Early Goal Directed Therapy for Septic Shock Is Feasible and Safe in Hematopoietic Stem Cell Transplant Patients.
Authors: Al-Kadhimi Zaid S. , Sandoval Argelia J. , Zain Jasmine M. , Forman Stephen J. 
Published: October 2019

Abstract
Hematopoietic stem cell transplant (HSCT) patients are at high risk for infection that can quickly progress to septic shock and multi-organ failure at various stages of their HSCT, with very high mortality and morbidity. One intervention that showed impact on outcomes is early goal directed therapy (EGDT), in which optimizing peripheral tissue oxygen delivery to meet hemodynamic endpoints using monitored early aggressive fluid resuscitation, hemoglobin correction, and pressors led to significant improvement in mortality and morbidity. Since that study did not include any HSCT patients who are considered such a high risk group with poor organ reserve function, immune suppression, micro-vascular injury caused by chemotherapy, radiation, implementing this aggressive approach for these patients in septic shock can raise concern of worsening respiratory, hemodynamic status and the added risk of inserting a new central line for monitoring central venous pressure (CVP) and Central venous Oxygen saturation (ScvO2) as a functional measure of cardiac output and oxygen delivery. In a pilot study we’ve tested the feasibility and safety of using EGDT approach in our HSCT patients in septic shock who needed ICU admission. We treated 10 consecutive patients upon admission to the ICU. Ages ranged from 24–70 years, all the patients were hypotensive with no response to at least 1500 mls of fluid boluses and low dose dopamine on the floor(5–7 mic/kg/min). Most of them were oliguric and some of them were in mild to moderate hypoxemia and tachypnea at the time of ICU transfer. In our institution most of these patients have right atrial catheters that can be used for measurement of CVP and ScvO2 through blood draws. In a sequenced approach CVP was kept between 8–12 mm hg with aggressive fluid resuscitation, Hgb at 10 and ScvO2 above 70%, levophed was used only if systolic BP was less than 90 mm hg. Dobutamine was used only if the ScvO2 was less than 70% despite all the above measures. All patients received 100 mg of hydrocortisone every 8 hours X 3–6 doses (to optimize adrenal function). All patients tolerated the treatment well. The average time of need for pressors was less than 14 hours. The average time with ICU care was 2.2 days. No complications reported as a result of the intervention, no end organ damage, and no renal or respiratory complications despite an average amount of IV fluid given in the 1st 12 hours of around 6.4 liters. All patients survived that ICU admission. The early aggressive approach of optimizing hemodynamic parameters in HSCT patients in septic shock is feasible, safe and may result in improved outcomes of survival, less ICU time and less end organ damage.
Patients Characteristics Patient Diagnosis Bacteria Transplant state Time of ICU care Levophed time hours 12 hours fluid intake mls PS1 ALL P Aerogenosa pre-transplant 1 day <12 8493 PS2 ALL none pre-transplant 2 days <12 5079 HB3 AML Citribacter Freundii 5 months post allo 2 days <17 8026 FD4 ALL E coli 8 years post allo 2 days <12 5411 JS5 NHL Xanthomanas 65 days post allo 1 day none 4361 RN6 Multiple myeloma Serratia M Pre-transplant 2 days <24 5007 AA7 AML E Coli Pre-transplant 2 days <12 hours 5904 AT8 AML Klebsilla Pneumonia Pre-transplant 4 days <12 hours 8000 DW9 Germ cell Tumor none Day 10 post auto 4 days <12 hours 8307 FA10 AML Staph Aureus Day 67 post MUD 2 days <24 hours 6130