Dobutamine and terlipressin in patients with septic shock
Stoke-on-Trent, UK
* E-mail: admin{at}cmc.myzen.co.uk
Editor—We read with interest the study by Morelli and colleagues1 describing the simultaneous infusion of dobutamine and terlipressin in patients with septic shock. The criteria chosen in the study to demonstrate adequate fluid resuscitation were a pulmonary artery occlusion pressure (PAOP) of 12–15 mm Hg and a central venous pressure (CVP) of 8–12 mm Hg. Although these are traditional and theoretical markers of intravascular filling, it has been clearly and repeatedly demonstrated that a static CVP or PAOP reading is not an indication of either the adequacy of intravascular volume or of fluid responsiveness.2 This holds true in experimental animal models of hypovolaemic shock, normal volunteers, septic patients, intensive care patients, and cardiac surgery patients. There is increasing evidence that dynamic criteria such as respiratory variations in haemodynamic variables (systolic pressure variation,3 pulse pressure variation,4 5 and stroke volume variation),6 7 the effect of passive leg raising,8 and changes in cardiac index (CI) in response to a fluid challenge9 are far more useful in guiding fluid resuscitation than their static counterparts.
It is likely that at least some of the patients in this trial would have shown evidence of fluid responsiveness had dynamic criteria for this been used. Vasoconstricting patients who are not adequately fluid resuscitated is likely to be detrimental via a reduction in CI and may compromise tissue oxygen delivery. There may have been a smaller reduction in SvO2 and CI in the terlipressin groups and less subsequent dobutamine use if a more evidence-based method of fluid resuscitation had been used.
1 Rome, Italy
2 Munster, Germany
* E-mail: andrea.morelli{at}uniroma1.it
Editor—We thank Drs Miller and Coleman for their relevant comment on our recent publication.1 One of the most important endpoints of our study was to evaluate the effects of terlipressin alone or in combination with dobutamine on oxygen delivery and oxygen consumption. Since virtually all patients included in the trial presented with or were at risk of pulmonary arterial hypertension, we decided to perform haemodynamic monitoring with a pulmonary artery catheter. It is well known that cardiac output can also be determined by pulse contour analyses, transpulmonary thermodilution, or echocardiography. In fact, dynamic variables, such as systolic pressure variation, pulse pressure variation, stroke volume variation, and changes in CI in response to a fluid challenge might be more useful in guiding fluid resuscitation than static parameters. However, the current sepsis guidelines suggest fluid therapy should aim to preserve CVP at 8–12 mm Hg, mean pulmonary occlusion pressure between 12 and 15 mm Hg, and an SvO2 (if available) of at least 65%. Since we wished to comply with the guidelines, fluid therapy was aimed to achieve these endpoints. It might be argued that some patients with high catecholamine doses benefit from PAOP values >12–15 mm Hg (especially in the presence of myocardial diastolic dysfunction). In this regard, it is important to note that mean PAOP was consistently within the upper limit of this range (between 14 and 16 mm Hg). Moreover, it has to be underlined that the thermodilution technique is still referred to as the gold standard of cardiac output measurement. Since dynamic parameters may be more accurate predictors of volume responsiveness in septic shock patients, they will hopefully be implemented into the next guidelines.
References
1 Morelli A, Ertmer C, Lange M, et al. Effects of short-term simultaneous infusion of dobutamine and terlipressin in patients with septic shock: the DOBUPRESS study. Br J Anaesth (2008) 100:494–503.
2 Michard F, Treboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest (2002) 121:2000–8.[CrossRef][Web of Science][Medline]
3 Perel A. The physiological basis of arterial pressure variation during positive-pressure ventilation. Reanimation (2005) 14:162–71.[CrossRef]
4 Michard F, Boussat S, Chemla D, et al. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med (2000) 162:134–8.
5 Bendjelid K, Suter PM, Romand JA. The respiratory change in preejection period: a new method to predict fluid responsiveness. J Appl Physiol (2004) 96:337–42.
6 Marx G, Cope T, McCrossan L, et al. Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis. Eur J Anaesthesiol (2004) 21:132–8.[CrossRef][Web of Science][Medline]
7 Berkenstadt H, Margalit M, Hadani M, et al. Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesth Analg (2001) 92:984–9.
8 Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med (2006) 34:1402–7.[CrossRef][Web of Science][Medline]
9 Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth (2002) 88:65–71.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||