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Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database.
Intensive Care Med. 2017 May; 43(5):625-632.IC

Abstract

PURPOSE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Authors+Show Affiliations

Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 410, Norfolk, VA, 23507, USA. marikpe@evms.edu.Trexin Consulting, Chicago, IL, USA.Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.Cheetah Medical, Newton, MA, USA.Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA. Cheetah Medical, Newton, MA, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

28130687

Citation

Marik, Paul E., et al. "Fluid Administration in Severe Sepsis and Septic Shock, Patterns and Outcomes: an Analysis of a Large National Database." Intensive Care Medicine, vol. 43, no. 5, 2017, pp. 625-632.
Marik PE, Linde-Zwirble WT, Bittner EA, et al. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med. 2017;43(5):625-632.
Marik, P. E., Linde-Zwirble, W. T., Bittner, E. A., Sahatjian, J., & Hansell, D. (2017). Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Medicine, 43(5), 625-632. https://doi.org/10.1007/s00134-016-4675-y
Marik PE, et al. Fluid Administration in Severe Sepsis and Septic Shock, Patterns and Outcomes: an Analysis of a Large National Database. Intensive Care Med. 2017;43(5):625-632. PubMed PMID: 28130687.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. AU - Marik,Paul E, AU - Linde-Zwirble,Walter T, AU - Bittner,Edward A, AU - Sahatjian,Jennifer, AU - Hansell,Douglas, Y1 - 2017/01/27/ PY - 2016/10/01/received PY - 2016/12/30/accepted PY - 2017/1/29/pubmed PY - 2017/9/15/medline PY - 2017/1/29/entrez KW - Fluid administration KW - Mortality KW - National database KW - Sepsis KW - Septic shock SP - 625 EP - 632 JF - Intensive care medicine JO - Intensive Care Med VL - 43 IS - 5 N2 - PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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. SN - 1432-1238 UR - https://www.unboundmedicine.com/medline/citation/28130687/Fluid_administration_in_severe_sepsis_and_septic_shock_patterns_and_outcomes:_an_analysis_of_a_large_national_database_ L2 - https://dx.doi.org/10.1007/s00134-016-4675-y DB - PRIME DP - Unbound Medicine ER -