Advertisement

Holistic Monitoring and Treatment in Septic Shock

  • Glenn Hernández
  • Lara Rosenthal
  • Jan Bakker
Chapter

Abstract

Sepsis-related circulatory dysfunction is usually manifested as an early hypovolemic state that can be reversed with initial fluid resuscitation. If not reversed early, this can progress into a persistent circulatory dysfunction. In contrast to a quite predictable course during the initial phase, persistent circulatory dysfunction is a complex and heterogeneous syndrome. All individual perfusion parameters have extensive limitations to adequately reflect tissue perfusion status in this phase. However, a multimodal approach integrating observation, macrohemodynamics, metabolic parameters, and peripheral and eventually microcirculatory perfusion parameters can overcome their individual limitations. This proposal may provide a holistic understanding of the predominant underlying mechanisms of hypoperfusion and lead to individualized and physiologically oriented therapeutic strategies.

Keywords

Monitoring Circulatory failure Shock Holistic 

References

  1. 1.
    Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40:1795–815.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101:1644–55.CrossRefGoogle Scholar
  3. 3.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, International Sepsis Definitions Conference. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med. 2003;29:530–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP. Surviving Sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43(3):304–77.CrossRefPubMedGoogle Scholar
  5. 5.
    Metkus TS, Kim BS. Bedside diagnosis in the intensive care unit. Is looking overlooked? Ann Am Thorac Soc. 2015;12:1447–50.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    John BV, Thomas SM. Physical examination. Lancet. 2003;362:2023; author reply 2024.CrossRefPubMedGoogle Scholar
  7. 7.
    Ioannidis JP. Physical examination. Lancet. 2003;362:2023; author reply 2024.CrossRefPubMedGoogle Scholar
  8. 8.
    Pehle B, Nast-Kolb D, Oberbeck R, Waydhas C, Ruchholtz S. [Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room]. Unfallchirurg. 2003;106:642–8.Google Scholar
  9. 9.
    Lima A, Jansen TC, Van Boommel J, Ince C, Bakker J. The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients. Crit Care Med. 2009;37:934–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Ait-Oufella H, Lemoinne S, Boelle PY, Galbois A, Baudel JL, Lemant J, Joffre J, Margetis D, Guidet B, Maury E, Offenstadt G. Mottling score predicts survival in septic shock. Intensive Care Med. 2011;37:801–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Vazquez R, Gheorghe C, Kaufman D, Manthous CA. Accuracy of bedside physical examination in distinguishing categories of shock: a pilot study. J Hosp Med. 2010;5:471–4.CrossRefPubMedGoogle Scholar
  12. 12.
    Smith T, Den Hartog D, Moerman T, Patka P, Van Lieshout EM, Schep NW. Accuracy of an expanded early warning score for patients in general and trauma surgery wards. Br J Surg. 2012;99:192–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Vincent JL, Ince C, Bakker J. Clinical review: circulatory shock—an update: a tribute to Professor Max Harry Weil. Crit Care. 2012;16:239.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Palizas F, Dubin A, Regueira T, Bruhn A, Knobel E, Lazzeri S, Baredes N, Hernandez G. Gastric tonometry versus cardiac index as resuscitation goals in septic shock: a multicenter, randomized, controlled trial. Crit Care. 2009;13:R44.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J. Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med. 2010;182:752–61.CrossRefPubMedGoogle Scholar
  16. 16.
    Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303:739–46.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Gattinoni L, Brazzi L, Pelosi P, Latini R, Tognoni G, Pesenti A, Fumagalli R. A trial of goal-oriented hemodynamic therapy in critically ill patients. SvO2 Collaborative Group. N Engl J Med. 1995;333:1025–32.CrossRefPubMedGoogle Scholar
  18. 18.
    Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.CrossRefPubMedGoogle Scholar
  19. 19.
