Comparison Of Goal-Directed Fluid Resuscitation Using Critical Ultrasound And Pulse Indicator Continuous Cardiac Output In Septic Shock

ObjectiveUsing critical ultrasound and pulse indicator continuous cardiac output to guide the fluid resuscitation of septic shock. To assessment the effects of ultrasound-guided fluid resuscitation on optimization of cardiac function, improvement of oxygen metabolism, prevention of pulmonary edema, prevention acute kidney injury and the prognosis.MethodsForty septic shock patients in Intensive Care Unit of ZheJiang Hospital were enrolled. All patients were randomized into two groups using the random number table:ultrasound group(n=20) and PiCCO group(n=20). Using ultrasound and PiCCO to guide the fluid resuscitation, respectively. The hemodynamic parameter, tissue perfusion and oxygen metabolism parameter were recorded at beginning of the study and 6h,12h,24h after the start of the study. Relevant ultrasound parameter were recorded in ultrasound group. Relevant PiCCO parameter were recorded in PiCCO group. The primary end point was mortality at day 28. The secondary end points were the rate of achieving the 6h resuscitative goal, the total volume of vasoactive drugs, the rate of needing for continuous renal-replacement therapy.Results(1) The mortality at day 28 were 40% in two groups, There was no significant differences in 28-day mortality. (2) There were no significant differences in the rate of achieving the 6h resuscitative goal and the total volume of vasoactive drugs (P>0.005). More patients in the PiCCO group than in the ultrasound group received renal-replacement therapy (55% VS 20%, P=0.022). (3) During the 24 hours after the start of the study, the number of B-line in PiCCO group were more than ultrasound group, the differences were statistically significant(19±9 VS 12±6, P=0.002). (4) During the 6,12,24 hours after the start of the study, the patients assigned to PiCCO group received significantly more fluid and more positive fluid balance than those assigned to ultrasound group (P<0.05). During the 6,12 hours after the start of the study, the patients assigned to PiCCO group had significantly less urine output than those assigned to ultrasound group(P<0.05). (5) During the 6,12,24hours after the start of the study, the ultrasound group have a significant increase in E/e’than the former point, the differences were statistically significant(P<0.05). (6) A total of 80 comparisons were obtained in PiCCO group, Significant correlations were found between the number of B-line and EVLWI(r=0.855, P<0.001). The change of B-line (ΔB-line) significant correlated to the change of EVLWI(ΔEVLWI) (r=0.781, P<0.001). (7) The patients were defined had fluid responsiveness when CI increased 15% or more after volume expansion. A SVV above 10% allowed prediction of fluid responsiveness with 93% sensitivity and 90% specificity. Respiratory variations of inferior vena cava diameter above 12% allowed prediction of fluid responsiveness with 90% sensitivity and 89% specificity.Conclusions(1) Compared with the EVLWI monitored by PiCCO, lung ultrasound also is a reliable method for detection of lung water in patients with septic shock;(2) Compared with the SVV monitored by PiCCO, respiratory variations of inferior vena cava diameter also is an accurate predictor of fluid responsiveness in septic patients;(3) Compared with PiCCO, ultrasound-guided fluid resuscitation of septic shock can reduce the risk of pulmonary edema;(4) Compared with PiCCO, ultrasound-guided fluid resuscitation of septic shock can reduce the risk of AKI;(5) Echocardiography is a more comprehensive method in assessing cardiac function of patients with septic shock. Echocardiography is superior to PiCCO in assessing diastolic dysfunction.