医学
复苏
随机对照试验
感染性休克
败血症
机械通风
麻醉
丸(消化)
临床试验
拯救脓毒症运动
人口
重症监护医学
急诊医学
外科
内科学
环境卫生
严重败血症
作者
Ivor S. Douglas,Philip Alapat,Keith Corl,Matthew C. Exline,Lui G. Forni,Andre Holder,David Kaufman,Akram Khan,Mitchell M. Levy,Grégory Martin,Jennifer Sahatjian,E. Scott Seeley,Wesley H. Self,Jeremy A. Weingarten,Mark D. Williams,Douglas Hansell
出处
期刊:Chest
[Elsevier]
日期:2020-10-01
卷期号:158 (4): 1431-1445
被引量:144
标识
DOI:10.1016/j.chest.2020.04.025
摘要
Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome.Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes?We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first.In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37 L favoring the intervention arm; 0.65 ± 2.85 L intervention arm vs 2.02 ± 3.44 L usual care arm; P = .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P = .04) or mechanical ventilation (17.7% vs 34.1%; P = .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals.Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care.NCT02837731.
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