In septic shock there is growing evidence of a state of hemodynamic "disconnection" with seemingly adequate macrocirculatory values despite actual microcirculation failing to meet cellular demand. Norepinephrine (NE) is recommended as first choice vasoactive agent for the treatment of septic shock. However, the dynamic effects of NE on macro- and microcirculation and perfusion parameters has not been described in detail in the context of septic shock, precluding rational individualized titration of NE and fluids, as recommended recently. In the present prospective observational multicenter study in adult septic shock patients, we intend to explore the effects of NE on preload dependency and tissue perfusion by evaluating the correlation and potential discrepancies between macro- and microcirculation both during titration of NE and after fluid resuscitation. The conclusions drawn from our study will contribute to the physiological knowledge necessary for establishing individualized evidence-based bedside management of hemodynamics in the setting of septic shock.
Study Type
OBSERVATIONAL
Enrollment
45
1. Extended monitoring equipment will be connected to the patient. Clinical and biochemical parameters will be collected for a baseline before the next step. A Safety check will be performed to ensure correct patient data, correct equipment function and safety measures are meet. A passive leg raise test will be performed to predict fluid responsiveness, in case of a positive test, a fluid challenge will be administered. 2. A stepwise reduction of the NE infusion rate from baseline while monitoring stroke volume (SV) to elucidate changes in SV and potential preloadresponsiveness. The reduction will occur in steps of 3-5 minute until either discontinuation of the norepinephrine infusion, a 50% reduction in SV or MAP\<40. 3. While maintaining the NE infusion rate from the previous step 2, a fluid challenge will be administrated, until additional fluid does not increase SV\>10%. 4. As in step 2, a stepwise increase in NE infusion rate to the baseline infusion level or the baseline BP.
Hvidovre Hospital
Hvidovre, Copenhagen, Denmark
RECRUITINGPreload responsiveness defined as stroke volume increase > 10%, measured by continuous arterial waveform analysis.
The number of patients who were preload responsive after down-titration of NE.
Time frame: Through study completion, an average of 1 year
Cardiac output response measured by lithium indicator dilution and Doppler ultrasound.
The effect on cardiac output after fluid bolus and subsequent up-titration of NE to the pre-intervention blood pressure target.
Time frame: Through study completion, an average of 1 year
Microcirculation/perfusion measures during intervention.
The effect of the intervention on measures of tissue perfusion. Different topical sites (Brain, Muscle, Finger, Urethra, Sublingual) by minimal- or noninvasive methods.
Time frame: Through study completion, an average of 1 year
CO measurement method
Assess the correlation between indirect measurements of CO and lithium dilution measured CO during NE titration.
Time frame: Through study completion, an average of 1 year
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.