How to implement the recent Surviving Sepsis Campaign Guidelines at the bedside? A focus on initial fluid resuscitation
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AuthorsManu L.N.G. Malbrain, Azriel Perel, Eran Segal
In order to use the recommendations for the management of patients with sepsis and septic shock as summarized in the Surviving Sepsis Campaign Guidelines (SSCG) one must fully understand the limitations of preload assessment with central venous pressure (CVP). Barometric preload indicators like CVP or the pulmonary artery occlusion pressure (PAOP) can indeed be erroneously increased in situations of increased intra thoracic pressure (ITP) as is seen with high positive end-expiratory pressure (PEEP) application or high intra-abdominal pressure (IAP). Chasing a CVP of 8 to 12 mmHg may lead to under-resuscitation in these situations. On the other hand, a low CVP does not always correspond to fluid responsiveness and may lead to over-resuscitation. When giving fluids during the initial resuscitation phase it is also important to assess fluid responsiveness with either a passive leg raising (PLR) manoeuvre or an end-expiratory occlusion (EEO) test. The use of functional hemodynamics with stroke volume variation (SVV) or pulse pressure variation (PPV) may further help to identify patients that will respond to fluid administration. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock one should think about (active) de- resuscitation guided by extravascular lung water index (EVLWI) measurements.