Fluid choice for resuscitation in septic patients: story of crystalloids / 医学研究生学报

A debate on the role of crystalloids vs colloids for fluid resuscitation has lasted over a century. Obviously, crystalloids were predominantly used in septic patients who were characterized with very complex pathophysiological abnormalities. Meanwhile, it remained controversial whether crystalloids induced an extra pathophysiological alternations while replacing volume depletion. This article was aimed at discussing physiological efficacy and safety of crystalloids for volume replacement through reviewing previous approaches on choice of fluids for septic patients.

Early fluid loading for septic patients: Any safety limit needed? / 中华创伤杂志(英文版)

Early adequate fluid loading was the corner stone of hemodynamic optimization for sepsis and septic shock. Meanwhile, recent recommended protocol for fluid resuscitation was increasingly debated on hemodynamic stability vs risk of overloading. In recent publications, it was found that a priority was often given to hemodynamic stability rather than organ function alternation in the early fluid resuscitation of sepsis. However, no safety limits were used at all in most of these reports. In this article, the rationality and safety of early aggressive fluid loading for septic patients were discussed. It was concluded that early aggressive fluid loading improved hemodynamics transitorily, but was probably traded off with a follow-up organ function impairment, such as worsening oxygenation by reduction of lung aeration, in a part of septic patients at least. Thus, a safeguard is needed against unnecessary excessive fluids in early aggressive fluid loading for septic patients.

Normal saline for intravenous fluid therapy in critically ill patients / 中华创伤杂志(英文版)

The efficacy and safety of normal saline (NS) for fluid therapy in critically ill patients remain controversy. In this review, we summarized the evidence of randomized controlled trials (RCTs) which compared NS with other solutions in critically ill patients. The results showed that when compared with 6% hydroxyethyl starch (HES), NS may reduce the onset of acute kidney injury (AKI). However, there is no significant different in mortality and incidence of AKI when compared with 10% HES, albumin and buffered crystalloid solution. Therefore, it is important to prescribe intravenous fluid for patients according to their individual condition.

Extensive variability in vasoactive agent therapy: a nationwide survey in Chinese intensive care units / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Inconsistencies in the use of the vasoactive agent therapy to treat shock are found in previous studies. A descriptive study was proposed to investigate current use of vasoactive agents for patients with shock in Chinese intensive care settings.</p><p><b>METHODS</b>A nationwide survey of physicians was conducted from August 17 to December 30, 2012. Physicians were asked to complete a questionnaire which focused on the selection of vasoactive agents, management in the use of vasopressor/inotropic therapy, monitoring protocols when using these agents, and demographic characteristics.</p><p><b>RESULTS</b>The response rate was 65.1% with physicians returning 586 valid questionnaires. Norepinephrine was the first choice of a vasopressor used to treat septic shock by 70.8% of respondents; 73.4% of respondents favored dopamine for hypovolemic shock; and 68.3% of respondents preferred dopamine for cardiogenic shock. Dobutamine was selected by 84.1%, 64.5%, and 60.6% of respondents for septic, hypovolemic, and cardiogenic shock, respectively. Vasodilator agents were prescribed by physicians in the management of cardiogenic shock (67.1%) rather than for septic (32.3%) and hypovolemic shock (6.5%). A significant number of physicians working in teaching hospitals were using vasoactive agents in an appropriate manner when compared to physicians in nonteaching hospitals.</p><p><b>CONCLUSIONS</b>Vasoactive agent use for treatment of shock is inconsistent according to self-report by Chinese intensive care physicians; however, the variation in use depends upon the form of shock being treated and the type of hospital; thus, corresponding educational programs about vasoactive agent use for shock management should be considered.</p>

