Original Contribution
Fluid balance in sepsis and septic shock as a determining factor of mortality

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Abstract

Objective

The objective was to assess whether fluid balance had a determinant impact on mortality rate in a cohort of critically ill patients with severe sepsis or septic shock.

Design

A prospective and observational study was carried out on an inception cohort.

Setting

The setting was an intensive care unit of a university hospital.

Patients

Patients admitted consecutively in the intensive care unit who were diagnosed with severe sepsis or septic shock were included.

Interventions

Demographic, laboratory, and clinical data were registered, as well as time of septic shock onset, illness severity (Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment), and comorbidities. Daily and accumulated fluid balance was registered at 24, 48, 72, and 96 hours. Survival curves representing 28-day mortality were built according to the Kaplan-Meier method.

Results

A total of 42 patients were included in the analysis: men, 64.3%; mean age, 61.8 ± 15.9 years. Septic shock was predominant in 69% of the cases. Positive blood cultures were obtained in 17 patients (40.5%). No age, sex, Sepsis-related Organ Failure Assessment, creatinine, lactate, venous saturation of O2, and troponin differences were observed upon admission between survivors and nonsurvivors. However, higher Simplified Acute Physiology Score II was observed in nonsurvivors, P = .016. Nonsurvivors also showed higher accumulated positive fluid balance at 48, 72, and 96 hours with statistically significant differences. Besides, significant differences (P = .02) were observed in the survival curve with the risk of mortality at 72 hours between patients with greater than 2.5 L and less than 2.5 L of accumulated fluid balance.

Conclusions

Fluid administration at the onset of severe sepsis or septic shock is the first line of hemodynamic treatment. However, the accumulated positive fluid balance in the first 48, 72, and 96 hours is associated with higher mortality in these critically ill patients.

Introduction

In severe sepsis and septic shock, the main elements of treatment are intravenous fluids, appropriate antibiotics, source control, vasopressors, and ventilatory support [1]. For more than 10 years, the administration of intravenous fluids has been known as a key in the initial stages of sepsis resuscitation, as proven by a classic article on goal-based treatments [2]. Anyway, it is now recognized that the administration of excess fluid in sepsis may lead to worsened respiratory function, increased intraabdominal pressure, worsened coagulopathy, and increased probability of cerebral edema [3]. Some authors observed difficulty in fluid balance management in critically ill patients, and positive fluid balance is associated with increased mortality rates in patients with acute lung injury and septic shock [4], [5]. For all these reasons, the present observational study was designed to assess whether fluid balance has a determinant impact on mortality in a well-defined cohort of patients with severe sepsis or septic shock.

Section snippets

Population and data collection

Our study includes the patients admitted consecutively in the intensive care unit (ICU) of a teaching hospital for 4 months (from October 2012 to January 2013) that were diagnosed with severe sepsis or septic shock. It is a prospective and observational study on an inception cohort. Patients with septic shock were identified by a specific team of intensivists. Demographic, laboratory, and clinical data were registered: age, sex, time of septic shock onset, focus of infection, presence of

Results

A total of 42 patients were included in the analysis. Epidemiologic results were as follows: predominance of men (64.3%); mean age was 61.8 ± 15.9 years; cases of septic shock were predominant (69%). Positive blood cultures were obtained in 17 patients (40.5% of the cases). The most frequent initial infectious focus was abdominal (48%), followed by respiratory (17%). Infections were community acquired in almost 70% of the cases. Severity scores upon ICU admission were 44.6 ± 16.1 and 7.1 ± 3.4

Discussion

Our observational study shows that the accumulated positive fluid balance at 48, 72, and 96 hours is associated with higher mortality in ICU-admitted patients with sepsis or septic shock.

These results are consistent with those by Boyd et al [5], who showed that higher positive fluid balance in resuscitation over the first 4 days was associated with increased risk of mortality in septic shock patients. Other factors such as creatinine, lactate, SatvO2, and troponin showed no statistical

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