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Resuscitating patients with early severe sepsis: A Canadian multicentre observational study

  • Lauralyn A. McIntyreEmail author
  • Dean Fergusson
  • Deborah J. Cook
  • Rama C. Nair
  • Dean Bell
  • Viinay Dhingra
  • Brian Hutton
  • Sheldon Magder
  • Paul C. Hébert
  • Canadian Critical Care Trials Group
Reports of Original Investigations

Abstract

Background

Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure.

Methods

A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure.

Results

Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 ± 16.5 yr and 29.0 ± 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval (CI)] for 2-4 L 1.67 (1.03-2.70) and > 4 L 2.34 (1.23-4.44) and a reduced risk of renal failure [OR, 95% CI for 2-4 L 0.48 (0.28-0.83) and > 4 L 0.45 (0.22-0.92)] in the first 24 hr of severe sepsis. Administration of colloid and crystalloid fluid as compared to crystalloid fluid alone was associated with a lower risk of renal failure [OR, 95% CI 0.45 (0.26 to 0.76)].

Conclusion

An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.

Contexte

La réanimation liquidienne est un facteur crucial pour restaurer la stabilité hémodynamique et la perfusion tissulaire chez les patients en septicémie sévère. Nous avons cherché à examiner les liens entre la quantité et le type de liquide administré durant les six premières heures suivant le diagnostic d’une septicémie sévère et la mortalité hospitalière, la mortalité aux soins intensifs et la défaillance systémique.

Méthode

Une étude de cohorte rétrospective et multi-centrique a été entreprise dans cinq unités de soins intensifs de soins tertiaires au Canada. Nous avons identifié les patients atteints de septicémie sévère admis aux soins intensifs entre le 1er juillet 2000 et le 30 juin 2002, en se fondant sur des bases de données administratives et cliniques. Les critères d’inclusion comprenaient: l’hypotension, la présence d’une source infectieuse, et au minimum deux critères du syndrome de réponse inflammatoire systémique. Nous avons enregistré la quantité totale et le type de liquide administré durant les six premières heures suivant le diagnostic d’une septicémie sévère. Le premier épisode d’hypotension a défini le point de départ pour la récolte des données concernant les liquides administrés. Des analyses de régression multivariées ont été menées afin d’examiner les liens entre la quantité et le type de liquide administré et la mortalité à l’hôpital/aux soins intensifs, ainsi que la défaillance systémique.

Résultats

Parmi les 2 026 dossiers de patients potentiellement éligibles, 496 patients ont présenté les critères d’admissibilité. L’âge moyen et le score APACHE II (Acute Physiology and Chronic Health Evaluation) étaient de 61,8 ± 16,5 ans et 29,0 ± 8,0, respective-ment. Aucun lien entre la quantité ou le type de liquide administré et la mortalité à l’hôpital ou aux soins intensifs n’a été identifié, et nous n’avons pas trouvé de liens statistiquement significatifs entre la quantité ou le type de liquide administré et la défaillance systémi-que. Toutefois, davantage de réanimation liquidienne a été associée a un risque accru de défaillance cardiovasculaire [rapport de cote (OR) et intervalle de confiance (CI) de 95 %] pour 2-4 L 1,67 (1,03-2,70) et> 4L 2,34 (1,23-4,44) ainsi qu’un risque réduit de défaillance rénale [OR, CI 95 % pour 2-4 L 0,48 (0,28-0,83) et> 4L 0,45 (0,22-0,92)] durant les premières 24 h de septicé-mie sévère. L’administration simultanée de colloïde et cristalloïde, comparativement à du cristalloïde seul, a été associée à un risque moindre de défaillance rénale [OR, CI 95 % 0,45 (0,26 à 0,76)].

Conclusion

Aucune association entre la mortalité à l’hôpital et la quantité ou le type de liquide administré durant les six premières heures suivant le diagnostic d’une septicémie sévère n’a pu être identifiée. Ces données devraient être considérées comme génératrices d’hypothèses et exigent leur confirmation ou, au contraire, leur réfutation, par des études randomisées contrôlées.

Keywords

Intensive Care Unit Septic Shock Severe Sepsis Hospital Mortality Sequential Organ Failure Assessment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Réanimation des patients en début de sepsie sévère: Une étude observationnelle multi-centrique canadienne

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Copyright information

© Canadian Anesthesiologists 2007

Authors and Affiliations

  • Lauralyn A. McIntyre
    • 1
    • 2
    • 8
    Email author
  • Dean Fergusson
    • 2
    • 3
  • Deborah J. Cook
    • 4
  • Rama C. Nair
    • 3
  • Dean Bell
    • 5
  • Viinay Dhingra
    • 6
  • Brian Hutton
    • 2
    • 3
  • Sheldon Magder
    • 7
  • Paul C. Hébert
    • 2
    • 3
  • Canadian Critical Care Trials Group
  1. 1.Department of Medicine (Critical Care)The Ottawa HospitalOttawa
  2. 2.Ottawa Health Research InstituteOttawa
  3. 3.Department of Epidemiology and Community MedicineUniversity of OttawaOttawa
  4. 4.McMaster UniversityLondon
  5. 5.University of ManitobaWinnipeg
  6. 6.University of British ColumbiaVancouver
  7. 7.McGill UniversityMontrealCanada
  8. 8.OttawaCanada

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