Easy method to determine fluid responsiveness in septic shock patients: end-tidal CO2 - a prospective observational study.

BACKGROUND: In critically ill patients, especially those with septic shock, fluid management can be a challenging aspect of clinical care. One of the primary steps in treating patients with hemodynamic instability is optimizing intravascular volume. The Passive Leg Raising (PLR) maneuver is a reliable test for assessing fluid responsiveness, as demonstrated by numerous studies and meta-analyses. However, its use requires the measurement of cardiac output, which is often complex and may necessitate clinician experience and specialized equipment. End-Tidal Carbon Dioxide (ETCO2) measurement is relatively easy and is generally stable under steady metabolic conditions. It depends on the body's CO2 production, diffusion of CO2 from the lungs into the bloodstream, and cardiac output. If the other two parameters (metabolic conditions and minute ventilation) are constant, ETCO2 can provide information about cardiac output. The aim of the present study is to investigate the sensitivity of ETCO2 measurement in demonstrating fluid responsiveness. METHODS: All patients diagnosed with septic shock and meeting the inclusion criteria were subjected to a passive leg raising test, and cardiac outputs were measured by echocardiography. An increase in cardiac output of 15% or more was considered indicative of the fluid responder group, while patients with an increase below 15% or no increase were classified as the non-responder group. Patients' intensive care unit admission diagnoses, initial laboratory parameters, tidal volume, minute volume before and after the PLR maneuver, mean and systolic blood pressure, heart rate, Pulse Pressure Variation (PPV) values, and ETCO2 values were recorded. RESULTS: Before and after the ETCO2 test, there was no statistically significant difference between the two groups. However, the change in ETCO2 (ΔETCO2) was significantly higher in the responder group. In the non-responder group, ΔETCO2 was 2.57% (0.81), whereas it was 5.71% (2.83) in the responder group (p<0.001). Receiver Operating Characteristic (ROC) analysis was performed for ΔETCO2, baseline Stroke Volume Variation (SVV), ΔSVV, baseline Heart Rate (HR), ΔHR, baseline PPV, and ΔPPV to predict fluid responsiveness. ΔETCO2 predicted fluid responsiveness with a sensitivity of 85% and a specificity of 86% when it was 4% or higher. When ΔETCO2 was 5% or higher, it predicted fluid responsiveness with a specificity of 99.3% and a sensitivity of 75.5%, with an Area Under the Curve (AUC) of 0.89 (95% confidence interval, 0.828-0.961). CONCLUSION: This study demonstrates that in septic patients, ETCO2 during the PLR test can indicate fluid responsiveness with high sensitivity and specificity and can be used as an alternative to cardiac output measurement.

Success of the Cytokine Absorption Therapies in COVID-19 Patients Diagnosed with Cytokine Release Syndrome.

OBJECTIVE: To compare the effects of cytokine absorption therapy with a resin-based cytokine absorption cartridge to tocilizumab treatment in critically ill COVID-19 patients diagnosed with cytokine release syndrome (CRS). STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: University of Health Sciences, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey from April 2020 to April 2021. METHODOLOGY: Twenty-four intensive care unit (ICU) patients were included in the study. Inclusion criteria were diagnosis of severe COVID-19, diagnosis of CRS and age of older than 18 years. Exclusion criteria were pregnancy, malignancy, prior COVID-19 vaccination, procalcitonin levels higher than 2 ng/ml and life-threatening comorbidities before ICU admission. Twelve patients received tocilizumab and the other 12 patients received cytokine absorption therapy. The groups were compared for clinical outcomes and inflammatory markers (CRP, fibrinogen, ferritin, D-dimer). RESULTS: Inflammatory markers showed smilar changes with both treatments, mostly toward improvement, on the same post-treatment days. The mortality rate was 58% (seven patients) in the cytokine absorption group and 50% (six patients) in the tocilizumab group (p = 0.682). CONCLUSION: It was found that the cytokine absorption therapy reduces inflammatory mediators in intubated and critically ill Covid-19 patients similar to tocilizumab treatment, and both treatments have comparable clinical outcomes. KEY WORDS: SARS-CoV-2, Cytokine release syndrome, Chemokines, Absorption, Tocilizumab.