Cardiac Output Monitoring Managing Intravenous Therapy (COMMIT) to treat emergency department patients with sepsis

Peter C. Hou, Michael R. Filbin, Anthony Napoli, Joseph Feldman, Peter S. Pang, Jeffrey Sankoff, Bruce M. Lo, Howard Dickey-White, Robert H. Birkhahn, Nathan I. Shapiro

Research output: Contribution to journalArticle

9 Scopus citations

Abstract

Objective: Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on preload dependence. The objectives of this study were to determine if a fluid responsiveness protocol would decrease progression of organ dysfunction, and a fluid responsiveness protocol would facilitate a more aggressive resuscitation. Methods: Prospective, 10-center, randomized interventional trial. Inclusion criteria: suspected sepsis and lactate 2.0 to 4.0mmol/L. Exclusion criteria (abbreviated): systolic blood pressure more than 90mmHg, and contraindication to aggressive fluid resuscitation. Intervention: fluid responsiveness protocol using Non-Invasive Cardiac Output Monitor (NICOM) to assess for fluid responsiveness (>10% increase in stroke volume in response to 5mL/kg fluid bolus) with balance of a liter given in responsive patients. Control: standard clinical care. Outcomes: primary - change in Sepsis-related Organ Failure Assessment (SOFA) score at least 1 over 72h; secondary - fluids administered. Trial was initially powered at 600 patients, but stopped early due to a change in sponsor's funding priorities. Results: Sixty-four patients were enrolled with 32 in the treatment arm. There were no significant differences between arms in age, comorbidities, baseline vital signs, or SOFA scores (P>0.05 for all). Comparing treatment versus Standard of Care - there was no difference in proportion of increase in SOFA score of at least 1 point (30% vs. 33%) (note bene underpowered, P=1.0) or mean preprotocol fluids 1,050mL (95% confidence interval [CI]: 786-1,314) vs. 1,031mL (95% CI: 741-1,325) (P=0.93); however, treatment patients received more fluids during the protocol (2,633mL [95% CI: 2,264-3,001] vs. 1,002mL [95% CI: 707-1,298]) (P<0.001). Conclusions: In this study of a "preshock" population, there was no change in progression of organ dysfunction with a fluid responsiveness protocol. A noninvasive fluid responsiveness protocol did facilitate delivery of an increased volume of fluid. Additional properly powered and enrolled outcomes studies are needed.

Original languageEnglish (US)
Pages (from-to)132-138
Number of pages7
JournalShock
Volume46
Issue number2
DOIs
StatePublished - Aug 1 2016

Keywords

  • Fluid resuscitation
  • sepsis
  • shock
  • stroke volume
  • volume responsiveness

ASJC Scopus subject areas

  • Emergency Medicine
  • Critical Care and Intensive Care Medicine

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    Hou, P. C., Filbin, M. R., Napoli, A., Feldman, J., Pang, P. S., Sankoff, J., Lo, B. M., Dickey-White, H., Birkhahn, R. H., & Shapiro, N. I. (2016). Cardiac Output Monitoring Managing Intravenous Therapy (COMMIT) to treat emergency department patients with sepsis. Shock, 46(2), 132-138. https://doi.org/10.1097/SHK.0000000000000564