Objective: To explore the effect of early goal-directed therapy (EGDT) according to pulse indicated continuous cardiac output (PiCCO) on septic shock patients.
Methods: Eighty-two septic shock patients in Subei People's Hospital of Jiangsu Province from January 2009 to December 2012 were enrolled and randomly divided into two groups using a random number table, standard surviving sepsis bundle group (n=40) and modified surviving sepsis bundles group (n=42). The patients received the standard EGDT bundles in standard surviving sepsis bundle group. PiCCO catheter was placed in modified surviving sepsis bundles group. Fluid resuscitation was guided by intrathoracic blood volume index (ITBVI) with the aim of 850-1 000 mL/m(2). Dobutamine was used to improve the heart function according to left ventricular contractile index (dPmax) and stroke volume index (SVI). The mean arterial blood pressure (MAP) was maintained 65 mmHg (1 mmHg=0.133 kPa) or above with norepinephrine. Extra-vascular lung water was monitored for the titration of liquid and diuretics. The acute physiology and chronic health evaluation II (APACHEII) score, sequential organ failure assessment (SOFA) score, the number of patients needed vasopressor, serum procalcitonin (PCT), lactic acid and lactate extraction ratio, the amount of fluid resuscitation, duration of mechanical ventilation, duration of intensive care unit (ICU) stay, hospital mortality were recorded in both groups.
Results: After treatment, the APACHEII score, SOFA score and the number of patients needed vasopressor were gradually reduced in both groups, and those in modified surviving sepsis bundle group were significantly lower than those of standard sepsis bundle group at 72 hours (APACHEII score: 13.1±6.5 vs. 20.9±7.5, SOFA score: 8.8±4.3 vs. 14.6±4.9, the number of patients needed vasopressor: 8 vs. 17, all P<0.05). Arterial blood lactate clearance rate was gradually increased after treatment in both groups. Lactate clearance rate in modified surviving sepsis bundle group was significantly higher than that of standard surviving sepsis bundle group [6 hours: (18.2±8.3)% vs. (10.8±7.5)%, t=-6.036, P=0.001; 12 hours: (22.6±7.3)% vs. (12.4±8.1)%, t=-4.536, P=0.001; 24 hours: (27.8±5.6)% vs. (16.4±9.5)%, t=-5.882, P=0.000]. The amount of fluid resuscitation within 6 hours in modified surviving sepsis bundle group increased significantly compared with standard surviving sepsis bundle group (3 608±715 mL vs. 2 809±795 mL, t=-3.865, P=0.033). The amount of fluid resuscitation within 24, 48 and 72 hours in modified surviving sepsis bundle group was significantly less than that of standard modified surviving sepsis bundle group with the nadir at 72 hours (918±351 mL vs. 1 805±420 mL, t=5.907, P=0.037). Duration of mechanical ventilation (98.4±20.3 hours vs. 143.3±29.6 hours, t=9.766, P=0.001) and ICU stay (7.1±3.1 days vs. 9.5±2.5 days, t=2.993, P=0.004) were significantly reduced in modified surviving sepsis bundle group compared with standard surviving sepsis bundle group. The hospital mortality in modified surviving sepsis bundle group was slightly lower than that in standard surviving sepsis bundle group [16.7% (7/42) vs. 17.5%(7/40), χ (2)=0.010, P=0.920].
Conclusions: Modified surviving sepsis bundle treatment according PiCCO can reduce the severity of disease in patients with septic shock, can make more accurately guide fluid resuscitation, and can reduce lung water and duration of mechanical ventilation and ICU stay. It has great clinical significance.