| Resucitación inicial con fluidos en los pacientes con shock séptico en terapia intensiva |
Initial fluid resuscitation of patients with septic shock in the intensive care unit
S. CARLSEN, A. PERNER,
for the East Danish Septic Shock Cohort Investigators
Acta Anaesthesiologica Scandinavica 2011;55:394-400.
Background: Fluid is the mainstay of resuscitation of patients with septic shock, but the optimal composition and volume are unknown. Our aim was to evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome associated with fluid volume. Methods: This was a prospective, cohort study of all patients with septic shock (n=132) admitted in six ICUs during a 3-month period. Patients were divided into two groups according to the overall median volume of resuscitation fluid administered during the first 24 h after the diagnosis. Baseline characteristics, other treatments, monitoring and outcome were compared between the groups. Results: The mean volume of resuscitation fluid was 4.9 l (median 4.0 l and SD 3.5). Patients in the higher volume group received more crystalloids (3.7 vs. 1.2 l, P<0.0001), colloids (1.8 vs. 0.9 l, P<0.0001), blood products (1.8 vs. 0.6 l, P=0.0004), a higher maximum vasopressor dose (0.37 vs. 0.21 μg/kg/min, P<0.0001) and had a higher initial plasma concentration of lactate (4.0 vs. 3.0 mM, P=0.009) compared with the lower volume group. Simplified acute physiology score II in the lower and higher dose group were 52 and 58 (P=0.07). There were no differences in 30-, 90- or 365-day mortality between the two fluid volume groups. Conclusion: In the ICU, patients with septic shock were resuscitated with a combination of crystalloids, colloids and blood products. Although the more severely shocked patients received higher volumes of crystalloids, colloids and blood products, mortality did not differ between the groups.
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| Tratamiento con corticoesteroides y terapia intensiva con insulina para adultos con shock séptico. Un estudio randomizado controlado. |
Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock in Adults. A Randomized Controlled Trial
Paul R. Sheehe, ScD
sheehep@upstate.edu
Department of Neuroscience and Physiology
Upstate Medical University
Syracuse, New York
JAMA. 2010;303(4):341-348
Context Corticosteroid therapy induces potentially detrimental hyperglycemia in septic shock. In addition, the benefit of adding fludrocortisone in this setting is unclear.Objectives To test the efficacy of intensive insulin therapy in patients whose septic shock was treated with hydrocortisone and to assess, as a secondary objective, the benefit of fludrocortisone. Design, Setting, and Patients A multicenter, 2_2 factorial, randomized trial, involving 509 adults with septic shock who presented with multiple organ dysfunction, as defined by a Sequential Organ Failure Assessment score of 8 or more, and who had received hydrocortisone treatment was conducted from January 2006 to January 2009 in 11 intensive care units in France. Interventions Patients were randomly assigned to 1 of 4 groups: continuous intravenous insulin infusion with hydrocortisone alone, continuous intravenous insulin infusion with hydrocortisone plus fludrocortisone, conventional insulin therapy with hydrocortisone alone, or conventional insulin therapy with intravenous hydrocortisone plus fludrocortisone. Hydrocortisonewasadministered in a50-mgbolus every 6 hours,andfludrocortisone was administered orally in 50-μg tablets once a day, each for 7 days. Main Outcome Measure In-hospital mortality. Results Ofthe 255 patients treated with intensive insulin, 117 (45.9%), and 109 of 254 (42.9%) treated with conventional insulin therapy died (relative risk [RR], 1.07;95%confidence interval [CI], 0.88-1.30;P=.50). Patients treated with intensive insulin experienced significantly more episodes of severe hypoglycemia (_40 mg/dL) than those in the conventional-treatment group, with a difference in mean number of episodes per patient of 0.15 (95% CI, 0.02-0.28; P=.003). At hospital discharge, 105 of 245 patients treated with fludrocortisone (42.9%) died and 121 of 264 (45.8%) in the control group died (RR, 0.94; 95% CI, 0.77-1.14; P=.50). Conclusions Compared with conventional insulin therapy, intensive insulin therapy did not improve in-hospital mortality among patients who were treated with hydrocortisone for septic shock. The addition of oral fludrocortisone did not result in a statistically significant improvement in in-hospital mortality.
Trial Registration clinicaltrials.gov Identifier: NCT00320099
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