Fluid-limiting treatment strategies among sepsis patients in the ICU: a retrospective causal analysis

Abstract

Objective: In septic patients, multiple retrospective studies show an association between large volumes of fluids administered in the first 24 h and mortality, suggesting a benefit to fluid restrictive strategies. However, these studies do not directly estimate the causal effects of fluid-restrictive strategies, nor do their analyses properly adjust for time-varying confounding by indication. In this study, we used causal inference techniques to estimate mortality outcomes that would result from imposing a range of arbitrary limits ("caps") on fluid volume administration during the first 24 h of intensive care unit (ICU) care. Design: Retrospective cohort study Setting: ICUs at the Beth Israel Deaconess Medical Center, 2008-2012 Patients: One thousand six hundred thirty-nine septic patients (defined by Sepsis-3 criteria) 18 years and older, admitted to the ICU from the emergency department (ED), who received less than 4 L fluids administered prior to ICU admission Measurements and main results: Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III). We employed a dynamic Marginal Structural Model fit by inverse probability of treatment weighting to obtain confounding adjusted estimates of mortality rates that would have been observed had fluid resuscitation volume caps between 4 L-12 L been imposed on the population. The 30-day mortality in our cohort was 17%. We estimated that caps between 6 and 10 L on 24 h fluid volume would have reduced 30-day mortality by − 0.6 to − 1.0%, with the greatest reduction at 8 L (− 1.0% mortality, 95% CI [− 1.6%, − 0.3%]). Conclusions:We found that 30-day mortality would have likely decreased relative to observed mortality under current practice if these patients had been subject to "caps" on the total volume of fluid administered between 6 and 10 L, with the greatest reduction in mortality rate at 8 L.

Twenty‐four‐hour fluid administration in emergency department patients with suspected infection: A multicenter, prospective, observational study

“…The accumulating evidence of harm associated with higher fluid volumes and positive fluid balances in sepsis in the ICU setting, 8,14,37‐40 and in a limited resource ED setting 41 raises several questions about the use of fluid for ED patients with less severe infection. Is IV fluid beneficial for those who can take oral fluids, only in those who cannot, or only in those with higher acute disease severity?…”

Relationship Between Fluid Therapy Strategies and Mortality Among Sepsis Patients in ICU with high CVP: A Retrospective Analysis of the eICU Database

“…In recent years, an increasing number of studies have reported that early large-volume uid therapy may increase mortality in patients [1,4,5,19]. Sadaka et al reported that mortality in patients with septic shock with uid volumes < 6 L at 24 h was signi cantly lower than that in patients with uid volumes of 6 L [11].…”

“…The guidelines of the Surviving Sepsis Campaign recommend that uid resuscitation should be started early with a 30-ml/kg uid balance [2]. However, recent reports suggested that super uous uid may increase mortality in sepsis patients [3][4][5][6][7][8][9][10]. A few studies reported that appropriate restriction in 24-h uid therapy may reduce mortality [7][8][9][10], and excessive uid therapy can aggravate tissue and organ edema and increase the incidence of AKI (acute kidney injury) and other complications [5].…”

“…However, recent reports suggested that super uous uid may increase mortality in sepsis patients [3][4][5][6][7][8][9][10]. A few studies reported that appropriate restriction in 24-h uid therapy may reduce mortality [7][8][9][10], and excessive uid therapy can aggravate tissue and organ edema and increase the incidence of AKI (acute kidney injury) and other complications [5]. It is important to adjust the uid therapy regime according to the patients' volume status for sepsis patients.…”

Artificial Intelligence for Clinical Decision Support in Sepsis

“…Another study also reported on fluid management strategies for patients with sepsis. Causal inference technology is used to estimate the mortality outcome caused by the “caps” setting of fluid volume administration in the first 24 h in ICU ( 36 ). It was found that if the total amount of fluid in these patients is limited to 6–10 L, the 30-day mortality rate may be lower than the mortality rate observed in current practice.…”