Shouyin Jiang

Early goal-directed resuscitation for patients with severe sepsis and septic shock: a meta-analysis and trial sequential analysis

BackgroundThe aim of this study was to explore whether early goal-directed therapy (EGDT) was associated with a lower mortality rate in comparison to usual care in patients with severe sepsis and septic shock.MethodsPubMed, EMBASE, Cochrane library and a Chinese database (SinoMed) were searched systematically to identify randomized controlled trials (RCTs) comparing standard EGDT with usual care in resuscitation of patients with severe sepsis and septic shock and the search time could date back to the publication of the study by Rivers in 2001. The study selection, data extraction and methodological evaluation were performed by two investigators independently. The primary outcome was all-cause mortality. The present meta-analysis had been registered in PROSPERO (CRD42015017667).ResultsOur meta-analysis identified 6 studies and enrolling 4336 patients. There was no significant difference in mortality between the two groups, and the pooled odds ratio (OR) was 0.83 (95xa0% confident interval, CI, 0.64–1.08) with significant heterogeneity (pu2009=u20090.02, I2u2009=u200964xa0%). However, the pooled OR of 3 multicenter RCTs was 1.03 (95xa0% CI, 0.89–1.21) with no heterogeneity (pu2009=u20090.78, I2u2009=u20090xa0%). The effects of EGDT on length of stay in the emergency department and intensive care unit were uncertain, and there was no effect of EGDT on hospital length of stay. There were no differences of mechanical ventilation rate and renal replacement therapy rate between the two groups, and patients in the EGDT group were more admitted in ICU than patients in the control group. During the early 6-h intervention period, patients in the EGDT group received more intravenous fluids, had a higher vasopressor usage rate, higher dobutamine usage rate and higher blood transfusion rate, than patients in the control group. Finally, there was no difference in the incidence of adverse events between the two groups, and the pooled OR was 1.06 (95%CI 0.80–1.39) with moderate heterogeneity (I2u2009=u200962xa0%, pu2009=u20090.07).DiscussionOur meta-analysis showed that the application of EGDT was not associated with lower mortality rate currently. However it does not mean that it is useless of EGDT in patients with sever sepsis and septic shock. On the contrary, there was no difference in mortality rate between the two groups may be due to the improvement of therapeutic strategies in these patients. And the results may be related to the different compliance rate of EGDT resuscitation bundle.ConclusionsThe current evidence does not support the significant advantage of Early goal-directed therapy (EGDT) in the resuscitation of patients with severe sepsis and septic shock.

Potential role of therapeutic hypothermia in the salvage of traumatic hemorrhagic shock

Although therapeutic hypothermia could serve as a potential therapeutic strategy for treatment of traumatic hemorrhagic shock, significant controversy exists regarding its safety and feasibility. The current resuscitation strategy in traumatic hemorrhagic shock may also require updating. In this article, we have carried out an extensive literature search in this field and propose an initial algorithm for use of therapeutic hypothermia in traumatic hemorrhagic shock. This work lays essential groundwork for future investigations in this field.

Ideal target arterial pressure after control of bleeding in a rabbit model of severe traumatic hemorrhagic shock: results from volume loading-based fluid resuscitation

BACKGROUNDnPreviously reported ideal target mean arterial pressure (MAP) after control of bleeding in traumatic hemorrhagic shock (THS) requires further verification in more clinically related models. The authors explored this issue via gradient volume loading without vasopressor therapy. As certain volume loading can induce secretion of atrial natriuretic peptide (ANP), which has been shown to be protective, the authors also observed its potential role.nnnMATERIALS AND METHODSnFifty male New Zealand rabbits were submitted to 1.5 h of uncontrolled THS (with another eight rabbits assigned to the sham group). After bleeding control, treated rabbits were randomly (n = 10, respectively) resuscitated with blood and Ringer lactate (1:2) to achieve target MAP of 50, 60, 70, 80, and 90 mm Hg within 1 h. During the following 2 h, they were resuscitated toward baseline MAP. Rabbits were observed until 7 h.nnnRESULTSnAfter resuscitation, infused fluid was lower and oxidative stress injury was milder in the 70 mm Hg group. Fluid volume loaded during the initial hour after hemostasis was negatively correlated with pH, oxygen saturation, and base excess at the end of resuscitation. It also correlated positively with proinflammatory responses in bronchoalveolar lavage fluid at 7 h and 7-h mortality. Moreover, after volume loading, the 80 mm Hg group showed significantly increased serum ANP level, which correlated with the expression of Akt protein in the jejunum at 7 h.nnnCONCLUSIONSnIn rabbits the ideal target MAP during the initial resuscitation of severe THS after hemostasis was 70 mm Hg. ANP may have a critical role in gut protection.

Hyperacute adrenal insufficiency after hemorrhagic shock: facts and fiction.

