Effect of inhaled nitric oxide in combination with almitrine on ventilation-perfusion distributions in experimental lung injury

Objective: To investigate a possible additive effect of combined nitric oxide (NO) and almitrine bismesylate (ALM) on pulmonary ventilation-perfusion (V˙._A/Q˙) ratio.¶Design: Prospective, controlled animal study.¶Setting: Animal research facility of a university hospital.¶Interventions: Three conditions were studied in ten female pigs with experimental acute lung injury (ALI) induced by repeated lung lavage: 1) 10 ppm NO, 2) 10 ppm NO with 1 μg/kg per min ALM, 3) 1 μg/kg per min ALM. For each condition, gas exchange, hemodynamics and V˙._A/Q˙ distributions were analyzed using the multiple inert gas elimination technique (MIGET).¶Measurement and results: With NO + ALM, arterial oxygen partial pressure (PaO₂) increased from 63 ± 18 mmHg to 202 ± 97 mmHg while intrapulmonary shunt decreased from 50 ± 15 % to 26 ± 12 % and blood flow to regions with a normal V˙._A/Q˙ ratio increased from 49 ± 16 % to 72 ± 15 %. These changes were significant when compared to untreated ALI (p < 0.05) and NO or ALM alone (p < 0.05), although improvements due to NO or ALM also reached statistical significance compared to ALI values (p < 0.05).¶Conclusions: We conclude that NO + ALM results in an additive improvement of pulmonary gas exchange in an experimental model of ALI by diverting additional blood flow from non-ventilated lung regions towards those with normal V˙._A/Q˙ relationships.     

Ceftazidime improves hemodynamics and oxygenation in ovine smoke inhalation injury and septic shock

OBJECTIVE: To investigate ceftazidime in acute lung injury (ALI) and sepsis. DESIGN AND SETTING: Prospective, randomized, controlled animal study in an investigational ICU at a university hospital. INTERVENTIONS: Eighteen female Merino sheep were prepared for chronic study and subjected to smoke inhalation and septic challenge according to an established protocol. MEASUREMENTS AND RESULTS: Whereas global hemodynamics and oxygenation remained stable in sham animals (no injury, no treatment), the injury contributed to a hypotensive-hyperdynamic circulation in the control group (smoke inhalation and sepsis, no treatment), as indicated by a significant increase in cardiac index) and heart rate and a drop in mean arterial pressure. Treatment with ceftazidime (smoke inhalation and sepsis, treatment group) stabilized cardiac index and heart rate and attenuated the decrease in mean arterial pressure. The deterioration in PaO2/FiO2 ratio and pulmonary shunt fraction (Qs/Qt) was significantly delayed and blunted by ceftazidime. At 24 h after injury a significant increase in airway obstruction scores of bronchi and bronchioles in both injured groups was observed. Ceftazidime significantly reduced airway obstruction vs. control animals. Whereas plasma nitrate/nitrite levels increased similarly in the two injured groups, lung 3-nitrotyrosine content remained at the baseline level in the ceftazidime group. CONCLUSIONS: In ovine lung injury ceftazidime improves global hemodynamics and oxygenation not only by bacterial clearance but also via reduction in toxic nitrogen species such as 3-nitrotyrosine. Therefore ceftazidime appears as a clinically relevant adjunct in the common setting of sepsis-associated lung injury.     

一氧化氮吸入对羊感染性急性呼吸窘迫综合征血液动力学和肺氧合功能的影响

目的：探讨一氧化氮（NO）吸入对羊感染性急性呼吸窘迫综合征（ARDS）血流动力学和肺氧合功能的影响。方法：静脉注入小剂量内毒素诱导羊感染性ARDS模型。随机分为两组：（1）NO组（n=6）为ARDS建立后，在容量控制通气基础上持续吸入40ppmNO 3h；（2）对照组（n=6)为ARDS一单纯容量控制通气，观察3h以确定模型的稳定性并与NO组比较，通过肺动脉导管和动脉血气分析，测定各组每小时肺气体交换和血流动力学参数，3h结束实验时，检测血中高铁血红蛋白（MetHb）浓度。结果：静脉注入小剂量内毒素能够诱导稳定的羊感染性ARDS模型，该模型的平均肺动脉压（MPAP）较基础值明显升高（P＜0．01），体循环血液动力学则能维持稳定。NO组各时点MPAP均较治疗前和同时点的对照组低（P＜0．01），动脉氧分压（PaO2）则明显增加（P＜0．01），肺泡动脉血氧分压差（PA－aO2)和肺内分流（Qs/Qt)明显低于治疗前和同时点的对照组（P＜0．01）。两组平均动脉压（MAP）和心排量（CO）各时点及治疗前后比较均无明显变化（P＞0．05），MetHb未见明显升高，结论：吸入NO选择性降低肺动脉压，改善肺氧合，无明显毒副作用。     

