title: Impact of septic shock hemodynamic resuscitation guidelines on rapid early volume replacement and reduced mortality.
abstract: BACKGROUND
  Septic shock is one of the most serious conditions associated with high mortality. We recently developed a modified septic shock management guideline focusing on rapid restoration of hemodynamics by using clinical endpoint. Our aim was to analyze patients' outcomes following the guideline implementation.
  
  
  METHODS
  A retrospective review of hemodynamic data sheet and clinical outcomes of patients admitted to medical ICU and medical Wards and during June 2004 and February 2006.
  
  
  RESULTS
  One hundred and four patients' records were retrieved. The patients' mean age was 62.5 +/- 18.6 year. Their mean APACHE II score were 24.9 +/- 6.7 and the overall mortality was 59%. Sixty eight patients (65.4%) underwent guideline directed therapy (guideline group). The guideline group received higher volume resuscitation from the first hour of resuscitation (1,016.3 + 675.0 ml vs. 521.4 + 359.2 ml, p < 0.001) to the forty eighth hour (10,096.9 +/- 3,256.1 ml vs. 8,067.3 +/- 2,591.9 ml, p = 0.006). More of them achieved the therapeutic goal within 6 hours (86.8% vs. 44.4%, p < 0.001) and their hospital mortality was lower (41.2% vs. 69.4%, p = 0.008). When analyzing differences between those who survived and those who died, more of the surviving patients underwent guideline directed treatment (79.5% vs. 55%, p = 0.012). They received higher volume replacement from the first hour to the end of the twelfth hour (first hour 1,098.0 +/- 723.0 vs. 660.9 +/- 478.9 ml, p < 0.001; the end of the twelfth hour 3,746.6 +/- 1,799 vs. 3,014.1 +/- 1,579.9 ml, p = 0.038) and more of them achieved the therapeutic goal within 6 hours (95.5% vs. 55%, p < 0.001). Multivariate analysis of factors associated with mortality disclosed APACHE II score, volume resuscitation more than 800 ml in the first hour and achievement of the therapeutic goal within 6 hours.
  
  
  CONCLUSIONS
  Implementation of our modified septic shock guideline is associated with rapid initial volume replacement, prompt achievement of therapeutic goal and improved outcomes. Volume resuscitation greater than 800 ml in the first hour is associated with better survival.
authors.affiliation: Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. sicpk@mahidol.ac.th
authors.forename: Chairat
authors.initials: C
authors.lastname: Permpikul
authors.forename: Surat
authors.initials: S
authors.lastname: Tongyoo
authors.forename: Ranistha
authors.initials: R
authors.lastname: Ratanarat
authors.forename: Warakarn
authors.initials: W
authors.lastname: Wilachone
authors.forename: Aekarin
authors.initials: A
authors.lastname: Poompichet
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D006748:Hospital Departments; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D012151:Resuscitation / Q000379:methods* / Q000592:standards; D012189:Retrospective Studies; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy*; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome