Sepsis and Pulse Pressure Variation: Dynamic Consequences

1St Mary's Medical Center, San Francisco, CA.

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 226

Case Presentation:

An 83‐year‐old man was admitted to the hospital with suspected right upper load pneumonia. His physical exam and laboratory values were significant for a temperature of 38.4°C, a heart rate of 108, a white blood cell (WBC) count of 15.6 K/μLand a lactate of 1.3 units/L. A chest x‐ray showed right upper lung infiltrate. He was started on levofloxacin 750 mg IV daily. On hospital day 2, he complained of hemoptysis and fever. At this time his exam showed a temperature of 39.4°C, a respiratory rale of 36 bpm, and blood pressure of 86/43; lab results showed a WBC of 11.5 K/μL, hemoglobin of 13.5 g/dL, and lactate of 4.1 units/L. He was transferred to the ICU for management of septic shock. Early goal‐directed therapy (EGDT) was initiated. and there was aggressive resuscitation with norma saline boluses central venous catheter insertion rac al arterial line placement, and measurement of central venous blood co‐oximetry. He was intubated to protect his airway. During EGDT, we made the decision to resuscitate using pulse pressure variation (PPV) measurement as a guideline. Using a PPV of 13% as in indicator of adequate intravascular volume, we added vasopressor agents because he remained hypotensive. In the meantime, his central venous pressure (CVP) monitoring showed values from 8 to 14 mm Hg, his MAP was maintained greater than 70 mm Hg, and an echocardiogram showed thai the IVC varied less than 20% with respirations. Throughout his managemenl of septic shock, the CVP varied from 4 to 20 mm Hg and was an unreliable indicator of adequate volume status. Instead, using PPV we provided 250 mL normal saline boluses when the variation was greater than 13% and were able to wean him off vasopressor agents on ICU day 2, and the management of his MRSA pneumonia was not complicated by pulmonary edema.

Discussion:

Early goal‐directed therapy ushered in a paradigm shift in the management of sepsis. Since 2001, controversy has surrounded effective hemodynamic markers that reflected resuscitation status. Michard et al. has shown that dynamic measures like PPV and stroke volume variation (SVV) are more predictive than static measures of intravascular volume like CVP and pulmonary artery occlusion pressure. Although aggressive hydration has been a mainstay of early sepsis management, Marik et al. have shown that the area under the ROC curve for predicting fluid responsiveness by CVP is only 0.56, whereas aggressive hydralion results in increased ventilator time and ICU days. Although the utility of PPV and SVV has not been assessed in the early managemenl of sepsis, its predictive value for fluid responsiveness (positive predictive value 95%, negative predictive value 93%) demonstrates a need for further prospective trials.

Conclusions:

This case illustrates the use of pulse pressure variation as a reliable indicator of fluid responsiveness in the early management of sepsis.

Author Disclosure:

P. Bui, none.

To cite this abstract:

Bui P. Sepsis and Pulse Pressure Variation: Dynamic Consequences. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 226. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/sepsis-and-pulse-pressure-variation-dynamic-consequences/. Accessed September 22, 2019.

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