Clinical Study On The Timing Of Reverse Fluid Resuscitation In Septic Shock Patients With Volume Overload

Background and objectiveSepsis and septic shock(SS)are a major clinical problem in the face of emergency and critical care medicine.The number of patients with Sepsis is more than 19 million,the number of deaths is 6 million,and the fatality rate is more than 1/4 worldwide.The shock and sepsis professional committee of the Chinese Research Hospital Association and the emergency physician branch of the Chinese Medical Doctor Association organized experts to establish the 2018 edition of China’s Emergency Treatment Guidelines for Sepsis/Septic Shock based on evidence-based medicine.The guideline points out that the fluid resuscitation of SS patients should be started as early as possible.After the initial resuscitation,the follow-up fluid application should be guided according to the hemodynamic state to avoid fluid overload.For patients with volume overload,the 2017 Expert Consensus on Critical Right Heart Function Management put forward the concept of "reverse fluid resuscitation",that is,to improve tissue and organ perfusion by reducing the volume of the heart and blood vessels,increasing cardiac output or changing the state of microcirculation.When does reverse fluid resuscitation start?How to implement reverse fluid resuscitation?It is necessary to make a comprehensive judgment according to the actual clinical situation.This study hopes to find relatively clear indicators and guide the timing of reverse fluid resuscitation for SS fluid overload patients by judging their cutoff points.MethodsSelect the SS patients in the emergency intensive care unit(EICU)of Kaifeng Central Hospital.If one of the following conditions occurs during the treatment,it may be considered that there may be fluid overload:① increased lung rales or increased lung water indicated by ultrasound;②Tissue edema;③Passive leg lifting test failed;④High central venous pressure(CVP)≥12cmH2O;⑤If the right ventricle is dilated(the end diastolic volume ratio of the right ventricle to the left ventricle assessed by ultrasound is≥0.6),reverse fluid resuscitation is performed.According to whether CO increased after reverse fluid resuscitation,the patients were divided into two groups[CO increased group and CO not increased group],and the patient’s gender,age,hypertension history,diabetes history,coronary heart disease history,CVP,inferior vena cava width,positive end expiratory pressure(PEEP),mean pulmonary artery pressure,left ventricular ejection fraction(LVEF),right heart/left heart ratio were counted;For the indicators with statistical difference between the two groups,the correlation between them and the increase of CO after reverse fluid resuscitation was evaluated by binary logistic regression analysis and a prediction model was established.SPSS 19.0 was used,and the difference was statistically significant(P<0.05).The X2 test was used for the inter group comparative counting data,and the T test was used for the measurement data.The single factor analysis was first performed for the basic data and test indicators within the group.For the indicators with significant differences between the two groups,the correlation between them and the results was evaluated through binary logistic regression analysis.ResultsA total of 85 patients were enrolled.After reverse fluid resuscitation,CO increased in 47 patients,while CO did not increase in 38 patients(6 patients had no change in CO,32 patients had a decrease in CO).There were significant differences between the two groups in age,history of hypertension,CVP,width of inferior vena cava,PEEP,LVEF,right heart/left heart ratio(P<0.05).The increase of CO after reverse fluid resuscitation was set as the dependent variable,and the indexes with statistical differences above were set as independent variables.Logistic regression analysis showed that the past history of hypertension(OR=3.638),CVP≥20cmH2O(OR=3.204),right heart/left heart ratio≥0.6(OR=7.142)were independently related to the outcome of CO increase after reverse fluid resuscitation.Establish the prediction model equation:logitP=In(P/1-P)=3.496+1.291 X(History of hypertension)+1.164 ×(CVP≥20cmH2O)+1.996 ×(Right heart/left heart ratio≥0.6).When the optimal critical value P is 0.1,the sensitivity and specificity of the prediction model are 77.8%and 75.4%respectively,suggesting that when P>0.1,the probability of CO increase after reverse fluid resuscitation is large.From January 2022 to March 2022,46 patients with SS who had fluid overload in the Department of Critical Care Medicine of Kaifeng Central Hospital were selected in chronological order.The model predicted that 30 patients had a high probability of CO increase after reverse fluid resuscitation,and reverse fluid resuscitation was carried out.The actual CO increased by 24 patients,and the predicted power was 80.0%.ConclusionHypertension history,CVP≥20cmH2O,right heart/left heart ratio≥0.6 are independent influencing factors to judge whether CO increases after reverse fluid resuscitation in patients with SS fluid overload.A predictive model equation for CO increases after reverse fluid resuscitation is established:logitP=In(P/1-P)=-3.496+1.291 ×(History of hypertension)+1.164 ×(CVP≥20cmH2O)+1.99×(Right heart/left heart ratio≥ 0.6).When the predictive value P>0.1,the success rate can be improved by starting reverse fluid resuscitation.This model has good predictive value and clinical application value in practical clinical work.