Elsevier

Journal of Critical Care

Volume 29, Issue 6, December 2014, Pages 1011-1015
Journal of Critical Care

Hemodynamic Monitoring
Volume of fluids administered during resuscitation for severe sepsis and septic shock and the development of the acute respiratory distress syndrome

https://doi.org/10.1016/j.jcrc.2014.06.005Get rights and content

Abstract

Purpose

The purpose of this study was to examine the association between the volume of intravenous (IV) fluids administered in the resuscitative phase of severe sepsis and septic shock and the development of the acute respiratory distress syndrome (ARDS).

Materials and methods

This was a retrospective cohort study of adult patients admitted with severe sepsis and septic shock at a large academic public hospital. The relationship between the volume of IV fluids administered and the development of ARDS was examined using multivariable logistic regression analysis.

Results

Among 296 patients hospitalized for severe sepsis and septic shock, 75 (25.3%) developed ARDS. After controlling for confounding variables, there was no significant association between the volume of IV fluids administered in the first 24 hours of hospitalization and the development of ARDS (odds ratio [OR], 1.05; 95% confidence interval [CI], 0.95-1.18). Serum albumin (OR, 0.52; 95% CI, 0.31-0.87) and Acute Physiology and Chronic Health Evaluation II score (OR, 1.08; 95% CI, 1.04-1.13) on admission were the most informative covariates for the development of ARDS in the regression model.

Conclusions

For patients hospitalized for severe sepsis and septic shock, fluid administration to improve end-organ perfusion should remain the top priority in early resuscitation despite the potential risk of inducing ARDS.

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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