Journal Reading

Dini Kamilah Islami

1610029053

Consultant : dr. Teddy Ferdinand I., Sp. An., KAKV

 Introduction
• Septic shock is defined as a systemic inflammatory respon
syndrome, triggered by an infection asssociated with refractory
hypotension, despite a fluid load of 30 mL/kg of body weight that
remains cause of morbidity and mortality among criticall ill
patients.
• Patients with sustained hypotension (MAP < 65 mmHg) or thous
with initial arterial lactate concentration > 4.0 mmol/L 
resuscitation guided by CVP, MAP, ScvO2, SvO2
• The goals to be achieved during the initial 6 hours resuscitation:
CVP : 8-12 mmHg (spontaneous breathing), 12-15
mmHg (under mechanical ventilation)
MAP :> 65 mmHg
ScvO2 or SvO2 : > 70% and 65%
Lactate clearance : > 10% (no central venous catheter)
 Why Fluids Are Given?
• Vascular bed changes  inflammatory
mediators  endhotelial cells  vasodillation
 hypovolemia
• Impaired tissue perfusion (stagnant hypoxia)
 blood flow augmentation
• Inotropes should be considered to improve
tissue oxygenation in patients requiring an
increased blood flow but no longer responsive
to fluid administration
 Early onset resusitacion
• Oxygen delivery
• Minimize progression cell Infection control
• Mitochondrial dysfunction  antibiotics

Multiple organ failure syndrome secondary

The main crystalloid solutions and their
composition
The main colloidal solutions
 CRYSTALLOIDS

- Recommended as a first choice resusicate septic

shock patients
- Normal saline (NaCl 0.9%)is considered as an
isotonic solution  osmolality closer to the
plasma osmolality, but chloride concentration is
1.5 – fold higher tan the physiologic serum
concentration non-balanced solution

- Hypercloremic acidosis
- Coagulation kidney function
- Immunologic response
• Balanced solution is considered as alternative
to normal saline  normotonic with SID 24
meq/L removing 24 meq/l of chloride from
Na Cl 0.9% replace with bicarbonate or
organics ions such as lactate or acetate
• Ringer laktat is a mild hypotonic solution (273
mOsm/kg) and has pottassium and calcium 
increase plasma laktat  lactate buffer
• Plasma lyte is another balanced solution with
osmolality of 295 mOsm/L, sodium
concentration 140 meq/L and chloride
concentration 98 meq/L
• Patients who has impaired kidney function
should be avoided  hyperkalemia
• Cohort study  53.448 resucitate with
balanced solution  decreased the risk of in-
hospital death
 COLLOIDS

• Colloids are defined as homogenous non-

crytalloids substance consisting of large
molecules or ultramicroscpic particcle
• Higher oncotic pressure  not able to cross
semi permeable membran
• Two kinds: natural and semisynthetic colloids
 HES

• Recent clinical data indicate that colloids do not

improve patient outcomes and may be harmful
depending on the setting and type of colloid.
• A prospective multicenter clinical trial was
performed to address the frequency of acute
renal failure in severe sepsis and septic shock
patients resuscitated with 6% HES (200kDa, 0.60;
0.66 substitution) or 3% fluid-modified gelatin.
 HES
• In those studies, resuscitation with a third
generation of HES was associated with an
increased risk of death, acute renal failure and
the need of renal replacement therapy,
especially among the septic patients
 ALBUMIN
• A subgroup analysis among septic shock
patients enrolled in the SAFE study showed a
trend on mortality reduction in favor to
albumin in comparison to normal saline
 ALBUMIN
• ALBIOS study (Volume Replacement With
Albumin in Severe Sepsis) randomized 1,818
severe sepsis and septic shock patients to receive
either 300mL of 20% albumin plus crystalloid or
to receive crystalloid alone from randomization
until day 28, or ICU discharge, aiming to maintain
serum albumin ≥30g/L.

• the albumin group when compared to crystalloids

group,neither the 28-day mortality nor the 90-
day mortality rate
 ALBUMIN
• clinical trial comparing a 4% albumin solution
with crystalloids to resuscitate septic shock
patients is required. For instance, albumin
solution is the only colloidal solution endorsed
by the Surviving Sepsis Campaign guidelines
for septic patients who are not responding to
crystalloid infusion
 CONCLUSION
• The body of evidence shows that crystalloids
solutions, whether balanced or not, are the
most advisable choice. Hypo-oncotic albumin
solutions can be used as an alternative for
those who need large amounts of fluids during
the initial resuscitation phase
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