Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure: Results of a Multicenter Clinician Survey

Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis

STUDY OBJECTIVE

To compare guideline-based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH.

DESIGN

Single-center, retrospective cohort study.

SETTING

Tertiary care academic medical center in Detroit, Michigan.

PATIENTS

Adult patients with or without PH hospitalized and diagnosed with sepsis from November 1, 2013 through December 31, 2019. Patients with sepsis were assigned to one of two groups based on a previous PH diagnosis or no PH diagnosis.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was incidence of respiratory support escalation within 72 h from sepsis time zero. Respiratory support escalation included high-flow nasal cannula, bilevel positive airway pressure, or intubation. One-hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non-PH patients (32.7% vs. 11.5%; p = 0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 h of time zero compared with non-PH patients (3.8% vs. 42.3%; p < 0.001). Vasopressor initiation was more common in patients with PH compared with the non-PH group (40.4% vs. 19.2%; p = 0.018). PH diagnosis was the only independent predictor of respiratory support escalation.

CONCLUSIONS

During initial sepsis management when compared with patients without PH, patients with PH had increased instances of respiratory support escalation within 72 h of sepsis time zero despite lower fluid resuscitation volumes.

Representation Learning and Spectral Clustering for the Development and External Validation of Dynamic Sepsis Phenotypes: Observational Cohort Study

BACKGROUND

Recent attempts at clinical phenotyping for sepsis have shown promise in identifying groups of patients with distinct treatment responses. Nonetheless, the replicability and actionability of these phenotypes remain an issue because the patient trajectory is a function of both the patient's physiological state and the interventions they receive.

OBJECTIVE

We aimed to develop a novel approach for deriving clinical phenotypes using unsupervised learning and transition modeling.

METHODS

Forty commonly used clinical variables from the electronic health record were used as inputs to a feed-forward neural network trained to predict the onset of sepsis. Using spectral clustering on the representations from this network, we derived and validated consistent phenotypes across a diverse cohort of patients with sepsis. We modeled phenotype dynamics as a Markov decision process with transitions as a function of the patient's current state and the interventions they received.

RESULTS

Four consistent and distinct phenotypes were derived from over 11,500 adult patients who were admitted from the University of California, San Diego emergency department (ED) with sepsis between January 1, 2016, and January 31, 2020. Over 2000 adult patients admitted from the University of California, Irvine ED with sepsis between November 4, 2017, and August 4, 2022, were involved in the external validation. We demonstrate that sepsis phenotypes are not static and evolve in response to physiological factors and based on interventions. We show that roughly 45% of patients change phenotype membership within the first 6 hours of ED arrival. We observed consistent trends in patient dynamics as a function of interventions including early administration of antibiotics.

CONCLUSIONS

We derived and describe 4 sepsis phenotypes present within 6 hours of triage in the ED. We observe that the administration of a 30 mL/kg fluid bolus may be associated with worse outcomes in certain phenotypes, whereas prompt antimicrobial therapy is associated with improved outcomes.

Fluid management of emergency department patients with sepsis-A survey of fluid resuscitation practices

BACKGROUND

Fluid administration and resuscitation of patients with sepsis admitted through emergency departments (ED) remains a challenge, and evidence is sparse especially in sepsis patients without shock. We aimed to investigate emergency medicine physicians' and nurses' perceptions, self-reported decision-making and daily behavior, and challenges in fluid administration of ED sepsis patients.

METHODS

We developed and conducted a multicenter, web-based, cross-sectional survey focusing on fluid administration to ED patients with sepsis sent to all nurses and physicians from the five EDs in the Central Denmark Region. The survey consisted of three sections: (1) baseline information; (2) perceptions of fluid administration and daily practice; and (3) clinical scenarios about fluid administration. The survey was performed from February to June, 2021.

RESULTS

In total, 138 of 246 physicians (56%) and 382 of 595 nurses (64%) responded to the survey. Of total, 94% of physicians and 97% of nurses regarded fluid as an important part of sepsis treatment. Of total, 80% of physicians and 61% of nurses faced challenges regarding fluid administration in the ED, and decisions were usually based on clinical judgment. The most common challenge was the lack of guidelines for fluid administration. Of total, 96% agreed that they would like to learn more about fluid administration, and 53% requested research in fluid administration of patients with sepsis. For a normotensive patient with sepsis, 46% of physicians and 44% of nurses administered 1000 ml fluid in the first hour. Of total, 95% of physicians and 89% of nurses preferred to administer ≥1000 ml within an hour if the patients' blood pressure was 95/60 at admission. There was marked variability in responses. Blood pressure was the most commonly used trigger for fluid administration. Respondents preferred to administer less fluid if the patient in the scenario had known renal impairment or heart failure. Normal saline was the preferred fluid.

