Document Detail


Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality.
MedLine Citation:
PMID:  20975548     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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.
Authors:
John H Boyd; Jason Forbes; Taka-aki Nakada; Keith R Walley; James A Russell
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Publication Detail:
Type:  Comparative Study; Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Critical care medicine     Volume:  39     ISSN:  1530-0293     ISO Abbreviation:  Crit. Care Med.     Publication Date:  2011 Feb 
Date Detail:
Created Date:  2011-01-20     Completed Date:  2011-03-04     Revised Date:  2011-10-24    
Medline Journal Info:
Nlm Unique ID:  0355501     Medline TA:  Crit Care Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  259-65     Citation Subset:  AIM; IM    
Affiliation:
University of British Columbia Critical Care Research Laboratories, Heart + Lung Institute, St Paul's Hospital, Vancouver, British Columbia, Canada. John.Boyd@hli.ubc.ca
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MeSH Terms
Descriptor/Qualifier:
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:
//Canadian Institutes of Health Research
Chemical
Reg. No./Substance:
51-41-2/Norepinephrine
Comments/Corrections
Comment In:
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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