Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, NY.
Emergency Medicine Service Line, Northwell Health, New Hyde Park, NY.
Crit Care Med. 2018 Feb;46(2):189-198. doi: 10.1097/CCM.0000000000002834.
The prevalence of responsiveness to initial fluid challenge among hypotensive sepsis patients is unclear. To avoid fluid overload, and unnecessary treatment, it is important to differentiate these phenotypes. We aimed to 1) determine the proportion of hypotensive sepsis patients sustaining favorable hemodynamic response after initial fluid challenge, 2) determine demographic and clinical risk factors that predicted refractory hypotension, and 3) assess the association between timeliness of fluid resuscitation and refractoriness.
Secondary analysis of a prospective, multisite, observational, consecutive-sample cohort.
Nine tertiary and community hospitals over 1.5 years.
Inclusion criteria 1) suspected or confirmed infection, 2) greater than or equal to two systemic inflammatory response syndrome criteria, 3) systolic blood pressure less than 90 mm Hg, greater than 40% decrease from baseline, or mean arterial pressure less than 65 mm Hg.
Sex, age, heart failure, renal failure, immunocompromise, source of infection, initial lactate, coagulopathy, temperature, altered mentation, altered gas exchange, and acute kidney injury were used to generate a risk score. The primary outcome was sustained normotension after fluid challenge without vasopressor titration. Among 3,686 patients, 2,350 (64%) were fluid responsive. Six candidate risk factors significantly predicted refractoriness in multivariable analysis: heart failure (odds ratio, 1.43; CI, 1.20-1.72), hypothermia (odds ratio, 1.37; 1.10-1.69), altered gas exchange (odds ratio, 1.33; 1.12-1.57), initial lactate greater than or equal to 4.0 mmol/L (odds ratio, 1.28; 1.08-1.52), immunocompromise (odds ratio, 1.23; 1.03-1.47), and coagulopathy (odds ratio, 1.23; 1.03-1.48). High-risk patients (≥ three risk factors) had 70% higher (CI, 48-96%) refractory risk (19% higher absolute risk; CI, 14-25%) versus low-risk (zero risk factors) patients. Initiating fluids in greater than 2 hours also predicted refractoriness (odds ratio, 1.96; CI, 1.49-2.58). Mortality was 15% higher (CI, 10-18%) for refractory patients.
Two in three hypotensive sepsis patients were responsive to initial fluid resuscitation. Heart failure, hypothermia, immunocompromise, hyperlactemia, and coagulopathy were associated with the refractory phenotype. Fluid resuscitation initiated after the initial 2 hours more strongly predicted refractoriness than any patient factor tested.
低血压性脓毒症患者对初始液体挑战有反应的流行率尚不清楚。为避免液体过载和不必要的治疗，区分这些表型很重要。我们旨在：1）确定初始液体挑战后维持有利血流动力学反应的低血压性脓毒症患者的比例，2）确定预测难治性低血压的人口统计学和临床危险因素，3）评估液体复苏及时性与难治性之间的关系。
前瞻性、多地点、观察性、连续样本队列的二次分析。
9 家三级和社区医院，历时 1.5 年。
纳入标准为 1）疑似或确诊感染，2）≥2 项全身炎症反应综合征标准，3）收缩压＜90mmHg，较基线下降≥40%，或平均动脉压＜65mmHg。
性别、年龄、心力衰竭、肾衰竭、免疫功能低下、感染源、初始乳酸、凝血障碍、体温、意识改变、气体交换改变和急性肾损伤用于生成风险评分。主要结局为液体挑战后无需血管加压药滴定即可持续正常血压。在 3686 例患者中，2350 例（64%）对液体有反应。多变量分析中，6 个候选危险因素显著预测难治性：心力衰竭（比值比，1.43；95%CI，1.20-1.72）、低体温（比值比，1.37；95%CI，1.10-1.69）、气体交换改变（比值比，1.33；95%CI，1.12-1.57）、初始乳酸≥4.0mmol/L（比值比，1.28；95%CI，1.08-1.52）、免疫功能低下（比值比，1.23；95%CI，1.03-1.47）和凝血障碍（比值比，1.23；95%CI，1.03-1.48）。高风险患者（≥3 个危险因素）的难治性风险（70%，95%CI，48-96%）比低风险患者（零危险因素）高 19%（绝对风险增加，95%CI，14-25%）。液体开始大于 2 小时也预测难治性（比值比，1.96；95%CI，1.49-2.58）。难治性患者的死亡率高 15%（95%CI，10-18%）。
三分之二的低血压性脓毒症患者对初始液体复苏有反应。心力衰竭、低体温、免疫功能低下、高乳酸血症和凝血障碍与难治性表型相关。与任何患者因素相比，初始 2 小时后开始的液体复苏更能强烈预测难治性。