CONCLUSION

Fluid administration is regarded as an important but challenging aspect of sepsis management. Responses to scenarios revealed variability in fluid volumes. Blood pressure was the most used trigger. ED nurses and physicians request evidence-based guidelines to improve fluid administration.

Irisin attenuates sepsis-induced cardiac dysfunction by attenuating inflammation-induced pyroptosis through a mitochondrial ubiquitin ligase-dependent mechanism

Sepsis-induced cardiac dysfunction is a leading cause of mortality in intensive care units. However, the molecular mechanisms underlying septic cardiomyopathy remain elusive. Irisin is a cleaved product of fibronectin type III domain-containing protein 5 (FNDC5) that protects the heart from ischemia/reperfusion injury through upregulation of mitochondrial ubiquitin ligase (MITOL). Gasdermin D (GSDMD)-dependent pyroptosis plays a pivotal role in septic cardiomyopathy by regulating mitochondrial homeostasis. However, whether irisin can regulate MITOL to inhibit GSDMD-dependent pyroptosis in septic cardiomyopathy is yet to be investigated. Thus, this study was designed to explore the role of irisin in septic cardiomyopathy and its underlying molecular mechanisms. Our results demonstrate that irisin improves cardiac function against sepsis-induced cardiac dysfunction by reducing cardiac inflammation and myocardial pyroptosis. Using MITOL siRNA in vitro, the results revealed that the protective role of irisin against lipopolysaccharide (LPS)-induced cell injury was mediated by MITOL activation and the resulting inhibition of GSDMD-dependent pyroptosis. Moreover, irisin alleviated LPS-induced H9c2 cell injury by suppressing IL-1β expression and reducing serum LDH and CK-MB concentrations in a MITOL/GSDMD-dependent manner. Collectively, our data suggest that irisin treatment ameliorates cardiac dysfunction in septic cardiomyopathy by activating MITOL and inhibiting GSDMD-dependent pyroptosis. These findings highlight the clinical relevance and therapeutic potential of irisin and MITOL for the management of sepsis-induced cardiac dysfunction.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

An Evaluation of the Use of Aggressive Fluid Resuscitation in the Early Treatment of Sepsis Patients

Introduction

Fluid resuscitation is a critical aspect of the sepsis protocol with the usual initial dose being 30 mL per kilogram. Although this dose is well accepted in patients with normal cardiac function, there is some significant variation in clinical practice concerning the optimal fluid resuscitation in septic patients with underlying congestive heart failure (CHF). Many different approaches have been tried to best treat these patients by using lesser volumes of fluid. The purpose of this retrospective study is to attempt to better define optimal fluid resuscitation in congestive heart failure patients and whether standard fluid resuscitation exacerbates CHF in these cases.

Methods

This was a retrospective study involving patients admitted to the Emergency Department (ED) during the time period of September of 2016 through March of 2019 with a primary diagnosis of sepsis and pre-existing CHF. Data collected from the data warehouse and patient charts included demographics, total amount of fluid received in the ED and outcome data. Evidence of fluid overload (chest X-ray [CXR] evidence, rising B-type natriuretic peptide [BNP], or use of diuretics), was evaluated with respect to in-hospital mortality, white blood cell (WBC) count and comorbidities (chronic obstructive pulmonary disease [COPD], hypertension and coronary artery disease).

Results

There were 422 patients included in the cohort. Of the 422, 113 (26.8%) patients showed evidence of fluid overload on CXR during hospital stay and received diuretics and therefore considered in the CHF exacerbation group. The patients that experienced CHF exacerbation were significantly older (mean ± SD, 70.9 ± 11.8 years versus 67.4 ± 15.1 years, p=0.014). Patients with exacerbation also received more fluid (median and interquartile range, 3.0, 2:5.5 L versus 2.0, 1:4.3 L, p=0.017). The receiver operating characteristic curve analysis for fluid to predict exacerbation resulted in an area under the curve of 0.59 with a 95% confidence interval (CI) of 0.52 to 0.65, p=0.012. The Youden Index was used to determine an optimal cutoff value of 2.6 L. The percentage of patients in the exacerbation group above the threshold was significantly higher (57.3%) than those without exacerbation (43.3%), p=0.019. Following multivariate analysis, age greater than 60 (odds ratio [OR]: 2.5; CI: 1.4-4.6, p=0.003) and fluid cutoff of 2.6 L (OR: 1.9; CI: 1.2-3.1, p=0.007) were both found to be independent predictors of CHF exacerbation. There was no significant difference in mortality based on the total fluid received in the ED.

Conclusion

The findings of this study showed that septic patients with pre-existing CHF who received more than 2.6 L of fluid in the ED were 90% more likely to develop symptoms of CHF exacerbation with no evidence of lowering mortality compared to the group that received less than 2.6 L. Our data supports the practice of limiting total fluid resuscitation in CHF to 2.6 L and reconfirms the idea that fluid resuscitation for patients with CHF needs to be individualized.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.