Peripheral Perfusion Targeted Fluid Management
- Conditions
- Severe SepsisSepsis
- Interventions
- Other: PPTFM
- Registration Number
- NCT01397474
- Lead Sponsor
- Erasmus Medical Center
- Brief Summary
* Impaired peripheral perfusion is related to worse outcome in critically ill patients. Although this is known, these parameters have never been used as target for hemodynamic therapy.
* We hypothesize that targeting of fluid administration on parameters of peripheral perfusion might prevent excessive fluid administration, leading to less formation of tissue edema, less respiratory dysfunction and shorter duration of mechanical ventilation in critically ill patients.
- Detailed Description
Rationale: Currently, fluid administration of critically ill patients is aimed at optimizing conventional hemodynamic parameters such as stroke volume and cardiac output. Fluid is infused repeatedly until patients become "non-responsive", i.e. cardiac output does not increase anymore. However, the ultimate goal of hemodynamic therapy should be to improve peripheral (i.e. tissue) perfusion. Recently we have shown that 1) increasing stroke volume does not always have an effect on peripheral perfusion and 2) that peripheral perfusion is not impaired when stroke volume can still be increased with fluid infusion. Furthermore, repeated administration of fluid in order to reach a maximum cardiac output can lead to an enormous accumulation of fluid in the patient. This leads to formation of lung edema and respiratory dysfunction and is associated with prolonged mechanical ventilation and ICU-stay. Recently, techniques have been developed which allow bedside assessment of peripheral perfusion. Although impaired peripheral perfusion was related to worse outcome, these parameters have never been used as target for hemodynamic therapy.
Objective: To study whether peripheral perfusion targeted fluid management (PPTFM) leads to less fluid administration, improved respiratory function and shorter mechanical ventilation.
Study design: The study is a pilot study and is designed as a randomized controlled trial. The study will be conducted as a single-center study at the Intensive Care of the Erasmus Medical Center.
Study population: We aim to include 40 adult patients who are admitted to the Intensive Care with hemodynamic instability (defined as mean arterial pressure \< 65 mmHg and an arterial lactate concentration \> 3.0 mmol/l) due to severe sepsis and septic shock.
Intervention: In the intervention group fluid management is targeted on peripheral perfusion parameters while in the control group fluid is administered in order to optimize cardiac output.
Main study parameters/endpoints: The main study endpoints are daily fluid balance and duration of mechanical ventilation.
Nature and extent of the burden and risks associated with participation, benefit and group relatedness: There is a possible risk that in the treatment group the patients will remain hypovolemic. To ensure that this will not occur, fluids will be administrated in this group, irrespective of peripheral perfusion parameters, until cardiac index is 2,5 L/min/m2. Assessment of peripheral perfusion is performed with non-invasive optical techniques that impose no burden to the patient.
Recruitment & Eligibility
- Status
- UNKNOWN
- Sex
- All
- Target Recruitment
- 40
- All adult patients (>18 years) admitted to the intensive care with 1) hemodynamic instability due to severe sepsis, and 2) a mean arterial pressure < 65 mmHg and 3) an arterial lactate concentration > 3.0 mmol/L will be considered for participation
- moribund.
- severe coagulation disorder (contraindication for central venous catheter placement).
- severe peripheral vascular disease (interfering with peripheral perfusion measurement).
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description PPTFM PPTFM The fluid management algorithm of the intervention group uses identical therapy (i.e. fluids) yet targeted at different endpoints (i.e. peripheral perfusion parameters). After evaluation of peripheral perfusion, only patients with a "bad peripheral perfusion" (i.e. 3 out of 4 criteria considered as bad) will receive a fluid challenge, the same way as in the standard care procedure (i.e. bolus of 250 ml of fluid). After each fluid challenge, patients will be re-evaluated for peripheral perfusion to access further need in fluid challenges. To ensure that no hypovolemia will occur in the intervention group, fluid will be administered irrespectively of peripheral perfusion parameters, if cardiac index falls below a value of 2,5 L/min/m2.
- Primary Outcome Measures
Name Time Method Fluid balance during Intensive Care Unit stay untill 72 hours after admission Total and daily fuid balance for a maximal time period of 72 hours
- Secondary Outcome Measures
Name Time Method CRT (Capillary refill time) Within 72 hours after admission Parameter of peripheral perfusion
Systemic hemodynamic variables Untill 72 hours after admission to the ICU * Heart Rate
* Mean Arterial Pressure
* Cardiac Index
* Cardiac output
* Stroke Volume
* Central Venous Pressure
* Systemic Vascular ResistanceRespiratory function Untill 72 hours after admission to the ICU * FiO2
* PEEP
* Breathing Frequency
* pCO2
* pO2PFI (Peripheral Flow Index) Untill 72 hours after ICU admission Parameter of peripheral perfusion
Tskindiff (Forearm-to-Fingertip temperature skin difference) Untill 72 hours after ICU admission Parameter of peripheral perfusion
StO2 (Peripheral tissue oxygenation) Untill 72 hours after ICU admission Parameter of peripheral perfusion
Trial Locations
- Locations (1)
ErasmusMC
🇳🇱Rotterdam, Zuid-Holland, Netherlands