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Fluid Administration in Severe Sepsis and Septic Shock, Patterns and Outcomes: An Analysis of a Large National Database
Marik PE, Linde-Zwirble WT, Bittner EA, et al. Intensive Care Med. 2017; 43: 625-32.
Study Question: Does administration of low volume (<5 L) compared to high volume (≥5 L) fluid resuscitation during the first ICU day in patients with severe sepsis and septic shock impact patient mortality?
Study Description: This was a retrospective cohort using the 2013 Premier Hospital Discharge Database of adult non-surgical ICU patients with a diagnosis of severe sepsis or septic shock. Exclusion criteria were patients who received less than 1 L of fluids and hospitals with the 25th percentile of day 1 fluids administered below 1 L. The primary outcome was hospital mortality. Secondary outcomes included ICU and hospital length of stay (LOS), mechanical ventilation duration and total cost of hospitalization. Patients were categorized by use of mechanical ventilation and presence of septic shock.
Results: Of the 23,513 patients evaluated from 344 hospitals, the median day 1 fluids administered was 4050 mL (IQR 2500-5800) and hospital mortality was 25.8%. Low volume fluid resuscitation was associated with a 0.7%/L reduction in mortality (p= 0.02) and high volume resuscitation was associated with a 2.3%/L increase in mortality for each L above 5 L (p=0.0003). High volume resuscitation increased mortality in mechanically ventilated patients with or without shock (3.4%/L, p=0.0036 and 2.0%/L, p=0.0087, respectively). A reduction in mortality was seen in non-mechanically ventilated patients with or without shock who received low volume resuscitation (1.5%/L, p=0.002 and 0.3%/L, p=0.049 respectively). Day 1 fluids greater than 5L was associated with a higher hospital cost ($999/L). There was no difference in ICU and hospital LOS or duration of mechanical ventilation between the low and high volume groups.
Conclusion(s): Patients high volume fluid resuscitation compared to low volume resuscitation during the first ICU day had an increased risk of mortality and higher hospital costs.
Perspective: Fluid resuscitation is one of the cornerstones of management in the treatment of severe sepsis and septic shock. The adequate volume of fluid for resuscitation has been debated with lack of evidence regarding a safe threshold. The authors of this study highlight the importance of optimal fluid resuscitation in sepsis. Results suggest excessive fluid administration is potentially harmful; however, the 5 L over-resuscitation limit warrants further investigation. Additionally, evaluation of the mL/kg of fluids that patients received would be more applicable to current guideline recommendations, compared to a fluid amount.