[Haemodynamic monitoring in sepsis and septic shock]. / Monitorización hemodinámica en la sepsis y el shock séptico.

Cardiovascular disturbances associated with sepsis cause hypoperfusion situations, which will negatively impact these patients' prognosis. The aim of haemodynamic monitoring is to guide the detection and correction of this hypoperfusion, and assist in decision making in optimising oxygen transport to tissues, primarily by manipulating cardiac output. This review seeks to summarise the different parameters of haemodynamic monitoring, the objectives of resuscitation, the physiological parameters, and the tools available to us for appropriate cardiac output manipulation.

Hemodynamic support in septic shock.

PURPOSE OF REVIEW: The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients. RECENT FINDINGS: The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center. SUMMARY: Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.

Thenar oxygen saturation (StO2) alterations during a spontaneous breathing trial predict extubation failure.

BACKGROUND: Weaning from mechanical ventilation (MV) is a cardiovascular stress test. Monitoring the regional oxygenation status has shown promising results in predicting the tolerance to spontaneously breathe in the process of weaning from MV. Our aim was to determine whether changes in skeletal muscle oxygen saturation (StO2) measured by near-infrared spectroscopy (NIRS) on the thenar eminence during a vascular occlusion test (VOT) can be used to predict extubation failure from mechanical ventilation. METHODS: We prospectively studied 206 adult patients with acute respiratory failure receiving MV for at least 48 h from a 30-bed mixed ICU, who were deemed ready to wean by their physicians. Patients underwent a 30-min spontaneous breathing trial (SBT), and were extubated according to the local protocol. Continuous StO2 was measured non-invasively on the thenar eminence. A VOT was performed prior to and at 30 min of the SBT (SBT30). The rate of StO2 deoxygenation (DeO2), StO2 reoxygenation (ReO2) rate and StO2 hyperemic response to ischemia (HAUC) were calculated. RESULTS: Thirty-six of the 206 patients (17%) failed their SBT. The remainder 170 patients (83%) were extubated. Twenty-three of these patients (13.5%) needed reinstitution of MV within 24 h. Reintubated patients displayed a lower HAUC at baseline, and higher relative changes in their StO2 deoxygenation rate between baseline and SBT30 (DeO2 Ratio). A logistic regression-derived StO2 score, combining baseline StO2, HAUC and DeO2 ratio, showed an AUC of 0.84 (95% CI 0.74-0.91) for prediction of extubation failure. CONCLUSIONS: Extubation failure was associated to baseline and dynamic StO2 alterations during the SBT. Monitoring StO2-derived parameters might be useful in predicting extubation outcome.

Trends in the incidence and mortality of patients with community-acquired septic shock 2003-2016.

PURPOSE: To evaluate the incidence and mortality of adult patients with community-acquired septic shock (CASS) and the influence of source control (SC) and other risk factors on the outcome. MATERIAL AND METHODS: The study included patients with CASS admitted to the ICU at a university hospital (2003-2016). Multivariate analyses were performed to identify risk factors of ICU mortality. RESULTS: A total of 625 patients were included. The incidence showed an average annual increase of 4.9% and the mortality an average annual decrease of 1.4%. The patients who required SC showed a lower mortality (20.4%) than patients who did not require SC (31.3%) (p = 0.002). However, the evolution in mortality was different: Mortality decreased in patients who did not require SC (from 56.3% to 20%; p = 0.02), but did not differ in those who required SC (from 21.4% to 27.6%; p = 0.43). In the multivariate analysis, severity at admission, age, alcoholism, cirrhosis, ARDS, neutropenia and thrombocytopenia were associated with worse outcome, whereas appropriate antibiotic treatment and adequate SC were independently associated with better survival. CONCLUSIONS: The incidence of CASS increased and the ICU mortality decreased during the study period. The mortality was mainly due to a decrease in mortality in infections not requiring SC.

Effect of pneumoperitoneum and steep reverse-Trendelenburg position on mean systemic filling pressure, venous return, and microcirculation during esophagectomy.

