Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database
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The optimal strategy of fluid resuscitation in the early hours of severe sepsis and septic shock is controversial, with both an aggressive and conservative approach being recommended.
We used the 2013 Premier Hospital Discharge database to analyse the administration of fluids on the first ICU day, in 23,513 patients with severe sepsis and septic shock, who were admitted to an ICU from the emergency department. Day 1 fluid was grouped into categories 1 L wide, starting with 1–1.99 L up to ≥9 L, to examine the effect of day 1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5 L of fluids on day 1, using patient age and acute conditions present on admission. Patients were grouped by the requirement for mechanical ventilation and the presence or absence of shock. We assessed trends in the difference between actual and expected mortality, in the low fluid range (1–5 L day 1 fluids) and the high fluid range (5 to ≥9 L day 1 fluids) categories, using weighted linear regression controlling for the effects of sample size and variation within the day 1 fluid category.
Day 1 fluid administration averaged 4.4 L being lowest in the group with no mechanical ventilation and no shock (3.6 L) and highest (5.4 L) in the group receiving mechanical ventilation and in shock. The administration of day 1 fluids was remarkably consistent on the basis of hospital size, teaching status, rural/urban location, and region of the country. The hospital mortality in the entire cohort was 25.8%, with a mean ICU and hospital length of stay of 5.1 and 9.1 days, respectively. In the entire cohort, low volume resuscitation (1–4.99 L) was associated with a small but significant reduction in mortality, of −0.7% per litre (95% CI −1.0%, −0.4%; p = 0.02). However, in patients receiving high volume resuscitation (5 to ≥9 L), the mortality increased by 2.3% (95% CI 2.0, 2.5%; p = 0.0003) for each additional litre above 5 L. Total hospital cost increased by $999 for each litre of fluid above 5 L (adjusted R 2 = 92.7%, p = 0.005).
The mean amount of fluid administered to patients with severe sepsis and septic shock in the USA during the first ICU day is less than that recommended by the Surviving Sepsis Campaign guidelines. The administration of more than 5 L of fluid during the first ICU day is associated with a significantly increased risk of death and significantly higher hospital costs.
KeywordsSepsis Septic shock Fluid administration Mortality National database
Compliance with ethical standards
Data extracted from the Premier database (Premier, Inc) and data analysis was supported by Cheetah Medical Inc.
Conflicts of interest
Doctors Marik, Linde-Zwirble and Bittner have no conflicts to declare. Dr. Hansell and Ms. Sahatjian are employees of Cheetah Medical, the manufacturer of the NICOM hemodynamic device.
- 2.Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 30:536–555CrossRefPubMedGoogle Scholar
- 3.(2015) Surviving Sepsis Campaign; 6 hour bundle revised. http://www.survivingsepsis.org/News/Pages/SSC-Six-Hour-Bundle-Revised.aspx. 4-9-2015. (Ref Type: Electronic Citation)
- 5.Marik PE, Monnet X, Teboul JL (2011) Hemodynamic parameters to guide fluid therapy. Ann Crit Care 1:1Google Scholar
- 21.Kelm DJ, Perrin JT, Cartin-Cebra R, Gajic O, Schenck L, Kennedy CC (2015) Fluid overload in patients with severe sepsis and septic shock treated with Early-Goal Directed Therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 43:68–73CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Ruberfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R (2013) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 39:165–228CrossRefPubMedGoogle Scholar
- 32.Hjortrup PB, Haase N, Bundgaard H, Thomsen SL, Winding R, Pettila V, Aaen A, Lodahl D, Berthelsen RE (2016) Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med 42:1695–1705CrossRefPubMedGoogle Scholar
- 33.Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, Blackwood B, Fan E (2016) Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. DOI, Intensive Care Med ePub. doi: 10.1007/s00134-016-4573-3 Google Scholar