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

Abstract

Rationale: Survivors of septic shock have impaired functional status. Volume overload is associated with poor outcomes in patients with septic shock, but the impact of volume overload on functional outcome and discharge destination of survivors is unknown.Objectives: This study describes patterns of fluid management both during and after septic shock. We examined factors associated with volume overload upon intensive care unit (ICU) discharge. We then examined associations between volume overload upon ICU discharge, mobility limitation, and discharge to a healthcare facility in septic shock survivors, with the hypothesis that volume overload is associated with increased odds of these outcomes. Methods:We retrospectively reviewed the medical records of 247 patients admitted with septic shock to an academic county hospital between June 2009 and April 2012 who survived to ICU discharge. We defined volume overload as a fluid balance expected to increase the subject's admission weight by 10%. Statistical methods included unadjusted analyses and multivariable logistic regression.Measurements and Main Results: Eighty-six percent of patients had a positive fluid balance, and 35% had volume overload upon ICU discharge. Factors associated with volume overload in unadjusted analyses included more severe illness, cirrhosis, blood transfusion during shock, and higher volumes of fluid administration both during and after shock. Blood transfusion during shock was independently associated with increased odds of volume overload (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.33-5.27; P = 0.01) after adjusting for preexisting conditions and severity of illness. Only 42% of patients received at least one dose of a diuretic during their hospitalization. Volume overload upon ICU discharge was independently associated with inability to ambulate upon hospital discharge (OR, 2.29; 95% CI, 1.24-4.25; P = 0.01) and, in patients admitted from home, upon discharge to a healthcare facility (OR, 2.34; 95% CI, 1.1-4.98; P = 0.03).Conclusions: Volume overload is independently associated with impaired mobility and discharge to a healthcare facility in survivors of septic shock. Prevention and treatment of volume overload in patients with septic shock warrants further investigation.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

“…We believe that the extrapolation of these data to patients in better-resourced settings is not valid and thus recommend that clinicians restore euvolemia with IV fluids, more urgently initially, and then more cautiously as the patient stabilizes. There is some evidence that a sustained positive fluid balance during ICU stay is harmful [231][232][233][234][235]. We do not recommend, therefore, that fluid be given beyond initial resuscitation without some estimate of the likelihood that the patient will respond positively.The absence of any clear benefit following the administration of colloid compared to crystalloid solutions in the combined subgroups of sepsis, in conjunction with the expense of albumin, supports a strong recommendation for the use of crystalloid solutions in the initial resuscitation of patients with sepsis and septic shock.We were unable to recommend one crystalloid solution over another because no direct comparisons have been made between isotonic saline and balanced salt solutions in patients with sepsis.…”

ICU-Acquired Weakness

“…6,34,36,39,40 There are single studies suggesting that other potentially modifiable ICU interventions, including liberal fluid administration and transfusion, journal.publications.chestnet.org may contribute to ICUAW, although these associations need verification in larger patient cohorts. 45,46 Prolonged immobilization is associated with atrophy in patients who are critically ill. Muscle disuse is associated with changes in muscle diameter, length, and contractile strength.…”

Use of diuretics in shock: Temporal trends and clinical impacts in a propensity-matched cohort study

“…Over two-thirds of critically ill patients qualify the definition of volume overload (i.e., increase the weight more than 10% of admission body weight) in their first day of intensive care unit (ICU) stay [6], and most patients will be discharged from ICU while volume overloaded [7]. Fluid overload is associated with increased mortality in different patient populations, such as patients with sepsis, acute lung injury (ALI), and acute kidney injury (AKI) [8][9][10][11][12][13][14].…”