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Abstract
The first-line therapy in severe sepsis and septic shock is volume resuscitation,
since relative and absolute hypovolemia are key symptoms of this illness. In addition
a small subset of patients present with a septic cardiomyopathy (10–15%), a type of
heart failure that barely responds to inotropes. Rapid restoration of blood flow and
of tissue oxygenation respectively is of utmost importance in order to prevent organ
dysfunction. So it is reasonable to postulate hemodynamic monitoring to diagnose pathophysiologic
features and to guide therapy in these severely ill patients; more so since it has
been shown recently that a substantial reduction in mortality could be achieved following
therapeutic goals [1].
The objective of the study was to evaluate monitoring habits in German ICUs in patients
with severe sepsis and septic shock.
A prospective observational cross-sectional study was performed in the ICUs of a representative
hospital sample randomly selected from a complete registry of German hospitals stratified
by size (≤ 200; 201–400; 401–600; >600 beds; university hospitals). From a total of
3877 patients screened, 415 patients (11%) fulfilled the ACCP/SCCM criteria for severe
sepsis or septic shock. In these patients, monitoring routines – arterial blood pressure
(ABP), central venous pressure (CVP), pulmonary artery catheter (PAC) and pulse contour
analysis (PCA) – were ascertained by physicians trained in critical care medicine
and compared with the data of a questionnaire that had been answered by the director
of the ICU.
In general there was a pronounced difference between the statements of the ICU directors
answering the questionnaire and the monitoring devices actually used. Only CVP measurement
had been performed in all ICU patients in all hospital strata, and there was no gap
between the questionnaire and instituted device. Patients in hospitals >400 beds were
monitored with invasive ABP measurement in the majority of all cases, while middle-sized
hospitals did this less frequently (60–75%). The PAC had been used in only a small
subset of patients (<12%), although especially in larger hospitals the ICU director
stated to use it more frequently (university: 40.4%). PCA, an excellent device to
guide volume resuscitation [2], had seldom been in use as well. Even in major hospitals
less than 15% of all patients monitored their patients in this way.