Volume of fluids administered during resuscitation for severe sepsis and septic shock and the development of the acute respiratory distress syndrome

Purpose

The purpose of this study was to examine the association between the volume of intravenous (IV) fluids administered in the resuscitative phase of severe sepsis and septic shock and the development of the acute respiratory distress syndrome (ARDS).

Materials and methods

This was a retrospective cohort study of adult patients admitted with severe sepsis and septic shock at a large academic public hospital. The relationship between the volume of IV fluids administered and the development of ARDS was examined using multivariable logistic regression analysis.

Results

Among 296 patients hospitalized for severe sepsis and septic shock, 75 (25.3%) developed ARDS. After controlling for confounding variables, there was no significant association between the volume of IV fluids administered in the first 24 hours of hospitalization and the development of ARDS (odds ratio [OR], 1.05; 95% confidence interval [CI], 0.95-1.18). Serum albumin (OR, 0.52; 95% CI, 0.31-0.87) and Acute Physiology and Chronic Health Evaluation II score (OR, 1.08; 95% CI, 1.04-1.13) on admission were the most informative covariates for the development of ARDS in the regression model.

Conclusions

For patients hospitalized for severe sepsis and septic shock, fluid administration to improve end-organ perfusion should remain the top priority in early resuscitation despite the potential risk of inducing ARDS.     

Acute effects of continuous rotational therapy on ventilation-perfusion inequality in lung injury

Objective: To investigate ventilation-perfusion (V_A/Q) relationships, during continuous axial rotation and in the supine position, in patients with acute lung injury (ALI) using the multiple inert gas elimination technique. Design: Prospective investigation. Setting: Eighteen-bed intensive care unit in a university hospital. Patients and interventions: Ten patients with ALI (PaO₂/FIO₂ ratio < 300 mm Hg) were mechanically ventilated in a pressure controlled mode and placed on a kinetic treatment table. Measurements and results: Distributions of V_A/Q were determined 1) during rotation (after a period of 20 min) and 2) after a resting period of 20 min in the supine position. During axial rotation, intrapulmonary shunt (19.1 ± 15 % of cardiac output) was significantly reduced in comparison with when in the supine position (23 ± 14 %, p < 0.05), areas with “low” V_A/Q were not affected by the positioning maneuver. General V_A/Q mismatch (logarithmic distribution of pulmonary blood flow) was decreased during rotation (0.87 ± 0.37) in comparison with when the patient was in the supine position (0.93 ± 0.37, p < 0.05). Arterial oxygenation was significantly improved during continuous rotation (PaO₂/FIO₂ = 217 ± 137 mm Hg) as compared with in the supine position (PaO₂/FIO₂ = 174 ± 82 mm Hg, p < 0.05). The positive response of the continuous rotation on arterial oxygenation was only demonstrated in patients with a Murray Score of 2.5 or less, indicating a “mild to moderate” lung injury, while in patients presenting with progressive ARDS (Murray Score > 2.5), the acute positive response was limited. Conclusions: Continuous axial rotation might be a method for an acute reduction of V_A/Q mismatch in patients with mild to moderate ALI, but this technique is not effective in late or progressive ARDS. Further studies including a large data collection are needed. Received: 19 June 1997 Accepted: 6 November 1997     

Improvement in oxygenation by prone position and nitric oxide in patients with acute respiratory distress syndrome

