Point-of-care Ultrasound (POCUS)-Guided Pragmatic Fluid and Albumin Resuscitation and Hemodynamic Monitoring in Cirrhosis and Septic Shock.

BACKGROUND & AIMS: Fluid resuscitation strategy in cirrhosis and septic shock remains unclear, especially in the setting of cirrhotic cardiomyopathy (CCM). In a single-center propensity-matched analysis (discovery cohort; group 1) and in a subsequent multicenter validation cohort (group 2), we compared two pragmatic point-of-care ultrasound (POCUS)-guided fluid resuscitation strategies in cirrhosis and septic shock. Patients received a crystalloid challenge to assess fluid responsiveness, followed by either balanced salt solution (BSS) with 20% albumin vs. BSS alone. Outcomes of interest were sepsis-related circulatory failure (need for fluids and additional vasopressor support) and all-cause mortality at 28 and 90 days.

METHODS

POCUS was performed at time 0h, 24 h, 48 h, 72 h, and repeated as clinically needed in patients with cirrhosis and septic shock with mean arterial pressure (MAP) <65 mmHg. Resuscitation targets were as follows: MAP ≥ 65 mmHg, inferior vena cava (IVC) parameters of adequate volume resuscitation (IVC diameter between 1.8 and 2 cm; IVC collapsibility index: 20-30%), lactate clearance, optimized cardiac index, and lung profile.

RESULTS

One hundred seventy patients (age: 51.1 ±9.3 years, 47.1% alcohol-associated cirrhosis, model for end-stage liver disease with sodium [MELD-Na]: 27.4 ± 4.3) were in group 1 and group 2 had 126 patients (age: 50.8 ± 11.4 years, alcohol-associated cirrhosis: 42.3%, MELD-Na: 27.6 ± 4.2). The 28-day mortality rate was similar with either resuscitation strategy: 36.5% vs. 31.8% (P = 0.314) in the discovery cohort and 35.9% vs. 30.6% (P = 0.330) in the validation cohort, respectively. At 90 days, mortality rates were 40% vs. 32.9% (P = 0.213) and 40.6% vs. 32.3% (P = 0.215), respectively. The total infused BSS was lower in the 20% albumin vs. BSS arm in both the discovery (1595 ± 315 mL vs. 1948 ± 318 mL, P < 0.001) and validation (1503.9 ± 249.8 mL vs. 2116.9 ± 380.6 mL, P < 0.001) cohorts, respectively. CCM was diagnosed in 75 (44.1%) and 43 (34.1%) in group 1 and group 2, respectively, and was predictive of circulatory failure (adjusted hazard ratio; aHR: 2.3, 95% [confidence interval]CI: 1.5-3.7, P < 0.001 & aHR: 2.1, 95%CI: 1.2-3.9, P = 0.009) and mortality (aHR: 2.9, 95% CI:1.7-4.9, P < 0.001 & aHR: 2.4, 95%CI: 1.2-4.9, P = 0.011), independent of fluid strategy, baseline MAP, and baseline MELD-Na.

CONCLUSION

In patients with cirrhosis and septic shock, mortality is influenced by the presence of CCM and not by crystalloid/albumin resuscitation strategy.