Hemodynamic MonitoringVolume of fluids administered during resuscitation for severe sepsis and septic shock and the development of the acute respiratory distress syndrome☆
Introduction
Severe sepsis and septic shock are the most severe manifestations of the sepsis syndrome and characterized by end-organ hypoperfusion and hypotension due to infection [1]. Previous studies have shown that early goal-directed resuscitation of patients with severe sepsis and septic shock improves mortality [1], [2]. One of the key interventions in early goal-directed therapy is aggressive administration of intravenous (IV) fluids using physiologic targets to assess for improvements in end-organ perfusion [2]. For patients with severe sepsis or septic shock, the Surviving Sepsis Guidelines recommend an initial bolus of 30 mL/kg of fluid followed by repeated fluid administration as long as there are continued responses in hemodynamic parameters [1]. The rationale for these recommendations is that, in the resuscitative phase of severe sepsis and septic shock, restoring intravascular volume and maintaining end-organ perfusion are the top priorities. However, one concern regarding aggressive volume resuscitation is that it may increase the risk for complications due to volume overload, such as the acute respiratory distress syndrome (ARDS) [3], [4], [5].
Acute respiratory distress syndrome is a devastating complication of sepsis that affects its clinical management and outcomes [6], [7], [8]. Previous studies have shown that interventions that minimize the administration of IV fluids in hemodynamically stable patients with ARDS decrease the duration of mechanical ventilation and intensive care unit (ICU) stay without compromising end-organ perfusion [9]. As such, the fluid management strategies for ARDS can become discordant with those of sepsis when pulmonary edema complicates the early resuscitative phase of the sepsis syndrome.
Given the increased propensity of the lungs to develop pulmonary edema during sepsis, it is possible that the effects of positive fluid balance during fluid resuscitation in patients admitted with severe sepsis and septic shock may increase the risk for developing ARDS. The objective of this study was explore this risk by examining the association between the volume of IV fluids administered in the first 24 hours of hospitalization for severe sepsis or septic shock and the development of ARDS. We hypothesized that increased IV fluid administration is associated with a greater incidence of ARDS despite controlling for known predisposing factors.
Section snippets
Study design and patients
This was a retrospective observational study of patients with severe sepsis or septic shock admitted to the emergency department of a large academic county hospital (Harbor-UCLA Medical Center, Torrance, CA) between December 2011 and January 2013. The cohort of patients with severe sepsis and septic shock was identified by retrospective chart review of all patients seen in the emergency department using the clinical definition from the Surviving Sepsis Guidelines and the Society of Critical
Baseline characteristics between the ARDS and control groups
The study cohort consisted of 296 patients who were admitted with severe sepsis or septic shock. Of these, 75 patients (25.3%) developed ARDS within 72 hours of hospital admission. There were multiple differences in the baseline characteristics between patients that developed ARDS and those that did not develop ARDS (Table 1). The ARDS group was older (mean age, 71.5 vs 62.9 years; P = .004). In addition, the ARDS group had a lower proportion of Hispanic patients compared to the no-ARDS group
Discussion
Fluid management in severe sepsis and septic shock is challenging, and the optimal strategy is unknown. Although there is general consensus that resuscitation with IV fluids should be a first-line intervention in patients with severe sepsis and septic shock, recent studies have shown that excessive fluid administration is associated with prolonged end-organ dysfunction and increased mortality [16], [17], [18]. These studies support the concern among clinicians that aggressive volume
Conclusions
The volume of fluid administered in the first 24 hours of hospitalization in patients with severe sepsis and septic shock is not significantly associated with the development of ARDS after controlling for confounding factors, including underlying comorbidities. Although this does not preclude the possibility of a small increased risk of developing ARDS due to aggressive fluid resuscitation, the findings of our study support the overall favorable risk-to-benefit profile of adequate volume
Acknowledgments
We thank Chi-hong Tseng, PhD, for his critical review of the statistical analysis and manuscript.
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2021, Critical Care ClinicsCitation Excerpt :There are few data examining the association of a liberal or conservative intravenous fluid resuscitation strategy and the development of ARDS. A small cohort study of 296 septic patients, in which 25% developed ARDS within 72 hours, showed no association between the amount of resuscitative intravenous fluid administered in the first 24 hours and the development of ARDS.22 These findings are limited by the small difference in volume of resuscitative fluid between study groups (5.5 vs 4.7 L) and the study’s limited sample size.
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2021, Australasian Emergency CareCitation Excerpt :Of the patients with sepsis who did not receive early intravenous fluids initiated by the ambulance, more than half showed signs of organ failure in ED. Conversely, of those who received intravenous fluids in their pre - hospital treatment, 40% showed improved outcomes [18]. The volume of intravenous fluids administered during the initial resuscitation phase plays a crucial role in patient outcomes.
Early fluid loading for septic patients: Any safety limit needed?
2018, Chinese Journal of Traumatology - English EditionCitation Excerpt :Significantly, there was a trend toward more and more aggressive, but far beyond the recommendations on early fluid loading in the past two decades. This aggressive approach of fluid loading no doubt would contribute to correcting hypovolemia and minimizing hypoperfusion in early phase of sepsis, especially in patients with hemodynamic instability.8–10 Meanwhile, a part of patients was probably placed at risk of receiving excessive unnecessary fluids,11 which was associated with poor outcomes.
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Research support: none.