Early goal-directed therapy of septic patients coming from the ward does not protect the kidneys

Introduction

Patients with severe sepsis or septic shock admitted to the emergency room appear to benefit from early goal-directed therapy, while this is unknown for patients admitted to the ICU from the ward.

Methods

We documented achievement of mean arterial pressure >65 mmHg, central venous pressure >8 mmHg and central venous oxygen saturation >70% within the first 12 hours after ICU consultation. Creatinine in the week prior to ICU admission, creatinine at ICU consultation and peak creatinine in the 2 weeks after ICU admission were recorded.

Results

Eighty-five patients were included, of which 40% achieved all goals within 6 hours (early achievement), whereas 33% did not but had all of them documented within the first 12 hours (no achievement), 27% had incomplete documentation of goals. Forty-four out of 85 patients (52%) developed acute kidney injury (AKI) according to the RIFLE criteria. Patients with incomplete documentation, early or no achievement of goals were comparable at baseline, APACHE II and interventions except for more use of inotropes in the no achievement group. The course of creatinine in patients was similar, regardless of achievement of goals: baseline – ICU consultation – peak, presented as median (IQR): early achievement group: 90 (61 to 119) – 118 (86 to 204) – 148 (86 to 249); no achievement group: 76 (56 to 98) – 121 (78 to 159) – 151 (88 to 205); incomplete documentation group: 81 (56 to 109) – 95 (65 to 175) – 114 (77 to 223). The patients that developed AKI had a significant increase in creatinine from baseline to the time of ICU consultation: baseline – ICU consultation – peak, presented as median (IQR): no AKI: 75 (59 to 114) – 87 (64 to 123) – 92 (72 to 129); AKI: 84 (61 to 105), P = 0.638 – 145 (102 to 205), P < 0.001 – 196 (153 to 276), P < 0.001. The development of AKI was independent of achievement of physiologic goals of resuscitation.

Conclusion

In septic patients admitted from the ward there is no association between the development of AKI and the timeliness of achievement of physiologic resuscitation goals. In view of the higher creatinine values measured at ICU admission in the patients that eventually suffer from AKI, it appears that the insult has occurred prior to the time of ICU consultation and that physiologic resuscitation does not reverse it.