    Hernandez G, Pedreros C, Veas E, Bruhn A, Romero C, Rovegno M, Neira R, Bravo S, Castro R, Kattan E, Ince C. Evolution of peripheral vs metabolic perfusion parameters during septic shock resuscitation. A clinical-physiologic study. J Crit Care. 2012;27:283–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Creteur J, Carollo T, Soldati G, Buchele G, De Backer D, Vincent JL. The prognostic value of muscle StO2 in septic patients. Intensive Care Med. 2007;33:1549–56.CrossRefPubMedGoogle Scholar
  21. 21.
    Lima A, van Bommel J, Jansen TC, Ince C, Bakker J. Low tissue oxygen saturation at the end of early goal-directed therapy is associated with worse outcome in critically ill patients. Crit Care. 2009;13 Suppl 5:S13.CrossRefPubMedGoogle Scholar
  22. 22.
    Ospina-Tascon GA, Bautista-Rincon DF, Umana M, Tafur JD, Gutierrez A, Garcia AF, Bermudez W, Granados M, Arango-Davila C, Hernandez G. Persistently high venous-to-arterial carbon dioxide differences during early resuscitation are associated with poor outcomes in septic shock. Crit Care. 2013;17:R294.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Bakker J, Vincent JL, Gris P, Leon M, Coffernils M, Kahn RJ. Veno-arterial carbon dioxide gradient in human septic shock. Chest. 1992;101:509–15.CrossRefPubMedGoogle Scholar
  24. 24.
    Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;32:1825–31.CrossRefPubMedGoogle Scholar
  25. 25.
    De Backer D, Donadello K, Sakr Y, Ospina-Tascon G, Salgado D, Scolletta S, Vincent JL. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med. 2013;41:791–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Ince C. The microcirculation is the motor of sepsis. Crit Care. 2005;9(Suppl 4):S13–9.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Boerma EC, Koopmans M, Konijn A, Kaiferova K, Bakker AJ, van Roon EN, Buter H, Bruins N, Egbers PH, Gerritsen RT, Koetsier PM, Kingma WP, Kuiper MA, Ince C. Effects of nitroglycerin on sublingual microcirculatory blood flow in patients with severe sepsis/septic shock after a strict resuscitation protocol: a double-blind randomized placebo controlled trial. Crit Care Med. 2010;38:93–100.CrossRefPubMedGoogle Scholar
  28. 28.
    Tisdall MM, Smith M. Multimodal monitoring in traumatic brain injury: current status and future directions. Br J Anaesth. 2007;99:61–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Werdan K, Russ M, Buerke M, Delle-Karth G, Geppert A, Schondube FA, German Cardiac Society, German Society of Intensive Care and Emergency Medicine, German Society for Thoracic and Cardiovascular Surgery, German Interdisciplinary Association of Intensive Care and Emergency Medicine, Austrian Society of Cardiology, German Society of Anaesthesiology and Intensive Care Medicine, German Society of Preventive Medicine and Rehabilitation. Cardiogenic shock due to myocardial infarction: diagnosis, monitoring and treatment: a German-Austrian S3 Guideline. Dtsch Arztebl Int. 2012;109:343–51.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, Delaney A, Harrison DA, Holdgate A, Howe B, Huang DT, Iwashyna T, Kellum JA, Peake SL, Pike F, Reade MC, Rowan KM, Singer M, Webb SA, Weissfeld LA, Yealy DM, Young JD. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med. 2015;41:1549–60.CrossRefPubMedGoogle Scholar
  31. 31.
    Hernandez G, Pena H, Cornejo R, Rovegno M, Retamal J, Navarro JL, Aranguiz I, Castro R, Bruhn A. Impact of emergency intubation on central venous oxygen saturation in critically ill patients: a multicenter observational study. Crit Care. 2009;13:R63.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Textoris J, Fouche L, Wiramus S, Antonini F, Tho S, Martin C, Leone M. High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality. Crit Care. 2011;15:R176.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Hernandez G, Bruhn A, Castro R, Regueira T. The holistic view on perfusion monitoring in septic shock. Curr Opin Crit Care. 2012;18:280–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Vincent JL, Quintairos ESA, Couto L Jr, Taccone FS. The value of blood lactate kinetics in critically ill patients: a systematic review. Crit Care. 2016;20:257.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Hernandez G, Luengo C, Bruhn A, Kattan E, Friedman G, Ospina-Tascon GA, Fuentealba A, Castro R, Regueira T, Romero C, Ince C, Bakker J. When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring. Ann Intensive Care. 2014;4:30.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Jansen TC, van Bommel J, Bakker J. Blood lactate monitoring in critically ill patients: a systematic health technology assessment. Crit Care Med. 2009;37:2827–39.PubMedGoogle Scholar
