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Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock
American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock☆ To the Editor, We read the letter “Fluid management decisions should not be guided by fixed central venous pressure targets” written by Polderman and Varon [1] with great interest. We thank them for their valuable contributions and criticisms. First of all, we did not cite the article number 4 that they had stated in their response. In that meta-analysis, 191 studies have been evaluated, 43 of them have been included in the study, and only 4 of them were associated with the patients who were in sepsis [2]. The title of our letter is questionable, but we do not agree with Polderman and Varon on the content [3]. Creatinine and lactate levels should be monitored closely for renal functions initially and after. Intravenous fluids, along with antibiotics, source control, vasopressors, inotropic agents, and mechanical ventilation are the key components in early management of septic shock [4,5]. For improving outcome in severe sepsis, early diagnosis, early antibiotics, and early and appropriate fluid resuscitation targeting is necessary for adequate tissue perfusion [6]. Of course, we oppose unnecessary extra fluids given to patients that result in "iatrogenic submersion." Hypotension often can be reversed with fluid administration alone. Volume repletion alone in patients with septic shock has been shown to produce significant improvement in cardiac function and systemic oxygen delivery, thereby enhancing tissue perfusion [7]. Fluid requirements for the initial resuscitation of the patients with septic shock are commonly large, with up to 10 L of crystalloids or 4 L of colloids required in the first 24 hours [7]. Rapid infusion of fluids is best initiated with boluses of 500 to 1000 mL titrated to end points, such as a mean arterial pressure of more than 70 mm Hg, heart rate less than 100 beats per minute, and urine output more than 0.5 mL/kg per hour during the initial 6 hours [7]. Fluid needs vary according to the comorbidities for each patient. We believe that every patient needs their own special fluid replacement, and also, do not think that the target values in the current guidelines should be achieved immediately. Initially, replacing less or more fluid is vital to the condition of the patients. However, because of the fear of iatrogenic submersion, to avoid required fluid timely may increase mortality as a result of organ hypoperfusion in patients with septic shock. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction [5]. What we criticize is that central venous pressure (CVP) values have not specified with the fluid balance, although there were central venous catheters of the patients in the study that was made by Sirvent et al [8]. We questioned how much fluid is given and which protocol was it based on, whether fluids were continued to be given to the patients who remained positive, and whether additional treatment was specified because in the study made by Coen et al [9], where central venous ☆ There is no conflict of interests.
catheter was inserted to 61.7% of patients, none of the patient’s CVPs were measured, and the fluid replacement method they had used to guide were not compared with CVP. How can we avoid the risk of iatrogenic submersion while still giving our patients the fluids that they may need? [10]. Are we unintentionally drowning these patients while trying to treat? Therefore, when, to what extent, and for how long are we required to restrict fluids of the patients who have a positive fluid balance? Will these patients recover completely when we stop fluid replacement? We believe that central venous catheter is purposeful to measure pressure, not to load fluid, especially for the patients in septic shock. Sometimes, the patient’s examination findings can be precious than any numerical value. Why do we not use a central venous catheter for measuring the pressure, which is already present in the patient, well running, and giving accurate results? Although the appropriate fluid replacement therapy, if CVP does not come to normal value, it is necessary to focus on the problem that leads to positive fluid balance, and we have to treat it. We are opposed to uncontrolled fluid replacement for raising CVP values and to cause drowning of the patients. We hope to enter more reliable and easy to apply methods in practice to guide fluid therapy in these patients (3). Hakan Sarlak MD Department of Internal Medicine, Diyarbakır Military Hospital Diyarbakır, Turkey Corresponding author. Department of Internal Medicine, Diyarbakır Military Hospital, Seref Inaloz St. 21100 Yenisehir, Diyarbakır, Turkey Tel.: +90 412 2288225; fax: +90 412 2236732 E-mail address: [email protected] Mustafa Tanrıseven MD Department of General Surgery, Diyarbakır Military Hospital Diyarbakır, Turkey Eyup Duran MD Department of General Surgery, Elazıg Military Hospital, Elazıg, Turkey http://dx.doi.org/10.1016/j.ajem.2015.05.014 References [1] Polderman KH, Varon J, Marik PE. Fluid management decisions should not be guided by fixed central venous pressure targets. Am J Emerg Med 2015 (Article in press. DOI: http://dx.doi.org/10.1016/j.ajem.2015.05.015). [2] Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some commen sense. Crit Care Med 2013;41:1774–81. [3] Sarlak H, Tanrıseven M, Duran E. Fluid necessity should be followed by central venous pressure. Am J Emerg Med 2015;33:471.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Sarlak H, et al, Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.014
2
Correspondence / American Journal of Emergency Medicine xxx (2015) xxx–xxx
[4] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [5] Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296–327. [6] Dellinger RP. The Surviving Sepsis Campaing 2014: An update on the management and performance improvement for adults in severe sepsis. Consultant 2014; 54(10):767–71.
[7] Raghavan M, Marik PE. Management of sepsis during the early “golden hours”. J Emerg Med 2006;31:185–99. [8] Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. Fluid balance in sepsis andseptic shock as a determining factor of mortality. Am J Emerg Med 2015;33:186–9. [9] Coen D, Cortellano F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a Less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014;32:563–8. [10] Polderman KH, Varon J. Do not drown the patient: appropriate fluid management in critical illness. Am J Emerg Med 2015;33:448–50.
