Objective: To assess shock reversal and required fluid volumes in patients with septic shock.
Design: Prospective before and after study comparing three different treatment periods.
Setting: Fifty-bed single-center surgical intensive care unit.
Patients: Consecutive patients with severe sepsis.
Interventions: Fluid therapy directed at preset hemodynamic goals with hydroxyethyl starch (predominantly 6% hydroxyethyl starch 130/0.4) in the first period, 4% gelatin in the second period, and only crystalloids in the third period.
Measurements and Main Results: Main outcome was time to shock reversal (serum lactate <2.2 mmol/L and discontinuation of vasopressor use). Hemodynamic goals were mean arterial pressure >70 mm Hg; ScvO2 <70%; central venous pressure >8 mm Hg. Safety outcomes were acute kidney injury defined by Risk, Injury, Failure, Loss, and End-stage kidney disease criteria and new need for renal replacement therapy. Hemodynamic measures, serum lactate, and creatinine were comparable at baseline in all study periods (hydroxyethyl starch n = 360, gelatin n = 352, only crystalloids n = 334). Severity scores, hospital length of stay, and intensive care unit or hospital mortality did not differ significantly among groups. All groups showed similar time to shock reversal. More fluid was needed over the first 4 days in the crystalloid group (fluid ratios 1.4:1 [crystalloids to hydroxyethyl starch] and 1.1:1 [crystalloids to gelatin]). After day 5, fluid balance was more negative in the crystalloid group. Hydroxyethyl starch and gelatin were independent risk factors for acute kidney injury (odds ratio, 95% confidence interval 2.55, 1.76–3.69 and 1.85, 1.31–2.62, respectively). Patients receiving synthetic colloids received significantly more allogeneic blood products.
Conclusions: Shock reversal was achieved equally fast with synthetic colloids or crystalloids. Use of colloids resulted in only marginally lower required volumes of resuscitation fluid. Both low molecular weight hydroxyethyl starch and gelatin may impair renal function.
From the Department of Anesthesiology and Intensive Care Medicine (OB, KR, BK, YS, MB, CH, NR), Friedrich-Schiller-University Jena, Jena, Germany; Department of Mechanical and Process Engineering (MK), Furtwangen University, Schwenningen, Germany; Department of Surgery (JM), Interdepartmental Division of Critical Care, the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto Canada; Jena University Hospital (KR, MB, CH, DS), Center for Sepsis Control and Care, Jena, Germany.
*See also p. 2709.
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Drs. Bayer and Reinhart contributed equally to this work.
The study was not funded by external sources. Dr. Bayer was supported, in part, by an unrestricted grant of the Thuringian Ministry of Cultural Affairs (Landesprogramm ProExzellenz; PE 108-2); the Foundation of Technology, Innovation, and Research Thuringia (STIFT); and the German Sepsis Society. The funding agencies played no role in the design or conduct of the study nor in the analysis of data or writing of the manuscript.
Drs. Bayer, Kohl, Kabisch, Marshall, Sakr, Bauer, Hartog, Schwarzkopf, and Riedemann have no financial relationships with any organization that might have an interest in the submitted work in the previous 3 yrs and no other relationships or activities that could appear to have influenced the submitted work. Dr. Reinhart has, in the past, received an unrestricted grant for the conduct of the VISEP study and speaker’s and consultancy fees from B. Braun, Melsungen, Germany. B. Braun, Melsungen also contributed to the German Sepsis Society to fund an endowed professorship for clinical sepsis research at the University Hospital of Jena. The local ethics board waived the need for informed consent because of the observational nature of the study.
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