BACKGROUND: Keeping adequate tissue perfusion during high-risk abdominal surgery is of utmost importance to decrease postoperative complications. The objective was to investigate the alteration in mean systemic filling pressure (MSFP), venous return (VR) and sublingual microcirculation during pneumoperitoneum and steep reverse-Trendelenburg position during thoracolaparoscopic esophagectomy. METHODS: This is a single-center prospective observational study in operating room at a university hospital. Eleven consecutive patients undergoing minimally invasive esophagectomy. Intraoperative hemodynamic and sublingual microcirculatory variables were simultaneously measured within 5 minutes at the following time points: T1, baseline supine position before the start of surgery; T2, pneumoperitoneum in supine position; T3, steep reverse-Trendelenburg position after the pneumoperitoneum. The cardiac output (CO) was obtained with continuous pulse contour waveform-derived measurements, and the MSFP was estimated with the analogue method. RESULTS: The pneumoperitoneum and reverse-Trendelenburg caused an increase in stroke volume variation (SVV), MSFP and central venous pressure (CVP), and a decrease in the microcirculatory perfusion index (MFI, <0.05). However, changes in CO, pressure gradient of VR, resistance of VR and blood pressure were not consistent and did not differ significantly across timepoints. Moreover, MFI is significantly related to CVP and MSFP but not to CO and blood pressure (BP). Measurements with MFI ≤2 have a higher CVP and MSFP compared to those with MFI >2. Using a CVP ≥23 mmHg to detect MFI ≤2 results in a sensitivity of 61.54% and a specificity of 100%. CONCLUSIONS: A high CVP is related to poor microcirculatory flow perfusion even if the macrocirculation has been maintained during pneumoperitoneum.

Passive leg raising for assessment of volume responsiveness: a review.

PURPOSE OF REVIEW: To evaluate the existing evidence on the passive leg raising (PLR) test for fluid responsiveness prediction. RECENT FINDINGS: It has been well established that either insufficient or excessive fluid administration derives in worse outcomes in critically ill patients, highlighting that a more accurate assessment of fluid management is required. Accordingly, several cardiovascular indices have been tested to improve our ability to predict patients' response to fluid loading at the bedside, the so-called functional hemodynamic monitoring. The standardized PLR is a relatively novel maneuver that, over the past 10 years, has repeatedly demonstrated high sensitivity and specificity for fluid responsiveness prediction. SUMMARY: The current review underlines that PLR is an easy-to-perform and reliable method to assess fluid responsiveness. Its excellent performance is maintained even in many situations in which other dynamic predictive indices are not consistent and represents a valid alternative to the fluid challenge to avoid unnecessary volume administration.

Central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference is associated with lactate evolution in the hemodynamic resuscitation process in early septic shock.

INTRODUCTION: Since normal or high central venous oxygen saturation (ScvO2) values cannot discriminate if tissue perfusion is adequate, integrating other markers of tissue hypoxia, such as central venous-to-arterial carbon dioxide difference (PcvaCO2 gap) has been proposed. In the present study, we aimed to evaluate the ability of the PcvaCO2 gap and the PcvaCO2/arterial-venous oxygen content difference ratio (PcvaCO2/CavO2) to predict lactate evolution in septic shock. METHODS: Observational study. Septic shock patients within the first 24 hours of ICU admission. After restoration of mean arterial pressure, and central venous oxygen saturation, the PcvaCO2 gap and the PcvaCO2/CavO2 ratio were calculated. Consecutive arterial and central venous blood samples were obtained for each patient within 24 hours. Lactate improvement was defined as the decrease ≥ 10% of the previous lactate value. RESULTS: Thirty-five septic shock patients were studied. At inclusion, the PcvaCO2 gap was 5.6 ± 2.1 mmHg, and the PcvaCO2/CavO2 ratio was 1.6 ± 0.7 mmHg · dL/mL O2. Those patients whose lactate values did not decrease had higher PcvaCO2/CavO2 ratio values at inclusion (1.8 ± 0.8vs. 1.4 ± 0.5, p 0.02). During the follow-up, 97 paired blood samples were obtained. No-improvement in lactate values was associated to higher PcvaCO2/CavO2 ratio values in the previous control. The ROC analysis showed an AUC 0.82 (p < 0.001), and a PcvaCO2/CavO2 ratio cut-off value of 1.4 mmHg · dL/mL O2 showed sensitivity 0.80 and specificity 0.75 for lactate improvement prediction. The odds ratio of an adequate lactate clearance was 0.10 (p < 0.001) in those patients with an elevated PcvaCO2/CavO2 ratio (≥1.4). CONCLUSION: In a population of septic shock patients with normalized MAP and ScvO2, the presence of elevated PcvaCO2/CavO2 ratio significantly reduced the odds of adequate lactate clearance during the following hours.