Objective: Inhaled nitric oxide (NO) and prone position improve arterial oxygenation in patients with the acute respiratory distress syndrome. This study was undertaken to assess the combined effects of NO and prone position in these patients. Design: Prospective clinical study. Setting: General intensive care service in a community teaching hospital. Patients: 14 mechanically ventilated adult patients with the acute respiratory distress syndrome (mean lung injury score 3.23 ± 0.27). Measurements and results: We measured hemodynamic and oxygenation parameters in the supine position and 2 h later in the prone position, before and during inhalation of 10 ppm NO. A positive response in oxygenation was defined as a ≥ 20 % increment in the arterial oxygen tension/fractional inspired oxygen ratio (PaO₂/FIO₂). In the prone position PaO₂/FIO₂ increased significantly (from 110 ± 55 to 161 ± 89 mmHg, p < 0.01) and venous admixture decreased (from 38 ± 12 to 30 ± 7 %, p < 0.01) compared to the supine position. Ten of the 14 patients were responders in the prone position. In the supine position, inhalation of NO improved oxygenation to a lesser extent, increasing PaO₂/FIO₂ to 134 ± 64 mmHg (p < 0.01) and decreasing venous admixture to 35 ± 12 %, (p < 0.01). Five of the 14 patients responded to NO inhalation supine and 8 of 14 responded prone (p = 0.22). The combination of NO therapy and prone positioning was additive in increasing PaO₂/FIO₂ (197 ± 92 mmHg) and decreasing venous admixture (27 ± 8 %) (p < 0.01). This combination also showed a positive oxygenation response on compared to the supine value without NO in 13 of the 14 patients (93 %). NO-induced changes in PaO₂/FIO₂ were correlated to changes in pulmonary vascular resistance only in the prone position. Conclusions: In patients with the acute respiratory distress syndrome, the combination of NO and prone position is a valuable adjunct to mechanical ventilation. Received: 15 June 1998 Final revision received: 13 October 1998 Accepted: 30 October 1998     

Acute respiratory distress syndrome and lung injury: Pathogenetic mechanism and therapeutic implication

To review possible mechanisms and therapeutics for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). ALI/ARDS causes high mortality. The risk factors include head injury, intracranial disorders, sepsis, infections and others. Investigations have indicated the detrimental role of nitric oxide (NO) through the inducible NO synthase (iNOS). The possible therapeutic regimen includes extracorporeal membrane oxygenation, prone position, fluid and hemodynamic management and permissive hypercapnic acidosis etc. Other pharmacological treatments are anti-inflammatory and/or antimicrobial agents, inhalation of NO, glucocorticoids, surfactant therapy and agents facilitating lung water resolution and ion transports. β-adrenergic agonists are able to accelerate lung fluid and ion removal and to stimulate surfactant secretion. In conscious rats, regular exercise training alleviates the endotoxin-induced ALI. Propofol and N-acetylcysteine exert protective effect on the ALI induced by endotoxin. Insulin possesses anti-inflammatory effect. Pentobarbital is capable of reducing the endotoxin-induced ALI. In addition, nicotinamide or niacinamide abrogates the ALI caused by ischemia/reperfusion or endotoxemia. This review includes historical retrospective of ALI/ARDS, the neurogenic pulmonary edema due to head injury, the detrimental role of NO, the risk factors, and the possible pathogenetic mechanisms as well as therapeutic regimen for ALI/ARDS.     

一氧化氮吸入复合呼气末正压治疗羊感染性急性呼吸窘迫综合征

目的　观察一氧化氮 (NO)吸入复合呼气末正压 (PEEP)通气对羊感染性急性呼吸窘迫综合征 (ARDS)血流动力学、肺气体交换和机械力学的影响。方法　静脉注入小剂量内毒素诱导的羊感染性ARDS模型 12只 ,随机均分为两组 ,NO组 :吸入 40ppmNO ;复合组 :PEEP(6cmH2 O)通气复合吸入 40ppmNO。通过肺动脉导管和动脉血气分析 ,测定基础、ARDS和治疗 3 0min后肺气体交换和血流动力学参数 ,记录相应时点的气道峰压 (PIP)、平均气道压 (Pm)。结果　NO组和复合组治疗期间平均肺动脉压较ARDS时显著降低 (P <0 0 1) ,动脉血压和心输出量则无明显变化 ;治疗 3 0min后 ,两组ARDS的PaO2 均明显升高 (P <0 0 1) ,肺泡动脉氧分压差 (P(A -a)O2 )和肺内分流 (Qs/Qt)显著减少 (P <0 0 1) ,复合组比NO组更为显著 (P<0 0 5 ) ;NO组各监测时点PIP、Pm均无明显变化 ,复合组的PIP、Pm较治疗前明显增高 (P <0 0 5 )。结论　吸入NO复合PEEP通气协同改善ARDS肺氧合 ,不影响体循环     

