In the PROCESS , ARISE and PROMISEtrials, the average volume of fluid received pre-randomisation was also in the range of 30 ml/kg, suggesting that this fluid volume has been adopted in routine clinical practice.
EGDT(early, goal-directed therapy): 6-hour resuscitation protocol for the administration of intravenous fluids, vasopressors, inotropes, and red-cell transfusion to achieve prespecified targets for arterial blood pressure, central venous pressure, central venous oxygen saturation, and hemoglobin level.
To avoid over- and under-resuscitation, fluid administration beyond the initial resuscitation should be guided by careful assessment of intravascular volume status and organ perfusion.
Heart rate, central venous pressure (CVP) and systolic blood pressure alone are poor indicators of fluid status.
Dynamic measures have demonstrated better diagnostic accuracy at predicting fluid responsiveness compared with static techniques. Dynamic measures include passive leg raising combined with cardiac output (CO) measurement, fluid challenges against stroke volume (SV), systolic pressure or pulse pressure, and increases of SV in response to changes in intrathoracic pressure.
혈청 젖산 수치는 조직 저산소증 등의 중요한 생체 지표이지만 조직 관류의 직접적인 측정 값은 아니다. 패혈성 쇼크의 초기 단계에서 젖산 수치는 낮추는 것을 resuscitation의 목표로 삼을 수는 있지만 이를 모두 만족할 수는 없다.
한 연구에서 CRT(capillary refill time) 정상화를 목표로 하는 것이 resuscitation 전략의 보다 더 효과적인 목표라는 것을 보여주었다. 3일차 CRT 그룹에서 SOFA 점수로 평가한 장기 기능 부전이 유의하게 적었지만 28일 사망률은 통계적으로 유의한 차이를 보이지 않았다.
reference:
1) Evans, Laura, et al. "Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021." Intensive care medicine (2021): 1-67.
2) Prism Investigators. "Early, goal-directed therapy for septic shock—a patient-level meta-analysis." New England Journal of Medicine 376.23 (2017): 2223-2234.
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