Impact of Initial Central Venous Pressure on Outcomes of Conservative Versus Liberal Fluid Management in Acute Respiratory Distress Syndrome

Abstract

Objective In acute respiratory distress syndrome (ARDS), conservative fluid management increases ventilator-free days without affecting mortality. Response to fluid management may differ based on patients’ initial central venous pressure (CVP). We hypothesized initial CVP would modify the effect of fluid management on outcomes. Design Retrospective analysis of the Fluid and Catheter Treatment Trial, a multicenter randomized trial comparing conservative to liberal fluid management in ARDS. We examined the relationship between initial CVP, fluid strategy, and 60-day mortality in univariate and multivariable analysis. Setting Twenty acute care hospitals. Patients Nine hundred and thirty-four ventilated ARDS patients with a CVP available at enrollment, 609 without baseline shock (for whom fluid balance was managed by study protocol). Interventions None. Measurements and Main Results Among patients without baseline shock, those with initial CVP > 8 mmHg experienced similar mortality with conservative and liberal fluid management (18% versus 18%, p=0.928), whereas those with CVP ≤8 mmHg experienced lower mortality with a conservative strategy (17% versus 36%, p=0.005). Multivariable analysis demonstrated an interaction between initial CVP and the effect of fluid strategy on mortality (p=0.031). At higher initial CVPs, the difference in treatment between arms was predominantly furosemide administration, which was not associated with mortality (p=0.122). At lower initial CVPs, the difference between arms was predominantly fluid administration, with additional fluid associated with increased mortality (p=0.013). Conclusions Conservative fluid management decreases mortality for ARDS patients with a low initial central venous pressure. In this population, the administration of intravenous fluids appears to increase mortality.

Liberal Versus Restrictive Intravenous Fluid Therapy for Early Septic Shock: Rationale for a Randomized Trial

“…A post-hoc analysis of the subgroup with an initial CVP ≤8 mm Hg demonstrated substantially greater volumes of fluid administration and higher mortality in patients randomized to the liberal arm compared to the restrictive arm; in the subgroup with initial CVP >8, volume of fluid administered and mortality did not substantially differ between the randomized arms, suggesting lower fluid volumes administered in the restrictive arm may have been a primary contributor to improved outcomes. 59 This and other similar trials 52,58 established the safety of restrictive fluid management in the post-resuscitative phase of critical illness and have led investigators to question the practice of large volume fluid resuscitation during the initial, acute phase of sepsis treatment as well.…”

Optimal right heart filling pressure in acute respiratory distress syndrome determined by strain echocardiography

“…[8][9][10][11] These indices, including the passive leg raising method, have not been validated in patients with RV dysfunction 12 and may falsely indicate preload dependency in this clinical context. 7,[14][15][16][17][18] Speckle tracking echocardiography (STE) is an evolving clinical technology that enables accurate tracking of ultrasound-derived grayscale speckles through space and time, rendering an objective assessment of RV systolic function. 7,[14][15][16][17][18] Speckle tracking echocardiography (STE) is an evolving clinical technology that enables accurate tracking of ultrasound-derived grayscale speckles through space and time, rendering an objective assessment of RV systolic function.…”

Pulmonary Arterial Compliance in Acute Respiratory Distress Syndrome: Clinical Determinants and Association With Outcome From the Fluid and Catheter Treatment Trial Cohort*

“…In a recent analysis from the FACTT data set, it was noted that among patients with lower filling pressures at baseline, a fluid conservative strategy was associated with benefit (13). Other studies in ARDS and critical illness have supported these findings as well (13, 24, 25). Avoiding positive fluid balance, when possible, should result in higher C PAdyn and reduce pulsatile RV afterload.…”

“…Lower C PA has been associated with mortality in both pulmonary arterial hypertension and left heart failure (9-12), but has not been studied in ARDS. Given a possible important role of fluid balance and cardiac filling pressure in mitigating outcome in ARDS (13-16), we hypothesized that C PA would predict mortality in patients with ARDS. We also sought to characterize the relationship of C PA and PVR in ARDS and to determine clinical factors associated with both C PA and PVR.…”