| Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. | |
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MedLine Citation:
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PMID: 20975548 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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OBJECTIVE: To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated with mortality. DESIGN: We conducted a retrospective review of the use of intravenous fluids during the first 4 days of care. SETTING: Multicenter randomized controlled trial. PATIENTS: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were receiving a minimum of 5 μg of norepinephrine per minute. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on net fluid balance, we determined whether one's fluid balance quartile was correlated with 28-day mortality. We also analyzed whether fluid balance was predictive of central venous pressure and furthermore whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage. At enrollment, which occurred on average 12 hrs after presentation, the average fluid balance was +4.2 L. By day 4, the cumulative average fluid balance was +11 L. After correcting for age and Acute Physiology and Chronic Health Evaluation II score, a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased mortality. Central venous pressure was correlated with fluid balance at 12 hrs, whereas on days 1-4, there was no significant correlation. At 12 hrs, patients with central venous pressure <8 mm Hg had the lowest mortality rate followed by those with central venous pressure 8-12 mm Hg. The highest mortality rate was observed in those with central venous pressure >12 mm Hg. Contrary to the overall effect, patients whose central venous pressure was <8 mm Hg had improved survival with a more positive fluid balance. CONCLUSIONS: A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased risk of mortality in septic shock. Central venous pressure may be used to gauge fluid balance ≤ 12 hrs into septic shock but becomes an unreliable marker of fluid balance thereafter. Optimal survival in the VASST study occurred with a positive fluid balance of approximately 3 L at 12 hrs. |
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Authors:
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John H Boyd; Jason Forbes; Taka-aki Nakada; Keith R Walley; James A Russell |
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Publication Detail:
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Type: Comparative Study; Journal Article; Research Support, Non-U.S. Gov't |
Journal Detail:
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Title: Critical care medicine Volume: 39 ISSN: 1530-0293 ISO Abbreviation: Crit. Care Med. Publication Date: 2011 Feb |
Date Detail:
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Created Date: 2011-01-20 Completed Date: 2011-03-04 Revised Date: 2011-10-24 |
Medline Journal Info:
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Nlm Unique ID: 0355501 Medline TA: Crit Care Med Country: United States |
Other Details:
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Languages: eng Pagination: 259-65 Citation Subset: AIM; IM |
Affiliation:
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University of British Columbia Critical Care Research Laboratories, Heart + Lung Institute, St Paul's Hospital, Vancouver, British Columbia, Canada. John.Boyd@hli.ubc.ca |
Export Citation:
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APA/MLA Format Download EndNote Download BibTex |
| MeSH Terms | |
Descriptor/Qualifier:
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APACHE Cause of Death Central Venous Pressure / physiology* Cohort Studies Female Fluid Therapy* Hospital Mortality / trends Humans Intensive Care / methods Intensive Care Units Male Norepinephrine / therapeutic use Predictive Value of Tests Resuscitation / methods*, mortality Retrospective Studies Risk Assessment Shock, Septic / mortality*, therapy* Survival Analysis Time Factors Water-Electrolyte Balance / physiology* |
| Grant Support | |
ID/Acronym/Agency:
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//Canadian Institutes of Health Research |
| Chemical | |
Reg. No./Substance:
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51-41-2/Norepinephrine |
| Comments/Corrections | |
Comment In:
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Crit Care Med. 2011 Oct;39(10):2387-8
[PMID:
21926513
]
Crit Care Med. 2011 May;39(5):1238-9; author reply 1239 [PMID: 21610600 ] Crit Care Med. 2011 Feb;39(2):396-7 [PMID: 21248517 ] |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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