Fluid resuscitation in septic shock Anders Perner Dept of Intensive Care, Rigshospitalet, University of Copenhagen Scandinavian Critical Care Trials G...
Fluid resuscitation in septic shock Anders Perner Dept of Intensive Care, Rigshospitalet, University of Copenhagen Scandinavian Critical Care Trials Group www.ssai.info/research/SCCTG Intensive Care Medicine http://icmjournal.esicm.org/index.html COIs - Research support from B Braun, Fresenius, CSL Behring Honoraria from Ferring, LFB
University of Copenhagen
Fluid resuscitation in septic shock
Triggers? Which fluid?
How much?
Administer 30 ml/kg crystalloid for hypotension or lactate > 4 mM
ICM 2013;39:165 CCM 2013;41:580
Hypotension a trigger for fluid resuscitation in sepsis? MAP > 65 associated to survival in septic shock Varpula ICM 2005; 31: 1066
Goal-directed fluid therapy of patients with hypotension or lactate > 4 mM
Rivers et al. NEJM 2001
Lactate > 4 mM as trigger for fluid in sepsis?
Rivers et al. NEJM 2001
Lower lactate trigger level?
SHOCK, Vol. 38, No. 1, pp. 4-10, 2012
6S
Lower lactate trigger level?
TRIAL
Fluid resuscitation in septic shock
Triggers? Which fluid?
How much?
ICM 2013;39:165 CCM 2013;41:580
6S TRIAL
6S TRIAL
Investigator-initiated & publicly-funded
6S TRIAL
Investigator-initiated & publicly-funded High internal validity Pre-publiced protocol and SAP Five-flod blinding 100% follow-up
6S TRIAL
Investigator-initiated & publicly-funded High internal validity Pre-publiced protocol and SAP Five-flod blinding 100% follow-up High external validity Pragmatic design 50% non-university hospitals 66% inclusion rate, simple inclusion and few exclusion criteria
6S TRIAL
Baseline characteristics Group
Starch
Ringers
Numbers
398
400
Age
66 (56-75)
67 (56-76)
4 (1-13)
4 (1-13)
SAPS II
50 (40-60)
51 (39-62)
Acute kidney injury
36%
35%
Shock
84%
84%
Time from ICU admin to rando
Values are medians (IQRs) or numbers (%)
6S TRIAL
Trial fluid Starch
Ringers
Volume, ml
Volume, ml
Day 1 (14 h)
1500 (1000-1500)
1500 (1000-1550)
Day 2
1000 (300-1500)
1000 (500-1500)
Day 3
500 (0-1000)
425 (0-500)
Day 4
0 (0-500)
0 (0-500)
Day 5
0 (0-500)
0 (0-500)
3000 (1500-5000)
3000 (1800-5500)
Total (90 days)
Starch increased….
6S TRIAL
6S TRIAL
Number needed to harm….
6S TRIAL
ICM 2013; 39: 1936
Meta-analysis of HES130 vs. crystalloid/HA in sepsis
Meta-analysis of HES130 vs. crystalloid/HA in sepsis
Renal replacement therapy
RR 1.4 (1.1-1.7)
BMJ 2013; 346: f839
Bleeding outcomes
6S TRIAL
ICM 2013, e-pub
6S
Time to bleeding
TRIAL
P=0.001
ICM 2013, e-pub
New data
The CRISTAL trial JAMA Oct. 2013 • Open-label trial in 57 ICUs in 4 countries in a 9-year period • ICU patients in shock • Randomisation by envelopes, fixed block size of 4 • Any colloid (maily HES) vs. any crystalloid (maily saline)
