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Importance of adequate fluid resuscitation in patients with severe septic shock on high catecholamine doses

Introduction

Evolution of hemodynamic monitoring revealed many septic shock patients on high catecholamines without proper fluid loading before. The aim of our study was to show that it is possible in quite a few cases to reduce these agents by a forced volume resuscitation combined with active reduction of catecholamines.

Methods

We studied 21 patients (15 males, six females; mean ± SE age, 72 ± 11 years) with septic shock on high catecholamines (norepinephrine 19.77 (range 6.7–56.7) mg/min (21 patients); dobutamine 294.17 (0–666.7) mg/min (14 patients); epinephrine 13.97 (0–33.3) mg/min (11 patients)), mottled-marbled cold extremities, a monitor showing sufficient blood pressure, central venous pressure 15 ± 7 mmHg and lactate 3.58 ± 2.24 mmol/l after major surgery (surgical ICU, university hospital). Intervention: forced volume challenge combined with an active induced reduction of catecholamines to achieve an adequate fluid loading status guided by passive leg-raising test, course of central venous pressure and in 14 cases by hemodynamic monitoring (Vigilance II n = 12; Vigileo n = 2 (Edwards)). It was stopped after clinical improvement with rewarmed extremities, increasing diuresis and lack of improvement by passive leg-raising test. Data collection: baseline characteristics, individual hemodynamic parameters, PAO2/FiO2, course of catecholamines, administered volume, lactate, time needed to wean from catecholamines, and outcome.

Results

Mean catecholamine doses decreased significantly in all patients: norepinephrine 2.0 ± 0.17 (0–10); dobutamine 166.7 ± 15.83 (0–333.3); epinephrine 1.8 ± 0.28 (0–6.7) mg/min (mean ± SEM, range; P < 0.05 (t test)). Volume challenge: 4,476 ± 2,976 ml Ringer (range up to 12,500 ml) and 1,062 ± 946 ml hydroxyethyl starch (range up to 3,500 ml) (mean ± SE), fluid balance during intervention 6,724 ± 3,971 ml (range 2,040–18,410 ml). Mean weaning time from catecholamines: 10.35 ± 6.57 hours (range 3–23 hours). All patients showed rewarmed extremities, decrease of mean lactate levels (2.44 ± 1.33 mmol/l (1.10–5.4)). Hemodynamic constellations were dishomogeneous without cardiac deterioration or mean PAO2/FiO2 deterioration (253 ± 122 to 284 ± 86 mmHg). Fifteen patients survived, six died.

Conclusion

It is possible to wean quite a few septic shock patients from high catecholamines. Adequate fluid loading preceding the use of high catecholamine doses should be a main subject of discussion in patients with severe septic shock.

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Lewejohann, J., Wichmann, D., Braasch, H. et al. Importance of adequate fluid resuscitation in patients with severe septic shock on high catecholamine doses. Crit Care 12, P409 (2008). https://doi.org/10.1186/cc6630

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Keywords

  • Catecholamine
  • Septic Shock
  • Dobutamine
  • Central Venous Pressure
  • Septic Shock Patient