  37. 37.
    Monnet X, Delaney A, Barnato A. Lactate-guided resuscitation saves lives: no. Intensive Care Med. 2016;42:470–1.CrossRefPubMedGoogle Scholar
  38. 38.
    Bloos F, Zhang Z, Boulain T. Lactate-guided resuscitation saves lives: yes. Intensive Care Med. 2016;42:466–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Bakker J, de Backer D, Hernandez G. Lactate-guided resuscitation saves lives: we are not sure. Intensive Care Med. 2016;42:472–4.CrossRefPubMedGoogle Scholar
  40. 40.
    Hernandez G, Castro R, Romero C, de la Hoz C, Angulo D, Aranguiz I, Larrondo J, Bujes A, Bruhn A. Persistent sepsis-induced hypotension without hyperlactatemia: Is it really septic shock? J Crit Care. 2011;26:435 e439–14.CrossRefGoogle Scholar
  41. 41.
    Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R, Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2012;39:165–228.CrossRefGoogle Scholar
  42. 42.
    Bakker J. Lactate levels and hemodynamic coherence in acute circulatory failure. Best Pract Res Clin Anaesthesiol. 2016;30:523–30.CrossRefPubMedGoogle Scholar
  43. 43.
    Dunser MW, Ruokonen E, Pettila V, Ulmer H, Torgersen C, Schmittinger CA, Jakob S, Takala J. Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial. Crit Care. 2009;13:R181.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Sakr Y, Rubatto Birri PN, Kotfis K, Nanchal R, Shah B, Kluge S, Schroeder ME, Marshall JC, Vincent JL, Intensive Care Over Nations Investigators. Higher fluid balance increases the risk of death from sepsis: results from a large international audit. Crit Care Med. 2017;45:386–94.CrossRefPubMedGoogle Scholar
  45. 45.
    Klijn E, van Velzen MHN, Lima AP, Bakker J, van Bommel J, Groeneveld ABJ. Tissue perfusion and oxygenation to monitor fluid responsiveness in critically ill, septic patients after initial resuscitation: a prospective observational study. J Clin Monit Comput. 2015;29:707–12.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Ospina-Tascon GA, Umana M, Bermudez W, Bautista-Rincon DF, Hernandez G, Bruhn A, Granados M, Salazar B, Arango-Davila C, De Backer D. Combination of arterial lactate levels and venous-arterial CO2 to arterial-venous O2 content difference ratio as markers of resuscitation in patients with septic shock. Intensive Care Med. 2015;41:796–805.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Trzeciak S, Dellinger RP, Parrillo JE, Guglielmi M, Bajaj J, Abate NL, Arnold RC, Colilla S, Zanotti S, Hollenberg SM, Microcirculatory Alterations in Resuscitation and Shock Investigators. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med. 2007;49:88–98, 98 e81–82CrossRefPubMedGoogle Scholar
  48. 48.
    Payen D, Luengo C, Heyer L, Resche-Rigon M, Kerever S, Damoisel C, Losser MR. Is thenar tissue hemoglobin oxygen saturation in septic shock related to macrohemodynamic variables and outcome? Crit Care. 2009;13 Suppl 5:S6.CrossRefPubMedGoogle Scholar
  49. 49.
    Pottecher J, Deruddre S, Teboul JL, Georger JF, Laplace C, Benhamou D, Vicaut E, Duranteau J. Both passive leg raising and intravascular volume expansion improve sublingual microcirculatory perfusion in severe sepsis and septic shock patients. Intensive Care Med. 2010;36:1867–74.CrossRefPubMedGoogle Scholar
  50. 50.
    Ospina-Tascon G, Neves AP, Occhipinti G, Donadello K, Buchele G, Simion D, Chierego ML, Silva TO, Fonseca A, Vincent JL, De Backer D. Effects of fluids on microvascular perfusion in patients with severe sepsis. Intensive Care Med. 2010;36:949–55.CrossRefPubMedGoogle Scholar
  51. 51.
    Dunser MW, Takala J, Brunauer A, Bakker J. Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. Crit Care. 2013;17:326.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Glenn Hernández
    • 1
  • Lara Rosenthal
    • 2
  • Jan Bakker
    • 1
    • 3
    • 4
    • 5
  1. 1.Departamento de Medicina Intensiva, Facultad de MedicinaPontificia Universidad Católica de ChileSantiagoChile
  2. 2.Rosenthal AcupunctureNew YorkUSA
  3. 3.Division of Pulmonary, Allergy, and Critical Care MedicineColumbia University Medical CenterNew YorkUSA
  4. 4.Department of Intensive Care AdultsErasmus MC University Medical CenterRotterdamNetherlands
  5. 5.Division of Pulmonary and Critical CareNew York University Langone Medical Center – Bellevue HospitalNew YorkUSA

Personalised recommendations