open 2019;2:e187571. DOI: https://doi.org/10.1001/jamanetworkopen.2018.7571
Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care 2015;30:653.e9–653.e17 DOI: https://doi.org/10.1016/j.jcrc.2015.01.014
Corradi F, Via G, Tavazzi G. What's new in ultrasound-based assessment of organ perfusion in the critically ill: expanding the bedside clinical monitoring window for hypoperfusion in shock. Intensive Care Med 2020;46:775-9. DOI: https://doi.org/10.1007/s00134-019-05791-y

How to Cite

Coen, D. (2023). Fluids and vasopressors in septic shock: basic knowledge for a first approach in the emergency department. Emergency Care Journal, 19(1). https://doi.org/10.4081/ecj.2023.10810