Optimal hemodynamic management according to the Surviving Sepsis Guidelines is not applicable to all ICU patients

Introduction

Guidelines for early goal-directed therapy (EGDT) in sepsis include target values of mean arterial pressure (MAP) ≥ 65 mmHg, central venous pressure (CVP) ≥ 8 mmHg, and central venous oxygen saturation (ScvO₂) ≥ 70%. It is unclear whether a similar goal-directed approach is applicable to general ICU patients.

Methods

Prospectively collected data were analyzed in order to determine whether there are differences in hemodynamics and in clinical decision-making in patients in whom these target values had been met versus those in whom they had not. One hundred and twelve critically ill patients in whom a PiCCO catheter was inserted were assigned into one of two groups: Group A (n = 54) – all EGDT goals were present; Group B (n = 58) – either MAP, CVP and/or ScvO₂ values were below target.

Results

The MAP, CVP and ScvO₂ were significantly higher in Group A as well as the cardiac index (4.2 ± 1.4 vs 3.5 ± 1.3 l/min/m², P < 0.0031). Lactate, pH, heart rate, systemic vascular resistance, global end-diastolic volume, extravascular lung water, PO₂/FiO₂, hemoglobin, and the number of patients with lactate >4 mmol/l (12 in group A and nine in B) were not different between the two groups. There was no difference between the therapeutic decisions that were made for Group A and Group B, respectively: fluid loading – 31 versus 30; blood – 3 versus 10; inotropic agents – 12 versus 15; vasoconstrictor – 19 versus 15; diuretic – 9 versus 11; dialysis/filtration – 7 versus 10. ScvO₂ was ≥ 70% in 76% of the patients with lactate >4 (n = 21) and in 66% of the patients with lactate <4 (n = 89). No correlation was found between lactate levels and ScvO₂ or between cardiac index and ScvO₂.

Conclusion

Patients in which all EGDT goals were present had a similar incidence of hyperlactatemia and a similar need for hemodynamic interventions as the ones in which these goals were not met. This suggests that hemodynamic management of critically ill patients in the ICU not be based solely on the parameters and goals that are recommended by the sepsis guidelines.