Please cite this article as: Sarlak H, et al, Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.014
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock☆ To the Editor, We read the letter “Fluid management decisions should not be guided by fixed central venous pressure targets” written by Polderman and Varon [1] with great interest. We thank them for their valuable contributions and criticisms. First of all, we did not cite the article number 4 that they had stated in their response. In that meta-analysis, 191 studies have been evaluated, 43 of them have been included in the study, and only 4 of them were associated with the patients who were in sepsis [2]. The title of our letter is questionable, but we do not agree with Polderman and Varon on the content [3]. Creatinine and lactate levels should be monitored closely for renal functions initially and after. Intravenous fluids, along with antibiotics, source control, vasopressors, inotropic agents, and mechanical ventilation are the key components in early management of septic shock [4,5]. For improving outcome in severe sepsis, early diagnosis, early antibiotics, and early and appropriate fluid resuscitation targeting is necessary for adequate tissue perfusion [6]. Of course, we oppose unnecessary extra fluids given to patients that result in "iatrogenic submersion." Hypotension often can be reversed with fluid administration alone. Volume repletion alone in patients with septic shock has been shown to produce significant improvement in cardiac function and systemic oxygen delivery, thereby enhancing tissue perfusion [7]. Fluid requirements for the initial resuscitation of the patients with septic shock are commonly large, with up to 10 L of crystalloids or 4 L of colloids required in the first 24 hours [7]. Rapid infusion of fluids is best initiated with boluses of 500 to 1000 mL titrated to end points, such as a mean arterial pressure of more than 70 mm Hg, heart rate less than 100 beats per minute, and urine output more than 0.5 mL/kg per hour during the initial 6 hours [7]. Fluid needs vary according to the comorbidities for each patient. We believe that every patient needs their own special fluid replacement, and also, do not think that the target values in the current guidelines should be achieved immediately. Initially, replacing less or more fluid is vital to the condition of the patients. However, because of the fear of iatrogenic submersion, to avoid required fluid timely may increase mortality as a result of organ hypoperfusion in patients with septic shock. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction [5]. What we criticize is that central venous pressure (CVP) values have not specified with the fluid balance, although there were central venous catheters of the patients in the study that was made by Sirvent et al [8]. We questioned how much fluid is given and which protocol was it based on, whether fluids were continued to be given to the patients who remained positive, and whether additional treatment was specified because in the study made by Coen et al [9], where central venous ☆ There is no conflict of interests.
catheter was inserted to 61.7% of patients, none of the patient’s CVPs were measured, and the fluid replacement method they had used to guide were not compared with CVP. How can we avoid the risk of iatrogenic submersion while still giving our patients the fluids that they may need? [10]. Are we unintentionally drowning these patients while trying to treat? Therefore, when, to what extent, and for how long are we required to restrict fluids of the patients who have a positive fluid balance? Will these patients recover completely when we stop fluid replacement? We believe that central venous catheter is purposeful to measure pressure, not to load fluid, especially for the patients in septic shock. Sometimes, the patient’s examination findings can be precious than any numerical value. Why do we not use a central venous catheter for measuring the pressure, which is already present in the patient, well running, and giving accurate results? Although the appropriate fluid replacement therapy, if CVP does not come to normal value, it is necessary to focus on the problem that leads to positive fluid balance, and we have to treat it. We are opposed to uncontrolled fluid replacement for raising CVP values and to cause drowning of the patients. We hope to enter more reliable and easy to apply methods in practice to guide fluid therapy in these patients (3). Hakan Sarlak MD Department of Internal Medicine, Diyarbakır Military Hospital Diyarbakır, Turkey Corresponding author. Department of Internal Medicine, Diyarbakır Military Hospital, Seref Inaloz St. 21100 Yenisehir, Diyarbakır, Turkey Tel.: +90 412 2288225; fax: +90 412 2236732 E-mail address: [email protected] Mustafa Tanrıseven MD Department of General Surgery, Diyarbakır Military Hospital Diyarbakır, Turkey Eyup Duran MD Department of General Surgery, Elazıg Military Hospital, Elazıg, Turkey http://dx.doi.org/10.1016/j.ajem.2015.05.014 References [1] Polderman KH, Varon J, Marik PE. Fluid management decisions should not be guided by fixed central venous pressure targets. Am J Emerg Med 2015 (Article in press. DOI: http://dx.doi.org/10.1016/j.ajem.2015.05.015). [2] Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some commen sense. Crit Care Med 2013;41:1774–81. [3] Sarlak H, Tanrıseven M, Duran E. Fluid necessity should be followed by central venous pressure. Am J Emerg Med 2015;33:471.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Sarlak H, et al, Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.014
2
Correspondence / American Journal of Emergency Medicine xxx (2015) xxx–xxx
[4] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [5] Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296–327. [6] Dellinger RP. The Surviving Sepsis Campaing 2014: An update on the management and performance improvement for adults in severe sepsis. Consultant 2014; 54(10):767–71.
[7] Raghavan M, Marik PE. Management of sepsis during the early “golden hours”. J Emerg Med 2006;31:185–99. [8] Sirvent JM, Ferri C, Baro A, Murcia C, Lorencio C. Fluid balance in sepsis andseptic shock as a determining factor of mortality. Am J Emerg Med 2015;33:186–9. [9] Coen D, Cortellano F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a Less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014;32:563–8. [10] Polderman KH, Varon J. Do not drown the patient: appropriate fluid management in critical illness. Am J Emerg Med 2015;33:448–50.
Please cite this article as: Sarlak H, et al, Fluid Management Dilemma in Patients with Severe Sepsis and Septic Shock, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.05.014