In Reply: We are grateful to Kulvatunyou et al. for their comments. We have carefully considered all the points they raise. During the course of our literature investigation, it is possible that we may have missed very few articles that do not contain the terms hernia, trauma, or abdominal wall. We were of course aware and actually went through the major reviews of Kulvatunyou et al., Bender et al., and Dennis et al. but were limited in the number of references we could include. We therefore referred to the first report regarding traumatic abdominal wall hernia (TAWH) by Netto et al., which preceded that of Kulvatunyou et al. by 5 years. In addition, the three major reviews by Kulvatunyou et al., Bender et al., and Dennis et al. originate either from the same institution or from the same team of authors with overlapping periods of reference and unclear reports about duplication of cases. We therefore believe that that the number of ‘‘overlooked’’ cases of patients with TAWH is less than 10 and by no means in the 50s, as Kulvatunyou et al. suggest. Another interesting point raised by Kulvatunyou et al. is the exclusion of lumbar hernias in our study. Indeed, this issue was brought up by one of the expert reviewers in the course of the peer review. Lumbar hernias result usually from penetrating abdominal wall trauma, a fact beyond the scope of our study, which involves blunt abdominal trauma. It is possible for lumbar hernias to occur following blunt abdominal wall trauma at the posterior wall triangles; however, it is difficult to tell whether they occurred as a result of trauma or they preexisted. In addition, the definition of lumbar hernias include hernias most commonly occurring at the superior lumbar triangle of GrynfelttLesshaft and the inferior lumbar triangle of Petit. However, many areas of weakness and hence herniations may occur within the lumbar region, often described as ‘‘lateral hernias,’’ which are included in this study. It is true that in our review article, we present a TAWH classification according to location, force, hernia size, mechanism, or type of accident (Table 1 in the article) based on historical citations.We did not attempt to suggest a new classification scheme because of the following: a. TAWH is a rare entity, and so far, all proposed classifications focus on specific situations, making a unifying scheme almost impossible. b. Irrespective of classification, treatment is always the main target. c. In the era of new diagnostic techniques and with the institution of new generation trauma computed tomographic scanners, every different attempt of classification usually proves to be suboptimal, compared with computed tomographic results.

Adrenaline use is associated with excess organ injury and mortality in cardiogenic shock: facts and fiction

We read with great interest the article by Tarvasmaki et al. [1], who observed the relationship between vasopressor/inotrope use and outcome in patients with cardiac shock (CS). Their results indicate that use of adrenaline in CS is associated with increased 90-day mortality and marked worsening of cardiac and renal biomarkers during the first few days. The study underscores the need for randomized controlled trials of adrenaline versus noradrenaline in CS.

Hemorrhagic shock following hypoxemia is not a clinical situation.

e242 www.ccmjournal.org March 2014 • Volume 42 • Number 3 Hemorrhagic Shock Following Hypoxemia Is Not a Clinical Situation To the Editor: Hemorrhagic shock (HS) is still one of the primary causes of early mortality in trauma patients (1). After HS, tissue suffers hypoxia and ischemia, and the remaining blood is pumped to the brain and heart to maintain life, which induces aggravated viscera ischemia and reduced blood flow. This reaction promotes margination, adhesion, and infiltration of leukocytes, leading to systemic proinflammatory responses and organ dysfunction. For intestinal tract, hypoxic and ischemic insult leads to increased gut mucosal permeability, causing bacterial translocation and ensuing sepsis, as well as multiple organ dysfunction syndrome. In a recent article in Critical Care Medicine, Harrois et al (2) using intravital microscopy to monitor changes in erythrocytes velocity and flux in ileal villi have shown that hypoxemia and hypovolemia have synergistic adverse effect on ileal blood perfusion. However, the combined factors did not exert similar effect on leukocytes adhesion to the endothelium. Thereby, they concluded that such synergistic effect can increase the risk of villous ischemia. It is likely that this study has reached its goal on interpreting the effect of hypoxemia, HS, and both on microcirculation. However, it has raised more questions than it has answered. First, according to the study protocol, mice in hypoxemia + HS group were initially managed with hypoxemia and then HS. This design, however, is obviously not the condition that happens in clinical HS because hypoxemia usually does not happen before HS. In fact, it has been better known as “hypoxic preconditioning” (HPC) (3). Although HPC has been demonstrated to be beneficial in promoting remote organ function, the exact effect of HPC on trauma/traumatic HS is still unknown (4). Second, mice in the control and hypoxemia group demonstrated much severer pH and base excess at baseline level compared with those in HS and hypoxemia + HS group. This makes the corresponding comparisons less credible, especially those between hypoxemia and hypoxemia + HS, although we could see the prominent combined effect of HS and hypoxemia on ileal blood perfusion. In addition, the volume of blood loss in HS group was higher compared with hypoxemia + HS group. We believe that these may have contributed to the reduced power in detecting the difference of leukocytes adhesion to the endothelium among groups. Third, the duration of HS in mice was too short (probably less than 30 min as shown in Fig. 1 in [2]), and this has confused us as what are the effects of hypoxemia and hypovolemia after more than 30 minutes of HS. This is important because many trauma patients suffer more than 30 minutes of ischemia before restoration of normal blood pressure. Harrois et al (2) also illustrated that the intestinal histologic abnormalities were not observed during HS and hypoxemia. So there is the possibility that the short-term period of HS did not induce gut injury as measured under microscope. Having found the synergistic effect of hypoxemia and hypovolemia on microcirculation, the second is to use a model that simulates hypoxemia following HS to confirm this finding. Then, further steps toward understanding the role of hypoxemia in microvascular alterations during HS are necessary. The authors have disclosed that they do not have any potential conflicts of interest.