Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina
Arnaldo Dubin, Cecilia Loudet, Vanina S. Kanoore Edul, Javier Osatnik, Fernando Ríos, Daniela Vásquez, Mario Pozo, Bernardo Lattanzio, Fernando Pálizas, Francisco Klein, Damián Piezny, Paolo N. Rubatto Birri, Graciela Tuhay, Analía García, Analía García, Graciela Zakalik, Cecilia González, Elisa Estenssoro, Carolina Enrico, Mariel Romitelli, Mariel Ayelén García, José Celia, Leandro Machuca, Fernando Pálizas, Mario Omar Pozo, Bernardo Lattanzio, Emanuel Valgolio, Mario Kenar, Carlos Sosa, Sergio Sarquis, Graciela Tuhay, Francisco Klein, Ariel Sosa, Daniel Ivulich, Luciana Bianchi, Enrique Ruben Correger, Carla Groer, Ma. Victoria Arrosagaray, Graciela Cueto, Carlos Cozzani, Gustavo Badariotti, Bernardo de Diego, Daniela N. Vásquez, Gustavo Plotnikov, Analía Santa María, Mariana Bertes, Alejandro Gomez, María Soledad Santagiuliana, Margarita Tavela, Pierina Bachetti, Célica Irrazabal, Alejandro Risso Vazquez, Paolo N. Rubatto Birri, Gabriel Olarte, Veronica Marcela Cannatelli, Anatilde Díaz, Analía García, Estefanía Minoldo, Cayetano Galletti, Esteban Payer, Marcelo Avilez, Silvio Ernesto Lazzeri, Luis A. Huespe, Lorena de los Ángeles Parra, Fernando Kurban, Carlos Anibal Pellegrini, Adrian Alfredo Martin, Graciela Zakalik, Magalí Sanchez, Natalia Barreto, Alfredo Elías Carreras, Johana Bastias, Julián Ivacachi, María Luz Campassi, Fabio Germán Repetto, María Gabriela Saenz, Cecilia Marchena, María Rosa Marino, Gerardo Ezcurra, Sebastián Caravaggio, María de los Ángeles García, Ana María Mazzola, Analía Piernatei, Estela Molinas, Mauro Iadanza, Mario Alejandro Traba, Leda Fiorella Bacci, Adriana Fernandez, Damián Piezny, Constanza Arias, Gustavo Chaparro, Graciela Celeste Lopez, Agustín Fernández, Catalina Reyes Najera, Adriana Baldiviezo, Alejandra Flores, Alejandro Risso Vazquez, Irma Moyano, Mónica Quinteros, Laura Budrovich
Abstract
Abstract Background Resuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. Our aim was to characterize cardiovascular and fluid management of sepsis in Argentina, a low and middle-income country (LMIC). Furthermore, we sought to test whether the utilization of dynamic tests of fluid responsiveness, as a guide for fluid therapy after initial resuscitation in patients with persistent or recurrent hypoperfusion, was associated with decreased mortality. Methods Secondary analysis of a national, multicenter prospective cohort study ( n = 787) fulfilling Sepsis-3 definitions. Epidemiological characteristics, hemodynamic management data, type of fluids and vasopressors administered, physiological variables denoting hypoperfusion, use of tests of fluid responsiveness, and outcomes, were registered. Independent predictors of mortality were identified with logistic regression analysis. Results Initially, 584 of 787 patients (74%) had mean arterial pressure (MAP) < 65 mm Hg and/or signs of hypoperfusion and received 30 mL/kg of fluids, mostly normal saline (53%) and Ringer lactate (35%). Vasopressors and/or inotropes were administered in 514 (65%) patients, mainly norepinephrine (100%) and dobutamine (9%); in 22%, vasopressors were administered before ending the fluid load. After this, 413 patients (53%) presented persisting or recurrent hypotension and/or hypoperfusion, which prompted administration of additional fluid, based on: lactate levels (66%), urine output (62%), heart rate (54%), central venous O 2 saturation (39%), central venous–arterial PCO 2 difference (38%), MAP (31%), dynamic tests of fluid responsiveness (30%), capillary-refill time (28%), mottling (26%), central venous pressure (24%), cardiac index (13%) and/or pulmonary wedge pressure (3%). Independent predictors of mortality were SOFA and Charlson scores, lactate, requirement of mechanical ventilation, and utilization of dynamic tests of fluid responsiveness. Conclusions In this prospective observational study assessing the characteristics of resuscitation of septic patients in Argentina, a LMIC, the prevalent use of initial fluid bolus with normal saline and Ringer lactate and the use of norepinephrine as the most frequent vasopressor, reflect current worldwide practices. After initial resuscitation with 30 mL/kg of fluids and vasopressors, 413 patients developed persistent or recurrent hypoperfusion, which required further volume expansion. In this setting, the assessment of fluid responsiveness with dynamic tests to guide fluid resuscitation was independently associated with decreased mortality.