Higher vs. lower fluid volume for septic shock: clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort

Smith, Søren Hübertz; Perner, Anders

doi:10.1186/cc11333

Cited by 68 publications

(57 citation statements)

References 21 publications

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“…Accordingly, our findings may not be generalizable beyond children ≤10 years of age with septic shock. Our findings in moderate to high risk patients are consistent with a recent study in adult patients with septic shock, which demonstrated no association between initial fluid status and mortality, although we did not replicate the association between higher fluid volumes and reduced mortality in patients with shock duration of three or more days (8). …”

Section: Discusssionsupporting

confidence: 84%

“…Over 20 years ago, Carcillo and colleagues reported that in children with septic shock, fluid resuscitation in excess of 40 ml/kg within the first hour of presentation was associated with improved survival, without increased risk of cardiogenic pulmonary edema or acute respiratory distress syndrome (2). Since then, aggressive fluid resuscitation has been a core intervention for the management of both pediatric and adult septic shock (3, 4), and the practice has been supported by subsequent observational and interventional studies (5-8). …”

Section: Introductionmentioning

confidence: 99%

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Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

Abulebda

Cvijanovich²,

Thomas

et al. 2014

Critical Care Medicine

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Objective: Observed associations between fluid balance and septic shock outcomes are likely confounded by initial mortality risk. We conducted a risk-stratified analysis of the association between post-intensive care unit (ICU) admission fluid balance and pediatric septic shock outcomes. Design: Retrospective analysis of an ongoing, multi-center pediatric septic shock clinical and biological database. Setting: Seventeen pediatric ICUs in the United States. Patients: Three hundred and seventeen children with septic shock. Interventions: None. Measurements and Main Results: We stratified subjects into three mortality risk categories (low, intermediate, and high) using a validated, biomarker-based stratification tool. Within each category, we assessed three fluid balance variables: total fluid intake/kg/day during the first 24 hours, percent positive fluid balance during the first 24 hours, and cumulative percent positive fluid balance up to seven days. We used logistic regression to estimate the effect of fluid balance on the odds of 28-day mortality, and on complicated course, defined as either death within 28 days or persistence of two or more organ failures at seven days. There were 40 deaths and 91 subjects had a complicated course. Increased cumulative percent positive fluid balance was associated with mortality in the low risk cohort (n = 204, OR 1.035, 95%CI 1.004 – 1.066), but not in the intermediate and high risk cohorts. No other associations with mortality were observed. Fluid intake, percent positive fluid balance in the first 24 hours, and cumulative percent positive fluid balance were all associated with increased odds of a complicated course in the low risk cohort, but not the intermediate and high risk cohorts. Conclusions: When stratified for mortality risk, increased fluid intake and positive fluid balance after ICU admission are associated with worse outcomes in pediatric septic shock patients with a low initial mortality risk, but not in patients at moderate or high mortality risk.

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Section: Discusssionsupporting

confidence: 84%

Section: Introductionmentioning

confidence: 99%

Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

Abulebda

Cvijanovich²,

Thomas

et al. 2014

Critical Care Medicine

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“…They also "assessed trends in the difference between actual and expected mortality in the low fluid range (1-5 L day one fluids) and the high fluid range (5-9+ L day one fluids)". The 5-L cut-off is interesting as it was defined by previously reported results [7] and confirmed very nicely by these authors. Day 1 fluid input averaged 4.4 L and was higher in patients who were ventilated and in shock than in patients without these diagnoses.…”

supporting

confidence: 73%

How much excess fluid impairs outcome of sepsis?

