Preload dependence indices to titrate volume expansion during septic shock: a randomized controlled trial

Jean-Christophe Richard, Frédérique Bayle, Gael Bourdin, Véronique Leray, Sophie Debord, Bertrand Delannoy, Alina Cividjian Stoian, Florent Wallet, Hodane Yonis, Claude Guerin

IntroductionIn septic shock, pulse pressure or cardiac output variation during passive leg raising are preload dependence indices reliable to predict fluid responsiveness. Therefore, they may help to identify those patients who need intravascular volume expansion, while avoiding unnecessary fluid administration in the other patients. However, whether their use improves septic shock prognosis remains unknown. The aim of this study was to assess the clinical benefits of using preload dependence indices to titrate intravascular fluids during septic shock.MethodsIn a single-center randomized controlled trial, 60 septic shock patients were allocated to preload dependence indices-guided (preload-dependence group) or central venous pressure-guided (control group) intravascular volume expansion, of 30 patients each. The primary endpoint was time to shock resolution, defined by vasopressor weaning.ResultsThere was no significant difference in time to shock resolution between groups (median (interquartile range) 2.0 (1.2 to 3.1) versus 2.3 (1.4 to 5.6) days in control and preload-dependence groups, respectively). The daily amount of fluids administered for intravascular volume expansion was higher in control than in preload-dependence group (917 (639 to 1511) versus 383 (211 to 604) mL, P¿=¿0.01), and the same held true for red cells transfusion (178 (82 to 304) versus 103 (0 to 183) mL, P¿=¿0.04). Physiologic variables values did not change over time between groups, except for plasma lactate (time over group interaction, P <0.01). Mortality was not significantly different between groups (23% in preload-dependence group versus 47% in control group, P¿=¿0.10). Intravascular volume expansion was lower in the preload-dependence group for patients with lower simplified acute physiology score II (SAPSII), and the opposite was found for patients in the upper two SAPSII quartiles. The amount of intravascular volume expansion did not change across the quartiles of severity in the control group, but steadily increased with severity in the preload-dependence group.ConclusionsIn patients with septic shock, titrating intravascular volume expansion with preload dependence indices did not change time to shock resolution, but resulted in less daily fluids intake, including red blood cells, without worsening patient outcome.Trial registrationClinicaltrials.gov NCT01972828. Registered October 11 2013.