Effectiveness of a Protocolized De-resuscitation with Vexus Scoring Along with a Standard Protocol as Compared to a Standard Protocol Alone on the Cumulative Fluid Balance in Sepsis Patients: A Prospective Observational Study

INTRODUCTION: Effective fluid resuscitation and timely de-resuscitation are crucial in the management of sepsis, which is otherwise a life-threatening situation. However, there is no ideal tool to predict when to stop resuscitation in septic shock and when to start de-resuscitation.(1,2) The venous congestion by point-of-care-ultrasound (VExUS) score is a recent concept to assess fluid status at the bedside.(4–7) This study aims to determine whether a protocolized de-resuscitation using VExUS scoring along with a standard protocol compared to a standard protocol alone is better in reducing cumulative fluid balance and other clinical outcomes.(3,8) OBJECTIVES: To compare between both the groups the cumulative fluid balance from ICU admission until the beginning of study day 3, day 5, and at ICU discharge, change in SOFA scores on study day 3 and day 5, ICU mortality, length of stay in ICU, incidence of AKI in both groups. MATERIALS AND METHODS: This was a single-centre prospective observational study. All critically ill patients above 18 years of age with confirmed or suspected sepsis admitted to ICU were screened for eligibility. Patients enrolled after exclusion were screened daily by a standard criterion for their eligibility for de-resuscitation, including fluid unresponsiveness (by negative PLR test), signs of volume overload, and a cumulative fluid balance of > 2 liters. Patients who met these criteria were assigned to either VExUS guided group if VExUS scoring showed signs of mild to severe congestion in addition or to a standard group if they met the standard criteria. Once eligibility. criteria for de-resuscitation were met, and both groups were de-resuscitated using diuretics or fluid removal by RRT until a negative balance of 1-2 L/day was achieved. RESULTS: 84 patients were enrolled in the study after screening for eligibility. Demographic characteristics were similar in both groups. There was no significant difference in the net cumulative fluid balance between the groups on the day of initiation of the study, day 3, and day 5 of de-resuscitation, though the cumulative balance was less in the VExUS group at the time of ICU discharge with 1331 (IQR 684 – 3202) mL vs 2006 (IQR1380 – 2897) mL (p-value 0.03). Also, there was a significant reduction in cumulative balance in the VExUS group from the start of the study to day 3, day 5, and day of discharge [median, IQR -1587 (-2162,1299) mL vs. -1183.5 (-1698,-1079) mL on day 3, -3015 (-3084,-2268) mL vs-2242 (-2919,1833) mL with a p-value of 0.01 on day 5 and -3538 (-4466,-2496) mL vs -1780 (-2889,1215) mL on day of discharge. There was no significant difference in delta SOFA on day 3 and day 5 of ICU stay from admission. There was an improvement in creatinine levels in the VExUS group without any significant difference in AKI stages. Other secondary parameters did not show any difference between the two groups. CONCLUSIONS: This study showed that using VExUS scoring in addition to the standard protocol for de-resuscitation demonstrated a significant reduction in the cumulative fluid balance in the VExUS group on days 3 and 5 of the study as well as on the day of discharge from the ICU, even though the net cumulative balance was comparable between both groups at all time points of the study and without any significant difference in other outcomes.