Acute respiratory failure after aspiration of activated charcoal with recurrent deposition and release from an intrapulmonary cavern

Objective  To report on the recurrent release of charcoal from an intrapulmonary cavern in a case of acute respiratory failure after charcoal aspiration. Design  Case report. Setting  Anaesthesiological ICU, university hospital. Patient  An 18-year-old ethanol intoxicated comatose patient regurgitated and aspirated activated charcoal during orotracheal intubation. Treatment  After 2 days of mechanical ventilation, the patient was transferred to a tertiary care university hospital. On admission, acute respiratory distress syndrome with bilateral pulmonary infiltrations was diagnosed. The patient’s recovery was hampered by recurrent release of charcoal from an intrapulmonary cavern. Sophisticated ventilatory support, prone positioning, secretolytics, repetitive bronchoscopy, and antibiotic therapy may have facilitated bronchoalveolar clearance and weaning after 18 days. Conclusion  Aspiration may be a dramatic complication if charcoal is administered in comatose patients without airway protection. In this case report, advanced intensive care measures were necessary to tackle the special feature of charcoal release from an intrapulmonary cavern.     

一氧化氮吸入对感染性休克并发急性呼吸窘迫综合征患者氧合功能的作用及血流动力学的安全性研究

目的 :评估吸入低浓度一氧化氮 (NO)治疗感染性休克并发急性呼吸窘迫综合征 (ARDS)患者的有效性及对患者血流动力学的影响。方法 :对 17例感染性休克并发 ARDS患者行机械通气 ,Swan Ganz导管检查 ,观察吸入 10 m mol/ L NO前后氧合功能和血流动力学的变化。结果 :吸入 NO后 ,患者动脉血氧分压、血氧饱和度及氧合指数分别由 (8.6 7± 2 .15 ) k Pa(1k Pa=7.5 mm Hg) ,0 .86± 0 .0 8和 (9.6 3± 3.0 7) k Pa上升至(17.74± 8.82 ) k Pa,0 .95± 0 .0 8和 (2 5 .33± 11.36 ) k Pa(P均 <0 .0 0 1) ;肺内分流率由 (4 7.4± 13.3) %下降至(2 8.1± 12 .7) % (P<0 .0 0 1) ;血流动力学参数 :平均动脉压、平均肺动脉压、心输出量、心脏指数、体肺循环阻力指数、中心静脉压及肺动脉楔压均无明显变化 (P均 >0 .0 5 )。结论 :吸入低浓度 NO对感染性休克并发ARDS患者的氧合功能、血气指标有明显改善且血流动力学稳定 ,安全有效     

Inhaled nitric oxide for a severe respiratory syncytial virus infection in an infant with bronchopulmonary dysplasia

Objective To report the first case of ARDS in children treated with nitric oxide (NO) inhalation.Methods A 13-months infant presented with BPD and severe hypoxemia related to RSV infection and ARDS. Inhaled NO was delivered in the ventilatory circuit of a continuous flow ventilator (Babylog 8000, Dräger) in a concentration of 20–80 ppm for 7 days. NO and NO₂ were continuously monitored (Polyton Draeger). Respiratory mechanics were evaluated by using the method of passive inflation by the ventilator.Results NO inhalation improved oxygenation (tcSaO₂) and reduced respiratory system resistance without affecting arterial pressure. NO₂ level remained below 5 ppm, and methaemoglobin level below 1%. The child survived without neurologic sequela.Conclusions Two mechanisms to explain oxygenation improvement can be suggested:selective improvement in perfusion of ventilated regions and bronchodilation.     

