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Figures
Fig. 1
Chest regions defined by the international-acknowledged definition. Each side of the chest consists in 4 regions named 1 to 4. Regions 1 and 2 denote the upper anterior and lower anterior chest areas. Regions 3 and 4 denote the upper lateral and basal lateral chest areas. PSL, parasternal line; AAL, anterior axillary line; PAL, posterior axillary line [41] .
Fig. 2
The “less invasive” EGDT protocol applied in the present study. As compared with the EGDT protocol of Rivers et al [14] , in this study, ΔIVC (#) is used instead of CVP as a marker of endovascular filling, and in addition, the serum lactate clearance (§) is used instead of Scvo2 to monitor tissue perfusion (see text for further explanation).
Abstract
Introduction
Early goal-directed therapy (EGDT) in septic shock defined by Rivers et al was proven to reduce mortality and validated by observational studies. However, criticism is centered in particular on the early requirement of a central venous catheter (CVC) and on central venous pressure (CVP) as an indicator of volume responsiveness. The present study is a pivotal study to investigate the reliability of a less invasive approach, which uses inferior vena cava (IVC) and lung ultrasounds (US) to guide the infusion of fluids and lactate clearance to monitor tissue perfusion.
Methods
We enrolled 51 patients with septic shock. As a marker of preload optimization, we measured IVC collapse in place of CVP and serum lactate clearance in place of central venous oxygen saturation as a marker of tissue perfusion. As outcomes, we considered the accomplishment of the noninvasive EGDT goals, the number of patients treated without the need of a CVC, the amount of fluids administered in the first 6 hours, the development of pulmonary edema, and the overall mortality rate.
Results
Inferior vena cava US evaluation resulted feasible in 92% of patients. Lung US was performed in 100% of cases. In the first 6 hours, only 61.7% of patients received a CVC, an average of 5.5 L of crystalloids were administered, and only 4 patients developed clinical overt pulmonary edema. Mortality was 34% at 28 days and 38.3% at 60 days.
Conclusions
Our approach to resuscitation in septic shock appears feasible in the emergency department and needs further study with a randomized controlled trial.
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☆Authors’ contributions: DC conceived the study, participated in the design, coordinated the study, and wrote the first draft of the study; FC participated in the design of the study, collected clinical data, and helped draft the study; SP participated in the design of the study, performed descriptive statistics, helped draft the study, and collected clinical data; VT participated in the design of the study and collected clinical data; AV participated in the design of the study and collected clinical data; LM participated in the design of the study and collected clinical data; MC participated in the design of the study and collected clinical data; and DB participated in the design of the study and collected clinical data. All authors read and approved the final manuscript.
☆☆The authors declare that they have no conflict of interest.
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