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Communications to the Editor |

Oxygen Delivery in Septic Shock FREE TO VIEW

Martijn Poeze, MD; Jan Willem M. Greve; Graham Ramsay, MD
Author and Funding Information

University Hospital Maastricht, Maastricht, The Netherlands

Correspondence to: Martijn Poeze, MD, Department of Surgery and Intensive Care, University Hospital Maastricht, PO Box AZ Maastricht, Maastricht, The Netherlands



Chest. 1999;116(4):1145. doi:10.1378/chest.116.4.1145
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To the Editor:

In the study by Alía and colleagues (February 1999),1 the effects of maximizing oxygen delivery in patients with severe sepsis and septic shock were studied. Although reduction of the mortality rate in patients with septic shock has been proven to be difficult to achieve, the data from the trials previously published on the subject of optimizing oxygen delivery in sepsis suggest that Alía et al may have aimed for inappropriate goals for this study population.

The trial originally carried out by Shoemaker et al2was based on the observation that trauma and perioperative patients had a higher survival rate when oxygen delivery and oxygen consumption were increased. They hypothesized that a protocolized increase in oxygen transport would be able to reduce the mortality rate. This was confirmed with a reduction in the mortality rate in the protocol group. The patients included were young patients with little comorbidity. The trial by Boyd et al3was carried out in preoperative, elderly patients. The perioperative optimization of oxygen delivery used in these patients also reduced mortality. In total, eight randomized trials have been performed using perioperative optimization of oxygen delivery in surgical or trauma patients, of which five showed a reduction in mortality rate. Moreover, some trials in perioperative optimization, although not specifically aiming at increased oxygen delivery, could demonstrate significant reductions in morbidity or mortality figures.46

This seems to be different in patients with sepsis. In total, four trials using an optimization protocol were carried out, of which none showed a decrease in mortality rate. In the trial by Hayes et al,7 the mortality rate even increased in the“ optimization” group. The trial by Alía et al1 confirms this overall picture. Although the differences in mortality rates were not significant in their trial, a 10 to 20% relative increase in mortality rate seemed to be present in the “optimized” patient group, which is comparable to the increase found in the trial by Hayes et al.7 The remark made by Alia et al in the“ Discussion” section of their article that their approach to optimize oxygen delivery may not have been aggressive enough, seems to be a dangerous one.

The differences that exist between optimization in surgical/trauma patients and that in septic patients may be caused by differences in pathophysiology. In perioperative and posttrauma optimization, the main pathophysiologic problem is hypovolemia, which easily can be reversed by standard resuscitation techniques. During sepsis, the problem is not“ simple” hypovolemia; rather, the ability to autoregulate the microcirculation is lost.8This “vasoplegia” in septic patients makes it difficult to improve the hemodynamic parameters in order to optimize oxygen transport.9 Intensive efforts to reach these goals in septic patients, as used in the trial by Hayes et al,7 may compromise the cardiac performance of these patients, resulting in increased mortality rate.

The studies published so far in patients with septic shock and multiple organ failure using goals for hemodynamic optimization have not been able to reduce morbidity. A more reasonable approach in septic patients could be to redefine the hemodynamic goals to aim, for example, at interventions reversing the loss in autoregulatory control of microcirculation during septic shock.

References

Alía, I, Esteban, A, Gordo, F, et al (1999) A randomized and controlled trial of the effect of treatment aimed at maximizing oxygen delivery in patients with severe sepsis or septic shock.Chest115,453-461. [PubMed] [CrossRef]
 
Shoemaker, WC, Appel, PL, Kram, HB, et al Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.Chest1988;94,1176-1186. [PubMed]
 
Boyd, O, Grounds, RM, Bennett, ED A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high- risk surgical patients.JAMA1993;270,2699-2707. [PubMed]
 
Sinclair, S, James, S, Singer, M Intraoperative intravascular volume optimisation and length of stay after repair of proximal femur fracture: randomised controlled trial.BMJ1997;315,909-912. [PubMed]
 
Mythen, MG, Webb, AR Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery.Arch Surg1995;130,423-429. [PubMed]
 
Garrison, RN, Wilson, MA, Matheson, PJ, et al Preoperative saline loading improves outcome after elective, noncardiac surgical procedures.Am Surg1996;62,223-231. [PubMed]
 
Hayes, MA, Timmins, AC, Yau, EHS, et al Elevation of systemic oxygen delivery in the treatment of critically ill patients.N Engl J Med1994;330,1717-1722. [PubMed]
 
Sibbald, WJ, Fox, G, Martin, C Abnormalities of vascular reactivity in the sepsis syndrome.Chest1991;100,155S-159S. [PubMed]
 
Bersten, AD, Hersch, M, Cheung, H, et al The effect of various sympathomimetics on the regional circulations in hyperdynamic sepsis.Surgery1992;112,549-561. [PubMed]
 

Figures

Tables

References

Alía, I, Esteban, A, Gordo, F, et al (1999) A randomized and controlled trial of the effect of treatment aimed at maximizing oxygen delivery in patients with severe sepsis or septic shock.Chest115,453-461. [PubMed] [CrossRef]
 
Shoemaker, WC, Appel, PL, Kram, HB, et al Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients.Chest1988;94,1176-1186. [PubMed]
 
Boyd, O, Grounds, RM, Bennett, ED A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high- risk surgical patients.JAMA1993;270,2699-2707. [PubMed]
 
Sinclair, S, James, S, Singer, M Intraoperative intravascular volume optimisation and length of stay after repair of proximal femur fracture: randomised controlled trial.BMJ1997;315,909-912. [PubMed]
 
Mythen, MG, Webb, AR Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery.Arch Surg1995;130,423-429. [PubMed]
 
Garrison, RN, Wilson, MA, Matheson, PJ, et al Preoperative saline loading improves outcome after elective, noncardiac surgical procedures.Am Surg1996;62,223-231. [PubMed]
 
Hayes, MA, Timmins, AC, Yau, EHS, et al Elevation of systemic oxygen delivery in the treatment of critically ill patients.N Engl J Med1994;330,1717-1722. [PubMed]
 
Sibbald, WJ, Fox, G, Martin, C Abnormalities of vascular reactivity in the sepsis syndrome.Chest1991;100,155S-159S. [PubMed]
 
Bersten, AD, Hersch, M, Cheung, H, et al The effect of various sympathomimetics on the regional circulations in hyperdynamic sepsis.Surgery1992;112,549-561. [PubMed]
 
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