Hemodynamic and gas exchange responses to inhalation of nitric oxide in patients with the acute respiratory distress syndrome and in hypoxemic patients with chronic obstructive pulmonary disease

Objective: Inhalation of nitric oxide (NO) can improve oxygenation and decrease mean pulmonary artery pressure (MPAP) in patients with the acute respiratory distress syndrome (ARDS). It is not known whether inhaled NO exerts a similar effect in hypoxemic patients with chronic obstructive pulmonary disease (COPD). Design: Prospective clinical study. Setting: General intensive care unit in Sabadell, Spain. Patients: Nine mechanically ventilated COPD patients (mean age 72±2 years; forced expiratory volume in 1 s 0.91±0.11 l) and nine ARDS patients (mean age 57±6 years; mean lung injury score 2.8±0.1) Measurements and results: We measured hemodynamic and gas exchange parameters before NO inhalation (basal 1), during inhalation of 10 ppm NO (NO-10), and 20 min after NO was discontinued (in basal 2) in the ARDS group. In the COPD group, these parameters were measured before NO inhalation (basal 1), during different doses of inhaled NO (10, 20, and 30 ppm), and 20 min after NO was discontinued (basal 2). A positive response to NO was defined as a 20% increment in basal arterial partial pressure of oxygen (PaO₂). MPAP and pulmonary vascular resistance (PVR) decreased significantly, while other hemodynamic parameters remained unchanged after NO-10 in both groups. Basal oxygenation was higher in the COPD group (PaO₂/FIO₂ (fractional inspired oxygen) 190±18 mmHg) than in the ARDS group (PaO₂/FIO₂ 98±12 mmHg), (p<0.01). After NO-10, PaO₂/FIO₂ increased (to 141±17 mmHg, p<0.01) and Qva/Qt decreased (39±3 to 34±3%, p<0.01) in the ARDS group. There were no changes in PaO₂/FIO₂ and Qva/Qt when the NO concentration was increased to 30 ppm in the COPD group. In both groups, a correlation was found between basal MPAP and basal PVR, and between the NO-induced decrease in MPAP and in PVR. The NO-induced increase in PaO₂/FIO₂ was not correlated with basal PaO₂/FIO₂. In the ARDS group, six of the nine patients (66%) responded to NO and in the COPD group, two of nine (22%) (p=0.05). Conclusions: NO inhalation had similar effects on hemodynamics but not on gas exchange in ARDS and COPD patients, and this response probably depends on the underlying disease. Received: 19 December 1995 Accepted: 28 September 1996     

急性重型胰腺炎并发SIRS和ARDS及其预后(附126例分析)

目的 提高急性重型胰腺炎（ＡＳＰ）并发全身炎症反应综合征（ＳＩＲＳ）和急性呼吸窘迫综合征（ＡＲＤＳ）的认识。方法 分析了１２６例ＡＳＰ患者的临床资料,病人至少符合修订后ＳＩＲＳ诊断标准。结果 １２６例ＡＳＰ患者中符合修订后ＳＩＲＳ２项标准者３５例（２７．８％）,３项者４３例（３４．１％）。４项者４８例（３８．１％）;ＳＩＲＳ２项者合并ＡＲＤＳ３例（８．６％）,３项者合并ＡＲＤＳ２１例（４８．８％）     

Association of type II secretory phospholipase A2 and surfactant protein D with the pulmonary oxygenation potential in patients with septic shock during polymyxin‐B immobilized fiber‐direct hemoperfusion

This study was undertaken to analyze the association of type II secretory phospholipase A₂ (sPLA₂‐II) and surfactant protein D (SP‐D) with the pulmonary oxygenation potential in patients with septic shock during polymyxin‐B immobilized fiber‐direct hemoperfusion (PMX‐DHP). The study was conducted in 25 patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). PMX‐DHP lowered the blood endotoxin level in all patients. Following PMX‐DHP, there were decreases from day 0 → day 1 → day 2 in both the mean plasma sPLA₂‐II level (340 → 260 → 189 ng/mL) and plasma SP‐D level (483 → 363 → 252 ng/mL). The PaO2/FiO2 ratio (P/F ratio) rose (210 → 237 → 262) in all patients. Upon the onset of ALI or ARDS, there was a significant negative correlation between the sPLA₂‐II level and the P/F ratio. Furthermore, there was a significant positive correlation between the sPLA₂‐II and TNF‐α levels. The results suggest that as the blood endotoxin levels were lowered by the PMX‐DHP, the inflammatory reactions were suppressed, with suppressed formation of sPLA₂‐II and improved pulmonary oxygenation potential. The results also suggested possible involvement of TNF‐α in the production of sPLA₂‐II.     

