fluid responsiveness evaluation in sepsis-associated hypotension

Conditions: Sepsis; Hypotension

Summary: this study assesses the mean difference in fluid balance at icu discharge and associated patient outcomes, based on a dynamic assessment of fluid responsiveness in septic patients with refractory hypotension in an icu setting.

multi-center randomized study comparing dynamic assessment of fluid responsiveness utilizing starling sv monitor compared to a control group. subjects will be randomized in a 2:1 treatment to control group ratio to increase power for sub-analysis by patient population. patients randomized to the starling sv arm will have treatment guided by a dynamic assessment of fluid responsiveness (measured by a change in stroke volume index \> 10%) as assessed by passive leg raise (plr). patients randomized to the control group will receive standard of care treatment.

Eligibility criteria:
inclusion criteria: 1. diagnosis of sepsis, as exhibited by 2 or more of the following systemic inflammatory response syndrome (sirs) criteria and a known or presumed infection at time of screening: * temperature of \> 38 c or \< 36 c * heart rate of \> 90/min * respiratory rate of \> 20/min or paco2 \< 32 mm hg (4.3 kpa) * white blood cell count \> 12000/mm3 or \ 10% immature bands 2. refractory hypotension despite initial fluid resuscitation (1l of treatment fluid) 3. patient enrolled in study as soon as possible (ideal window of 0-12 hours) and within 24 hours of arrival to the hospital 4. anticipated icu admission 5. able to provide signed informed consent or consent can be obtained from the patient's authorized representative exclusion criteria: 1. primary diagnosis of: acute cerebral vascular event, acute coronary syndrome, acute pulmonary edema, status asthmaticus, major cardiac arrhythmia, drug overdose, or injury from burn or trauma 2. known aortic insufficiency, or aortic abnormalities 3. hemodynamic instability due to active gastrointestinal hemorrhage 4. patient has received \>3 liters of iv fluid prior to study randomization 5. requires immediate surgery 6. patient transferred to the icu from another hospital unit 7. do not attempt resuscitation (dnar or dnr) order 8. advanced directives restricting implementation of the resuscitation protocol 9. contraindication to blood transfusion 10. attending clinician deems aggressive resuscitation unsuitable 11. transferred from another in-hospital setting 12. not able to commence treatment protocol within 1 hour after randomization 13. known intraventricular heart defect, such as ventral septal defect or atrial septal defect 14. use of additional hemodynamic monitoring involving stroke volume variation (svv) to determine fluid responsiveness 15. seizure in the last 24 hours 16. prisoner 17. pregnancy 18. age \<18 19. known allergy to sensor material or gel 20. inability or contraindication to doing a passive leg raise with both extremities, such as inability to interrupt venous compression boots 21. patient has an epidural catheter in place 22. suspected intra-abdominal hypertension 23. inability to obtain iv access 24. diabetic ketoacidosis 25. hyper-osmolarity syndrome 26. patient uncouples from treatment algorithm 27. patient should be excluded based on the opinion of the clinician/investigator