Department of Emergency Medicine, 8784University of California, San Diego, CA, USA.
Division of Pulmonary, Critical Care, and Sleep Medicine, 8784University of California, San Diego, CA, USA.
J Intensive Care Med. 2020 Nov;35(11):1338-1345. doi: 10.1177/0885066619871247. Epub 2019 Aug 25.
PURPOSE: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. METHODS: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. RESULTS: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF ( < .01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. CONCLUSIONS: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.
目的：国际临床实践指南呼吁对败血症性低血压或休克患者进行至少 30ml/kg 体重的初始容量复苏。尽管在指南中没有考虑，但预先存在的心脏功能障碍可能是临床医生在决定败血症性休克患者容量复苏量时需要权衡的一个重要因素。
方法：我们对常规治疗败血症患者的临床医生进行了一项多中心调查，以评估他们对伴有射血分数降低的心力衰竭（HFrEF）<40%的败血症患者初始容量复苏的信念、行为、知识和感知结构障碍。初始容量复苏偏好以有序值捕获，并根据需要使用 McNemar 和 Wilcoxon 符号秩检验进行额外的容量复苏偏好检验。使用单变量逻辑回归模型确定≥30ml/kg 液体给药的显著预测因子。
结果：共有 9 家美国医院的 317 名临床医生完成了调查（应答率为 47.3%）。大多数受访者是内科或急诊医学的专家。对于伴有 HFrEF 的败血症患者的复苏偏好存在很大的异质性。39.4%的受访者认为败血症性休克和 HFrEF 患者应豁免当前的败血症捆绑计划。只有 56.4%的受访者认为伴有 HFrEF 的败血症性休克患者需要进行 30ml/kg 左右或更多的最小液体冲击，而没有 HFrEF 的患者则为 89.1%（<0.01）。急诊医师最有可能认为<30ml/kg 是败血症性休克和 HFrEF 患者最适宜的。
结论：对于败血症性低血压或休克合并 HFrEF 的患者，初始容量复苏存在临床平衡。未来的研究和临床实践指南应明确解决这一亚群的复苏问题。
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