EIT监测ARDS脱机困难患者早期活动过程中肺部通气变化

目的观察电阻抗断层成像术（EIT）监测急性呼吸窘迫综合征（ARDS）脱机困难患者早期活动过程中肺部通气变化。 方法选取2020年6月至8月入住北京协和医院ICU需进行早期活动的20例ARDS脱机困难患者,根据其早期活动过程中血氧饱和度（SpO₂）变化情况,将其分为改善组（SpO₂改善,10例）及未改善组（SpO₂无变化或下降,10例）。应用EIT监测患者的肺部通气,记录其一般资料及其SpO₂,针对其对肺部划分的平行的ROI1~4区（ROI1,ROI2,ROI3,ROI4）,记录其早期活动前、早期活动30 min、早期活动60 min、早期活动结束后的区域通气比例。 结果改善组早期活动30 min［（97.0±1.4）%］及60 min［（97.1±1.5）%］的SpO₂明显改善,与早期活动前［（94.1±2.6）%］比较,差异均有统计学意义（t=5.117,P＜0.01;t=3.557,P＜0.01）,同时EIT显示,早期活动30 min［（9.3±6.1）%］及60 min［（10.8±7.2）%］的ROI4区通气状况明显改善,与早期活动前［（4.8±2.7）%］比较,差异有统计学意义（t=2.942,P=0.016;t=2.905,P=0.017）。未改善组早期活动30 min［（97.0±1.7）%］及60 min［（97.1±1.4）%］SpO₂下降,与早期活动前［（98.4±1.6）%］比较,差异均有统计学意义（t=8.573,P＜0.01;t=4.333,P=0.020）,同时EIT显示,仅ROI4区早期活动30 min［（7.6±3.4）%］与早期活动前［（10.3±4.0）%］比较,差异有统计学意义（t=3.199,P=0.011）,其他各区早期活动30 min及60 min通气均无明显改善,差异均无统计学意义（P＞0.05）。 结论EIT可以监测和评估重症ARDS脱机困难患者早期活动过程中肺部的通气情况。     

主动脉内球囊反搏支持下急性心肌梗死的急诊介入治疗

目的探讨主动脉内球囊反搏支持下的急性心肌梗死合并心源性休克患者行急诊介入治疗的可行性、安全性及疗效。方法回顾性分析浙江大学医学院附属第2医院2005年9月至2007年2月确诊急性心肌梗死合并心源性休克,在主动脉内球囊反搏支持下行急诊介入治疗的患者27例,观察血流动力学改变、急诊介入治疗特点、住院期间及术后1个月的病死率、主要心脏不良事件、心功能恢复状况。结果应用主动脉内球囊反搏30min后血流动力学即开始改善,2～6h达血流动力学稳定。27例患者在主动脉内球囊反搏支持下均成功完成急诊介入治疗,无术中死亡,住院期间死亡2例,随访1个月死亡1例。术后1个月的左室射血分数和室壁运动评分均较术后第1天显著改善。结论主动脉内球囊反搏支持下的急诊介入治疗能显著提高急性心肌梗死合并心源性休克患者的生存率,显著改善心肌梗死后的心功能状态。     

Effectiveness of sepsis bundle application in cirrhotic patients with septic shock: a single-center experience

Purpose

To evaluate the effect of adherence to evidence-based guidelines of the Surviving Sepsis Campaign (SSC) on the outcome of cirrhotic patients with septic shock admitted to the intensive care unit.

Methods

This prospective observational cohort study included 38 patients with documented liver cirrhosis and septic shock admitted to a multidisciplinary intensive care unit at a University Hospital from January 2005 to June 2009. In each patient, the compliance to 4 resuscitation (ie, 6-hour bundle) and to 3 management (i.e. 24-hour bundle) interventions recommended by the SSC guidelines and the 30-day mortality were measured.

Results

The 6-hour, 24-hour, and all bundles were completed in 50 %, 52%, and 39% of the patients, respectively. The characteristics at admission and the 30-day mortality of patients with all-bundle compliance (n = 15; mortality 86.6%) were similar to those of patients without bundle compliance (n = 23; mortality 78.2%), except for central venous O₂ saturation. Unadjusted and adjusted regression analysis showed that none of the single sepsis interventions and bundles were independently associated with 30-day mortality.

Conclusions

In our observational study, the adherence to the interventions recommended by the SSC evidence-based guidelines did not provide an improvement in the survival rate of cirrhotic patients with septic shock.