Corticosteroids in Severe Sepsis and Septic Shock: A Concise Review.
Salluh JI, Póvoa P. Shock. 2017 Jan;47(1S Suppl 1):47-51.
For decades, corticosteroids are proposed as adjuvant therapies for severe infections. Despite mounting evidence from randomized controlled trials, there is still an intense debate regarding the role of systemic low-dose corticosteroids as a part of the treatment of septic shock. In the present article, we review the current literature and detail aspects on the pathophysiologic rationale, the current evidence, actual practice, and future directions on this topic. lire l’article sur HemodynXPERT
Perioperative goal-directed haemodynamic therapy based on flow parameters: a concept in evolution.
Meng L, Heerdt PM. Br J Anaesth. 2016 Dec;117(suppl 3):iii3-iii17.
Haemodynamic management incorporating direct or surrogate stroke volume monitoring has experienced a rapid evolution, because of emergence of the « goal-directed therapy » concept and technological developments aimed at providing a parameter leading to the goal. Nonetheless, consensus on both definitions of the ideal « goal » and strategies for achieving it remain elusive. For this review, we first consider basic physiological and patient monitoring factors relevant to the concept of « fluid responsiveness », and then focus upon randomized controlled trials and meta-analyses involving goal-directed haemodynamic therapy based on various flow parameters. Finally, we discuss the current status of noninvasive methods for monitoring fluid responsiveness. lire l’article sur HemodynXPERT
Fluid resuscitation for acute kidney injury: an empty promise.
Watkins SC1, Shaw AD. Curr Opin Crit Care. 2016 Dec;22(6):527-532.
PURPOSE OF REVIEW:
The past decade has seen more advances in our understanding of fluid therapy than the preceding decades combined. What was once thought to be a relatively benign panacea is increasingly being recognized as a potent pharmacological and physiological intervention that may pose as much harm as benefit.
Recent studies have clearly indicated that the amount, type, and timing of fluid administration have profound effects on patient morbidity and outcomes. The practice of aggressive volume resuscitation for ‘renal protection’ and ‘hemodynamic support’ may in fact be contributing to end organ dysfunction. The practice of early goal-directed therapy for patients suffering from critical illness or undergoing surgery appears to offer no benefit over conventional therapy and may in fact be harmful. A new conceptual model for fluid resuscitation of critically ill patients has recently been developed and is explored here.
The practice of giving more fluid early and often is being replaced with new conceptual models of fluid resuscitation that suggest fluid therapy be ‘personalized’ to individual patient pathophysiology. lire l’article sur HemodynXPERT
The passive leg raising test to guide fluid removal in critically ill patients.
Monnet X, Cipriani F, Camous L, Sentenac P, Dres M, Krastinova E, Anguel N, Richard C, Teboul JL. Ann Intensive Care. 2016 Dec;6(1):46. doi: 10.1186/s13613-016-0149-1. Epub 2016 May 20.
To investigate whether haemodynamic intolerance to fluid removal during intermittent renal replacement therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT.
We included 39 patients where intermittent RRT with weight loss was decided. Intradialytic hypotension was defined as hypotension requiring a therapeutic intervention, as decided by the physicians in charge. Before RRT, the maximal increase in cardiac index (CI, pulse contour analysis) induced by a PLR test was recorded. RRT was then started.
Ultrafiltration rate was similar in patients with and without intradialytic hypotension. Thirteen patients presented intradialytic hypotension, while 26 did not. In patients with intradialytic hypotension, it occurred 120 min [interquartile range 60-180 min] after onset of RRT. In the 26 patients without intradialytic hypotension, the PLR test induced no significant change in CI. Conversely, in patients with intradialytic hypotension, PLR significantly increased CI by 15 % [interquartile range 11-36 %]. The PLR-induced increase in CI predicted intradialytic hypotension with an area under the ROC curve of 0.89 (95 % interval confidence 0.75-0.97) (p < 0.05 from 0.50). The best diagnostic threshold was 9 %. The sensitivity was 77 % (95 % confidence interval 46-95 %), the specificity was 96 % (80-100 %), the positive predictive value was 91 % (57-100 %), and the negative predictive value was 89 % (72-98 %). Compared to patients without intolerance to RRT, CI decreased significantly faster in patients with intradialytic hypotension, with a slope difference of -0.17 L/min/m(2)/h.
The presence of preload dependence, as assessed by a positive PLR test before starting RRT with fluid removal, predicts that RRT will induce haemodynamic intolerance. Article en Open Access
Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan Study.
Funcke S, Sander M, Goepfert MS, Groesdonk H, Heringlake M, Hirsch J, Kluge S, Krenn C, Maggiorini M, Meybohm P, Salzwedel C, Saugel B, Wagenpfeil G, Wagenpfeil S, Reuter DA; ICU-CardioMan Investigators. Ann Intensive Care. 2016 Dec;6(1):49. doi: 10.1186/s13613-016-0148-2. Epub 2016 May 31.
Hemodynamic instability is frequent and outcome-relevant in critical illness. The understanding of complex hemodynamic disturbances and their monitoring and management plays an important role in treatment of intensive care patients. An increasing number of treatment recommendations and guidelines in intensive care medicine emphasize hemodynamic goals, which go beyond the measurement of blood pressures. Yet, it is not known to which extent the infrastructural prerequisites for extended hemodynamic monitoring are given in intensive care units (ICUs) and how hemodynamic management is performed in clinical practice. Further, it is still unclear which factors trigger the use of extended hemodynamic monitoring.
In this multicenter, 1-day (November 7, 2013, and the preceding 24 h) cross-sectional study, we retrieved data on patient monitoring from ICUs in Germany, Austria, and Switzerland by means of a web-based case report form. One hundred and sixty-one intensive care units contributed detailed information on availability of hemodynamic monitoring. In addition, detailed information on hemodynamic monitoring of 1789 patients that were treated on due date was collected, and independent factors triggering the use of extended hemodynamic monitoring were identified by multivariate analysis.
Besides basic monitoring with electrocardiography (ECG), pulse oximetry, and blood pressure monitoring, the majority of patients received invasive arterial (77.9 %) and central venous catheterization (55.2 %). All over, additional extended hemodynamic monitoring for assessment of cardiac output was only performed in 12.3 % of patients, while echocardiographic examination was used in only 1.9 %. The strongest independent predictors for the use of extended hemodynamic monitoring of any kind were mechanical ventilation, the need for catecholamine therapy, and treatment backed by protocols. In 71.6 % of patients in whom extended hemodynamic monitoring was added during the study period, this extension led to changes in treatment.
Extended hemodynamic monitoring, which goes beyond the measurement of blood pressures, to date plays a minor role in the surveillance of critically ill patients in German, Austrian, and Swiss ICUs. This includes also consensus-based recommended diagnostic and monitoring applications, such as echocardiography and cardiac output monitoring. Mechanical ventilation, the use of catecholamines, and treatment backed by protocol could be identified as factors independently associated with higher use of extended hemodynamic monitoring. Article en Open Access
Corticosteroids in Severe Sepsis and Septic Shock: A Concise Review.