Genga

Russell

2017

Intensive Care Med

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Dear Editor, Fluid administration is fundamental in the treatment of sepsis and septic shock, but it is more difficult than a simple chemistry titration. Trials [1] and guidelines [2] recommend early and adequate fluid resuscitation in patients with sepsis and septic shock, as too little fluid may extend the duration of shock and organ ischemia, both important predictors of outcome. However, we [3] and others [4] have found associations between excess fluid administration and increased mortality due to septic shock, leading us to recommend a cautious approach to fluid resuscitation [5]. The definition of just how much fluid is adequate (or not) for good management of septic patients has been debated for years, and it is not yet clear precisely how much fluid is "excessive", thereby increasing the risk of mortality.In a recent article in Intensive Care Medicine, Marik and colleagues [6] reported the results of their carefully designed cohort study of a large U.S. database (2013 Premier Hospital Discharge database; n = 23,513 patients) in which they examined the relationships of fluid administration with outcomes (hospital mortality) of severe sepsis and septic shock. They also "assessed trends in the difference between actual and expected mortality in the low fluid range (1-5 L day one fluids) and the high fluid range (5-9+ L day one fluids)". The 5-L cut-off is interesting as it was defined by previously reported results [7] and confirmed very nicely by these authors. Day 1 fluid input averaged 4.4 L and was higher in patients who were ventilated and in shock than in patients without these diagnoses. Lower fluid volume (1-4.99 L) was associated with slightly lower mortality. Increasing fluid volume to >5 L was associated with increased risk of death-an additional 2.3% for each extra liter exceeding 5 L. In addition, the actual mortality exceeded the expected mortality for patients who received >5 L of fluids on day 1, particularly in those receiving ≥7 L. This difference (actual vs. expected mortality) was found in patients who were (1) ventilated but not in shock, (2) in shock but not ventilated, and (3) ventilated and in shock (as demonstrated in Fig. 3 in the original paper).

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“…There is an emerging consensus in trauma management that avoidance of excessive non-blood product administration (i.e. synthetic colloid and crystalloid) around a strategy of damage control surgery improves outcome [170,171]; this has not been established in sepsis management where fluid volumes administered may be much higher, but the correct volume to administer remains ill-defined [172,173]. However, many workers have suggested benefit to prompt resuscitation following trauma and so 'permissive hypotension' and delayed resuscitation must be based around early surgical control to allow more complete resuscitation [174].…”

Section: Intravenous Fluid Therapy -Which Fluid and How Much?mentioning

confidence: 99%

The principles and conduct of anaesthesia for emergency surgery

Gray

Morris

2012

Anaesthesia

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SummaryIn this second article we examine the principles underlying delivery of the components of anaesthesia. Topics considered include anaesthetic technique, management of the airway and lung ventilation, induction and maintenance of anaesthesia, patient monitoring including the place of cardiac output devices. We summarise recent research on the management of shock and sepsis syndromes including goal directed therapy and examine some controversies around intravenous fluid therapy. Finally, we discuss intra-operative awareness and challenges during emergence including perioperative cognitive dysfunction. Choice of anaesthetic techniqueOptimal anaesthetic technique is dependent upon an individualised assessment of patient and surgical requirements. Prospective, randomised, controlled trials of rival anaesthetic techniques, e.g. the GALA trial, are rare [1]. Emergency anaesthesia lacks this evidence base and extrapolations from meta-analyses typically fail to reach clear recommendations for clinicians [2]. The nature of surgery, patient co-morbidities, and urgency will frequently decide the anaesthetic choice but clinicians should remain mindful of the options of local or regional anaesthesia and sedation in appropriate patients, especially when a 'lesser' procedure becomes feasible e.g. percutaneous drainage. Management and protection of the airway including pulmonary aspirationThe fourth National Audit Project (NAP4) of the Royal College of Anaesthetists recorded the epidemiology and management of airway complications in UK practice and is essential reading [3]. It is emphasised that 25% of emergency airway management takes place outside operating theatres and since publication, several resources and recommendations have become available [4][5][6]. In the UK, out-of-theatre tracheal intubation frequently occurs in the absence of essential staff and equipment and capnography was not used in nearly a third of cases in a large observational study [7].Both difficult laryngoscopy and difficult tracheal intubation are more common in emergency patients, often outside the theatre setting [8,9]. One American study of non-theatre emergency tracheal intubation by experienced practitioners identified difficulties in over 10%, with over 4% suffering complications [10]. Predictors of complications included multiple attempts and poor views at laryngoscopy and intubation in a ward or emergency department setting. Human factors are increasingly recognised in airway complications and an unfamiliar environment during airway management is likely to be important [3].

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Higher vs. lower fluid volume for septic shock: clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort

Cited by 68 publications

References 21 publications

Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

How much excess fluid impairs outcome of sepsis?

The principles and conduct of anaesthesia for emergency surgery

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