Fluid Overload in Patients With Severe Sepsis and Septic Shock Treated With Early Goal-Directed Therapy Is Associated With Increased Acute Need for Fluid-Related Medical Interventions and Hospital Death

Abstract

Early-goal-directed therapy (EGDT) consists of early, aggressive fluid resuscitation and is known to improve survival in sepsis. It is unknown how often EGDT leads to subsequent fluid overload and whether post-EGDT fluid overload affects patients’ outcomes. Our hypothesis was that septic patients treated with EGDT were at risk for fluid overload and that fluid overload would be associated with adverse outcomes. We conducted a retrospective cohort of 405 consecutive patients admitted with severe sepsis and septic shock to the medical intensive care unit of a tertiary care academic hospital from January 2008 to December 2009. Baseline demographics, daily weights, fluid status, clinical or radiographic evidence of fluid overload, and medical interventions (thoracentesis, paracentesis, diuretic use, and ultrafiltration) were abstracted and associations explored using univariate and multivariate logistic and linear regression analyses. At day 1, 67% of patients developed evidence of fluid overload and in 48% fluid overload persisted to day three. Inter-rater agreement for presence of fluid overload was substantial (kappa=0.7). An increased trend in weight was noted in those with persistent clinical and radiologic evidence of fluid overload, but not with recorded positive fluid balance. When adjusted for baseline severity of illness, fluid overload was associated with increased use of fluid-related medical interventions (thoracentesis and diuretics) and hospital mortality (OR 1.92 [1.16-3.22]). In patients with severe sepsis and septic shock treated with EGDT, clinical evidence of persistent fluid overload is common and is associated with increased use of medical interventions and hospital mortality.

Volume Overload: Prevalence, Risk Factors, and Functional Outcome in Survivors of Septic Shock

“…In 2011 Boyd and colleagues reported a mean fluid balance at 4 days of 11 6 8.9 L in a cohort of patients with septic shock (12), whereas 5 years earlier the European Sepsis Occurrence in Acutely Ill Patients study investigators reported a 72-hour mean fluid balance of 1.8 6 5 L (10). The authors of a recent single-center study reported a 44% prevalence of diuretic use in patients with clinical evidence of volume overload at Day 3 after admission for septic shock (9). Although there appears to be variability in practice over time, based on geographic location, and between studies, our results are within the range of what might be expected on the basis of previous reports.…”

“…Several studies in patients with sepsis have shown an association between positive fluid balance or volume overload and mortality, acute kidney injury (AKI), or need for fluid-related interventions (9)(10)(11)(12)(13).…”

The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid!

“…In a recent study from Mayo Clinic, Kelm and colleagues demonstrated that the SSC approach to fluid resuscitation results in fluid overload in 67% of patients with fluid overload being an independent predictor of death with an odds ratio 1.92 (1.16-3.22) [11]. Acheampong and Vincent recently demonstrated that a large positive fluid balance starting on ICU day two was an independent predictor of death [12].…”

AME evidence series 001—The Society for Translational Medicine: clinical practice guidelines for diagnosis and early identification of sepsis in the hospital

“…False positive (e.g., patients testing positive for sepsis but actually not septic) will result in unnecessary resuscitation procedures, more antibiotic exposure, and higher cost. Extensive evidence shows that a persisting positive fluid balance is associated with adverse outcomes (51)(52)(53)(54)(55)(56). Therefore, inappropriate fluid management based on false positive results may create an unwarranted positive fluid balance with a corresponding higher mortality risk.…”