Valoración y tratamiento de la pancreatitis aguda. Documento de posicionamiento de la Societat Catalana de Digestologia, Societat Catalana de Cirurgia y Societat Catalana de Pàncrees / Assessment and treatment of acute pancreatitis. Position document of the Catalan Society of Gastroenterology, Catalan Society of Surgery and Catalan Society of the Pancreas

La pancreatitis aguda (PA) tiene una incidencia creciente y es una de las enfermedades gastrointestinales que con más frecuencia requiere hospitalización. Numerosas evidencias científicas en los últimos años han comportado modificaciones importantes del tratamiento médico y quirúrgico de la PA. Los nuevos conocimientos sobre la fisiopatología de la enfermedad nos indican que la gravedad de la PA viene marcada por la repercusión sistémica que ocasiona (fallo orgánico), sobre todo si es persistente, y también por las complicaciones locales que se pueden desarrollar (colecciones líquidas o necrosis), especialmente si se infectan. El tratamiento ha de ser personalizado y la actuación dependerá de la situación clínica, la localización de la necrosis y el momento evolutivo en que se encuentre el paciente

The incidence of acute pancreatitis (AP) is increasing. AP is one of the gastrointestinal diseases that most frequently requires hospital admission in affected individuals. In the last few years, considerable scientific evidence has led to substantial changes in the medical and surgical treatment of this disease. New knowledge of the physiopathology of AP indicates that its severity is influenced by its systemic effects (organ failure), especially if the disease is persistent, and also by local complications (fluid collections or necrosis), especially if these become infected. Treatment should be personalized and depends on the patient's clinical status, the location of the necrosis, and disease stage

[Assessment and treatment of acute pancreatitis. Position document of the Catalan Society of Gastroenterology, Catalan Society of Surgery and Catalan Society of the Pancreas]. / Valoración y tratamiento de la pancreatitis aguda. Documento de posicionamiento de la Societat Catalana de Digestologia, Societat Catalana de Cirurgia y Societat Catalana de Pàncrees.

The incidence of acute pancreatitis (AP) is increasing. AP is one of the gastrointestinal diseases that most frequently requires hospital admission in affected individuals. In the last few years, considerable scientific evidence has led to substantial changes in the medical and surgical treatment of this disease. New knowledge of the physiopathology of AP indicates that its severity is influenced by its systemic effects (organ failure), especially if the disease is persistent, and also by local complications (fluid collections or necrosis), especially if these become infected. Treatment should be personalized and depends on the patient's clinical status, the location of the necrosis, and disease stage.

Thenar oxygen saturation during weaning from mechanical ventilation: an observational study.

Our aim was to determine whether thenar tissue oxygen saturation (S(tO2)), measured by noninvasive near-infrared spectroscopy, and its changes derived from an ischaemic challenge are associated with weaning outcome. Our study comprised a prospective observational study in a 26-bed medical-surgical intensive care unit. Patients receiving mechanical ventilation for >48 h, and considered ready to wean by their physicians underwent a 30-min weaning trial. S(tO2) was measured continuously on the thenar eminence. A transient vascular occlusion test was performed prior to and at the end of the 30-min weaning trial, in order to obtain S(tO2) deoxygenation and reoxygenation rates, and estimated local oxygen consumption. 37 patients were studied. Patients were classified as weaning success (n=24) or weaning failure (n=13). No significant demographic, respiratory or haemodynamic differences were observed between the groups at inclusion. Patients who failed the overall weaning process showed a significant increase in deoxygenation and in local oxygen consumption from baseline to 30 min of weaning trial, whereas no significant changes were observed in the weaning success group. Failure to wean from mechanical ventilation was associated with higher relative increases in deoxygenation after 30 min of spontaneous ventilation.

Thenar oxygen saturation and invasive oxygen delivery measurements in critically ill patients in early septic shock.

This prospective study was aimed to test the hypothesis that tissue hemoglobin oxygen saturation (StO2) measured noninvasively using near-infrared spectroscopy is a reliable indicator of global oxygen delivery (DO2) measured invasively using a pulmonary artery catheter (PAC) in patients with septic shock. The study setting was a 26-bed medical-surgical intensive care unit at a university hospital. Subjects were adult patients in septic shock who required PAC hemodynamic monitoring for resuscitation. Interventions included transient ischemic challenge on the forearm. After blood pressure normalization, hemodynamic and oximetric PAC variables and, simultaneously, steady-state StO2 and its changes from ischemic challenge (deoxygenation and reoxygenation rates) were measured. Fifteen patients were studied. All the patients had a mean arterial pressure above 65 mmHg. The DO2 index (iDO2) range in the studied population was 215 to 674 mL O2/min per m. The mean mixed venous oxygen saturation value was 61% ± 10%, mean cardiac index was 3.4 ± 0.9 L/min per m, and blood lactate level was 4.6 ± 2.7 mmol/L. Steady-state StO2 significantly correlated with iDO2, arterial and venous O2 content, and O2 extraction ratio. A StO2 cutoff value of 75% predicted iDO2 below 450, with a sensitivity of 0.9 and a specificity of 0.9. In patients in septic shock and normalized MAP, low StO2 reflects extremely low iDO2. Steady-state StO2 does not correlate with moderately low iDO2, indicating poor sensitivity of StO2 to rule out hypoperfusion.