Sources of Heterogeneity in Trials Reporting Hydroxyethyl Starch 130/0.4 or 0.42 Associated Excess Mortality in Septic Patients: A Systematic Review and Meta-regression / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>This meta-analysis was to determine the association of the cumulative dose of 130/0.4 or 0.42 (hydroxyethyl starch [HES] 130/0.4*) or delta daily fluid balance (i.e., daily fluid balance in HES group over or below control group) with the heterogeneity of risk ratio (RR) for mortality in randomized control trials (RCTs).</p><p><b>METHODS</b>Three databases (PubMed, EMBASE, Cochrane) were searched to identify prospective RCTs reporting mortality in adult patients with sepsis to compare HES130/0.4* with crystalloids or albumin. Meta-analysis was performed using random effects. Sensitivity and meta-regression analyses were used to examine the heterogeneity sources of RR for mortality.</p><p><b>RESULTS</b>A total number of 4408 patients from 11 RCTs were included. The pooled RR showed no significant difference for overall mortality in patients with administration of HES130/0.4* compared with treatment of control fluids (RR: 1.02, 95% confidence interval: 0.90-1.17; P = 0.73). Heterogeneity was moderate across recruited trials (I2 = 34%, P = 0.13). But, a significant variation was demonstrated in subgroup with crystalloids as control fluids (I2 = 42%, P < 0.1). Sensitivity analysis revealed that trials with high risk of bias did not significantly impact the pooled estimates for mortality. Meta-regression analysis also did not determine a dose-effect relationship of HES130/0.4* with mortality (P = 0.298), but suggested daily delta fluid balance being likely associated with mortality in septic patients receiving HES130/130/0.4* (P = 0.079).</p><p><b>CONCLUSIONS</b>Inappropriate daily positive fluid balance was likely an important source of heterogeneity in these trials reporting HES130/0.4* associated with excess mortality in septic patients.</p>

Factors associated with low adherence to head-of-bed elevation during mechanical ventilation in Chinese intensive care units / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Elevating the head of bed (HOB) 30° - 45° has been widely supported as a means of ventilator associated pneumonia (VAP) prevention. However, it was poorly adhered in clinical practice. This observational study aimed to investigate the factors impeding this simple practice at the bedside.</p><p><b>METHODS</b>This prospective study was conducted in 33 Chinese academic hospital intensive care units (ICUs). HOB angle was measured four times daily at 5 - 7 hour intervals. The predefined HOB elevation goal was an angle ≥ 30°.</p><p><b>RESULTS</b>The overall rate of achieving the HOB goal was 27.8% of the 8647 measurements in 314 patients during 2842 ventilation days. The HOB goal of ≥ 3 times/d was consistently achieved only in 15.9% of the cases. Almost 60% of patients had at least one 24 hours period during which the HOB goal was never documented. This low rate of protocol compliance was not associated with acute physiology and chronic health evaluation (APACHE) II score or dependence on vasopressors. In a survey, "nurse workload" was identified as the most important factor for non-compliance with the HOB goal. In addition, the rates of compliance were significantly different (P < 0.001) between physicians self-reporting that they either did or did not know the Institutes of Healthcare Improvement (IHI) ventilator bundle.</p><p><b>CONCLUSIONS</b>Low adherence to a HOB angle of ≥ 30° was found in this nationwide survey. Nursing workload and lack of knowledge on VAP prevention were important barriers to changing this practice.</p>

Knowledge and challenge: Inspiration gained from the epidemiological trend of sepsis / 解放军医学杂志

Associated with high morbility and mortality, sepsis has been seriously threatening human's health. Epidemiological trend of sepsis indicated that the increase of prevalence rate of sepsis was partially related with the current innovations in medical care, especially the rapid increase in invasive techniques for caring patients suffering from critical illness. Because the pathogenesis of sepsis remains unclear, with a low specificity of the ESICM/SCCM consensus diagnostic criteria for sepsis, the diagnosis of 'severe sepsis' has attracted a great deal of attention of medical scientists due to its higher accordance with the septic pathophysiological process of this clinical syndrome. In addition, the lack of knowledge on diagnostic criteria and management guideline seriously impede clinical application of some valid interventions for severe sepsis, thus resulting in consistent high incidence and mortality of sepsis. Moreover, lack of knowledge for sepsis in the society and even among the healthcare providers is the serious barrier to sepsis prevention and management.