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
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
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.
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