Case 1.. back to the pressor.

Thank you and welcome to all the followers through WordPress, Twitter, and Facebook over the past week.

The #icurounds discussion on fluid choice had some great contributions (@petrosoniak, @brambo43, @canibagthat, @RB_cavalcanti, @joshualandy, @ACSmaggus, @rjggoldberg). Seems as though the consensus is initial fluid resuscitation with a crystalloid – normal saline or Ringer’s Lactate. 

So let’s go back to our patient, a 75 year old with community acquired pneumonia admitted earlier in the day. Upon reviewing the chart, you find that he’s been resuscitated with 4L of NS to this point.

His pressure is 86/52 with a heart rate of 120, on dopamine 10 mcg/kg/min.

What would you do at this point for pharmacological support of his blood pressure?

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Case 1 continued… the fluid debate

Thanks @RB_Cavalcanti, @canibagthat, and @rjggoldberg for being the first contributors in the #icurounds discussion.

Great points were raised – shouldn’t we address fluids before talking about pressors? What type of fluid?

Let’s take a look at some of the evidence behind fluid choice in resuscitation…

The SAFE trial looked at 4% albumin vs normal saline for intravascular fluid resuscitation in critically ill patients over the first 28 days of hospitalization. There was no difference in any endpoint, including mortality. When looking at the subset of patients with septic shock, there was also no difference in mortality.

The 2008 VISEP trial  was a two-by-two factorial trial looking at glycemic control and fluid resuscitation in patients with septic shock. 10% Pentastarch and modified Ringer’s lactate were used for fluid resuscitation. The trial was stopped early because of a trend towards increased 90 day mortality in patients receiving pentastarch.

Finally, in 2012 the 6S trial  resuscitated patients with septic shock with either hydroxyethyl starch or ringers acetate up to 33 ml/kg/day. At 28 days, mortality (51 vs 43%) and use of renal replacement therapy (22 vs 16%) was higher in the hydroxyethyl starch group.

That’s a fair amount of evidence suggesting that crystalloids are the best choice for fluid resuscitation. But which type? Normal saline? Ringer’s lactate?

The CHLORIDE trial looked at the use of high chloride solutions (0.9%  saline, 4% succinylated gelatin solution, or 4% albumin solution) vs “low” chloride solutions (Hartmann solution, Plasma-Lyte 148, or chloride poor 20% albumin). There was no difference in mortality, ICU length of stay, or need for long term renal replacement therapy. There was however a trend to higher rates of acute kidney injury and use of in-hospital renal replacement therapy in the high chloride group.

With all of that considered – should we consider a buffered, low-chloride, crystalloid solution (i.e. Ringer’s Lactate or Hartmann’s Solution) to be the ideal initial fluid for resuscitation in septic shock?

Please contribute your thoughts below, on twitter with the hashtag #icurounds, or on our Facebook page.

Case 1: A pressing issue…

A 75 year old patient is brought to the ICU from the general medicine ward with hypotension. He was admitted a few hours earlier with community acquired pneumonia but had progressive hypotension. He was started on dopamine at 10 mcg/kg/min and currently has a blood pressure of 86/52 with a heart rate 120 on the floor and on arrival to the unit, you’re asked whether you are happy with dopamine or if you would like to switch to another “pressor”?

What are your thoughts on choice of pharmacological support in this patient with septic shock?