Title: Immediate Replacement of Fluid Volume vs Immediate Treatment with Vasopressors in Sepsis
Authors: Milad Karami Jouzestani, MAMS, Wais Seddiqi, MAMS, Phil Mattocks, PhD
Introduction
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. If it is not recognized early and managed promptly, it can lead to septic shock, multiple organ failure, and death. Sepsis is a major healthcare problem in the US. As of 2014, there were an estimated 270,000 annual attributable deaths and an estimated annual cost of almost $60 billion. Clinicians have many challenges in the diagnosis, treatment, and management of patients with sepsis. There are different treatment options for sepsis, but replacement of fluids volume and treatment with vasopressors are the most common. The goal of this research is to figure out which treatment is a better choice to be given first to the patient with sepsis (first crystalloid fluid followed by vasopressors if needed vs first vasopressors followed by fluid if needed).
Method
A literature search was performed through PubMed, Google, and Google Scholar. We customized our searches to find articles based on the sepsis definition. Sepsis is now defined as an infection associated with organ injury distant from the site of infection. Fever, tachycardia, tachypnoea, and white blood cell changes reflect infection only and are too broad to be applied in the definition of sepsis. Based on inclusion and exclusion criteria 20 related studies were reviewed. The criteria were studies that have been done between 1990-2021 on adult patients (18years and older) confirmed with infection and hypotension due to sepsis.
Result
We found that liberal fluids treatment is the dominant current ED care in the United States, but there is no adequate evidence to support the provision of liberal fluid over vasopressors. Therefore, an alternative approach has emerged. Currently, the patient receives some amount of fluid first (up to 3or 4 liters) followed by vasopressor if needed.
Discussion
Based on our studies, the success of the treatment in sepsis depends on early diagnosis, and immediately starting appropriate treatment. It is very complicated to set up a specific approach for sepsis treatment because most sepsis determinants are nonspecific, patients don’t have the same response to the treatments, and physicians create differences in treatments. The main target in sepsis treatment is regulating blood volume and providing sufficient tissue perfusion. Vasopressors can be added to the treatment in patients whose fluid deficit is met but still have hypotension.
Thanks for presenting information on this interesting topic. You didn’t mention antibiotic treatment in sepsis patients. As a judge for this project, my question for you is – are there any reasons to choose fluid volume replacement versus vasopressors that would be dependent on the antibiotic that also is being administered? Thanks!
Hello Diana, thank you for reviewing my presentation.
In response to your question, I would like to say I agree with you. We did not mention antibiotic therapy in this study( only mentioned in the conclusion) because all severe sepsis patients receive antibiotics that are critical tools for treating life-threatening infections like sepsis. The initiation time for antibiotic administration and the type of antibiotics are very important topics that can impact sepsis patient outcomes and could be considered in the study as well, but the main focus of this study was on comparing fluid vs vasopressors treatments in sepsis.
Antibiotics are used from the beginning to manage the infection, but IVF and vasopressors are used to regulate blood pressure. Intravenous fluid replacement is used to replace lost blood volume. If blood pressure drops and cannot be improved with intravenous fluids, medications will be used to increase blood pressure.
I hope I could answer your question. Please let me know if you have any questions. Thank you
Thank you for your presentation. As a judge for this project, I would like to know more specifically the criteria you used to narrow down the 180 articles into 20 articles.
Hello Julie, thank you for reviewing my presentation.
In response to your question, I would like to say there are many articles related to sepsis. After an initial search for articles related to sepsis, we focused to choose articles that discussed either Liberal fluid treatment or Vassopressors treatments. Few articles compared liberal fluid vs restrictive fluid ( vasopressin) we chose them as well. A total of 180 articles were identified. Then we filtered articles based on the topics, articles’ conclusions, the trend of discussion, and data analysis.
For example, we excluded studies if they did not have control and study groups, no data was provided to compare the study groups, or conclusions did not clarify the outcome. Also, some articles were comparing two vasopressors together or two crystalloid fluids together, we excluded them as well because the data was not useful for our study.
The easiest way to select articles was based on the topics of the articles. If the title of the article was written in such a way that we thought it is close to our purpose, we focused on it and reviewed it. Then If the data analysis, discussions, or conclusion were related to our purpose, it was selected to be in our final list to be used.
I hope I could explain it well.
Thank you for your presentation. I am a judge for this presentation and would like to know what are the other treatments that were excluded and how often are these used. Is the liberal fluid treatment the current standard of care and the vasopressor treatment emerging?
Hi Tiffany, thank you for reviewing my presentation.
In response to your question, I would like to say besides fluid and vasopressor therapy there are other supportive treatments for septic shock including blood product transfusion, immunoglobulin, mechanical ventilation, Glucocorticoid therapy, nutrition, and surgery. These supportive treatments are used usually after the resuscitation phase of treatment. The need for use of supportive treatments is very from patient to patient and it is based on the initial resuscitation treatment outcome.
Currently, IV fluid resuscitation(1-3L) is the first-line therapy and it is the standard care in ED and ICU for sepsis patients. Vasopressors is administered if the patient remains hypertensive. The difference between sepsis treatment from now and two decades ago is in the amount of IVF administration (less IVF in current treatment) and starting vasopressors sooner.
Based on the studies, the treatment can vary from patient to patient because patients don’t have the same response to the treatments, and also physicians create differences in treatments. In some cases, patients received fluid first, in other cases patients receive vasopressor first, and in some cases, patients receive both simultaneously.
I hope I could answer your question.
Hi Tiffany, sorry for some spelling errors in the previous response. this is the correct response.
In response to your question, I would like to say besides fluid and vasopressor therapy there are other supportive treatments for septic shock including blood product transfusion, immunoglobulin, mechanical ventilation, Glucocorticoid therapy, nutrition, and surgery. These supportive treatments are used usually after the resuscitation phase of treatment. The need for use of supportive treatments is vary from patient to patient and it is based on the initial resuscitation treatment outcome.
Currently, IV fluid resuscitation(1-3L) is the first-line therapy and it is the standard care in ED and ICU for sepsis patients. Vasopressors is administered if the patient remains hypotensive. The difference between sepsis treatment from now and two decades ago is in the amount of IVF administration (less IVF in current treatment) and starting vasopressors sooner.
Based on the studies, the treatment can vary from patient to patient because patients don’t have the same response to the treatments, and also physicians create differences in treatments. In some cases, patients receive fluid first, in other cases patients receive vasopressor first, and in some cases, patients receive both simultaneously.
I hope I could answer your question.
Hello and thanks for your presentation. I was NOT assigned to judge your presentation but I do have a question. I wondered how your findings compare to the 2021 Surviving Sepsis Campaign Guidelines published in the journal, Critical Care Medicine last November? Thank you again!
Hello Kathleen, thank you for reviewing my presentation.
In response to your question, I want to say unfortunately I did not have access to this article ( it should be purchased), but I have compared my finding with the sepsis guideline published in 2019 in the New England Journal of medicine. The guidelines recommend that for all patients presenting with sepsis, the condition should be managed with a set of interventions, known as a “bundle,” within 1-3 hours after the presentation. The bundle consists of measuring lactate level, obtaining blood cultures before administering antibiotics, administering broad-spectrum antibiotics, administering 30 ml of crystalloid per kilogram of bodyweight if the patient has hypotension or a lactate level higher than 4 mmol per liter, and administering vasopressors if the patient remains hypotensive despite fluid resuscitation.