Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
Emergency Medicine, University Medical Centre Groningen, Groningen, The Netherlands.
Emerg Med J. 2021 Jun;38(6):416-422. doi: 10.1136/emermed-2020-209771. Epub 2021 Apr 22.
Little is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock.
In a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge.
Seven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44-78) vs 37 (23-47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p<0.001).
The results of the present study demonstrate that in patients with sepsis in the absence of shock, three out of four patients do not demonstrate a clinically relevant increase in CI after a standardised fluid challenge. Non-invasive CO monitoring in combination with a PLR test has the potential to identify patients who might benefit from fluid resuscitation and may contribute to a better tailored treatment of these patients.
对于没有休克表现的脓毒症患者，在急诊科接受治疗时，我们对其最佳液体治疗方法知之甚少。在本研究中，我们旨在量化液体冲击对无休克脓毒症患者无创测量的心脏指数（CI）的影响。
在一项前瞻性队列研究中，2018 年 5 月至 2019 年 3 月期间，在荷兰一家大型教学医院的急诊科，使用 ClearSight 系统对 30 名没有休克表现的脓毒症患者进行了无创 CI、每搏量（SV）和全身血管阻力（SVR）的测量。在进行基线测量后，进行被动抬腿（PLR）以模拟液体冲击。在 PLR 后 30、60、90 和 120 秒重复测量。最后，在 PLR 后给予标准 500mL 生理盐水 0.9%静脉滴注，然后进行最终测量。液体反应性定义为标准液体冲击后 CI 增加>15%。
30 名患者中有 7 名（23%）在 PLR 后和 500mL 液体冲击后 CI 增加>15%。液体反应者的估计肾小球滤过率（eGFR）更高（64（44-78）比 37（23-47），p=0.009），但与非反应者相比，患者和治疗特征相似。心输出量（CO）、CI、SV 和 SVR 的基线测量与 PLR 液体反应性无关。PLR 后 CI 的变化与 500mL 生理盐水 0.9%液体冲击后 CI 的变化呈强正相关（r=0.88，p<0.001）。
本研究结果表明，在没有休克的脓毒症患者中，四分之三的患者在接受标准液体冲击后，CI 无临床相关增加。非侵入性 CO 监测与 PLR 试验相结合，有可能识别出可能受益于液体复苏的患者，并有助于更好地为这些患者量身定制治疗方案。
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