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The aim of our study was to assess the association between the macrohemodynamic profile and sepsis induced acute kidney injury (AKI). We also investigated which minimally invasive hemodynamic parameters may help identify patients at risk for sepsis-AKI. We included 71 patients with sepsis and septic shock. We performed the initial fluid resuscitation using local protocols and continued to give fluids guided by the minimally invasive hemodynamic parameters. We assessed the hemodynamic status by transpulmonary thermodilution technique. Sequential organ failure assessment (SOFA score) (AUC 0.74, 95% CI 0.61-0.83, p < 0.01) and cardiovascular SOFA (AUC 0.73, 95% CI 0.61-0.83, p < 0.01) were found to be predictors for sepsis-induced AKI, with cut-off values of 9 and 3 points respectively. Persistent low stroke volume index (SVI) ≤ 32 mL/m2/beat (AUC 0.67, 95% CI 0.54-0.78, p < 0.05) and global end-diastolic index (GEDI) < 583 mL/m2 (AUC 0.67, 95% CI 0.54-0.78, p < 0.05) after the initial fluid resuscitation are predictive for oliguria/anuria at 24 h after study inclusion. The combination of higher vasopressor dependency index (VDI, calculated as the (dobutamine dose × 1 + dopamine dose × 1 + norepinephrine dose × 100 + vasopressin × 100 + epinephrine × 100)/MAP) and norepinephrine, lower systemic vascular resistance index (SVRI), and mean arterial blood pressure (MAP) levels, in the setting of normal preload parameters, showed a more severe vasoplegia. Severe vasoplegia in the first 24 h of sepsis is associated with a higher risk of sepsis induced AKI. The SOFA and cardiovascular SOFA scores may identify patients at risk for sepsis AKI. Persistent low SVI and GEDI values after the initial fluid resuscitation may predict renal outcome.
RESUMO
INTRODUCTION: Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality. AIM OF THE STUDY: The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW). METHODS: Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by transpulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours. RESULTS: 68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid. CONCLUSIONS: Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.
