Negative Fluid Balance Predicts Negative Fluid Balance Predicts SurvivalSurvivalin Patients With Septic Shockin Patients With Septic Shock

A Retrospective Pilot StudyA Retrospective Pilot StudyFrom: From: CHEST 2000; 117:1749–1754CHEST 2000; 117:1749–1754By: By: Fadi Alsous, MD; Mohammad Khamiees, MD, et alFadi Alsous, MD; Mohammad Khamiees, MD, et al

本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時 , 須獲得原期刊之同意授權

ObjectiveObjective

• hypothesized that patients with sephypothesized that patients with septic shock who achieve negative fluid tic shock who achieve negative fluid balance (balance (< < = - = - 500 mL) on any day in t500 mL) on any day in the first 3 days of management are mhe first 3 days of management are more likely to survive than those who ore likely to survive than those who do notdo not

IntroductionIntroduction

• cardiovascular derangements of septicardiovascular derangements of septic shock in humans include arteriolar ac shock in humans include arteriolar and venular dilation and capillary leaknd venular dilation and capillary leak

• Intravascular volume replacement Intravascular volume replacement f frequently converts circulation to a higrequently converts circulation to a high-output hypotensive state h-output hypotensive state recovery recovery to a diuretic phase later if the heart anto a diuretic phase later if the heart and kidneys are OKd kidneys are OK

Materials and MethodsMaterials and Methods

• MICU in MICU in Division of Pulmonary and Division of Pulmonary and Critical Care, Bridgeport Hospital and Critical Care, Bridgeport Hospital and Yale University School of Medicine, Yale University School of Medicine, BridgeportBridgeport

• between July 1997 and March 1999 between July 1997 and March 1999 with the ICU admitting diagnosis of with the ICU admitting diagnosis of septic shockseptic shock

• meeting criteria for septic shock and meeting criteria for septic shock and not receiving dialysis prior to not receiving dialysis prior to admission were included in this studyadmission were included in this study

Criteria of Septic ShockCriteria of Septic ShockConsensus conference: definitions for sepsis andConsensus conference: definitions for sepsis andorgan failure and guidelines for the use of innovative therapiesorgan failure and guidelines for the use of innovative therapiesin sepsis. Crit Care Med 1992; 20:864–874in sepsis. Crit Care Med 1992; 20:864–874

• (1) systolic BP (1) systolic BP <<90 mm Hg or a 30 mm 90 mm Hg or a 30 mm Hg decrease from baseline that is Hg decrease from baseline that is unrunresponsiveesponsive to fluids and/or to the to fluids and/or to the requi requirementrement of inotropic medications of inotropic medications

• (2) hypothermia or hyperthermia (tem(2) hypothermia or hyperthermia (temperature< 36°C or perature< 36°C or >>38°C, respectively)38°C, respectively)

• (3) tachypnea ((3) tachypnea (>>20 breaths/min).20 breaths/min).

Collecting datasCollecting datas• age; gender; APACHE II score (on the firage; gender; APACHE II score (on the fir

st day of septic shock); daily fluid inputst day of septic shock); daily fluid inputs and outputs; lowest recorded MAP eas and outputs; lowest recorded MAP each day; daily ABG levels and laboratory ch day; daily ABG levels and laboratory test results; daily Glasgow coma scale test results; daily Glasgow coma scale scores; highest doses of vasoactive mescores; highest doses of vasoactive medications each day; administered diuredications each day; administered diuretics; culture results; daily SOFA scorestics; culture results; daily SOFA scores

• physiologic and demographic charactphysiologic and demographic characteristics of patients who survived were eristics of patients who survived were compared to those who did not survivcompared to those who did not survive by nonpaired Student’s e by nonpaired Student’s t t teststests

• risk ratios (RRs) of survival for patientrisk ratios (RRs) of survival for patients with net negative fluid balance (s with net negative fluid balance (<= - <= - 500500 mL) on any of the first 3 days of th mL) on any of the first 3 days of therapy compared to those failed to acherapy compared to those failed to achieve net negative balance on any of thieve net negative balance on any of the first 3 dayse first 3 days

• thresholds were an APACHE II score of < 20, thresholds were an APACHE II score of < 20, a SOFA score of a SOFA score of < < 10, age 10, age < < 65 years, and a s65 years, and a serum Cr level erum Cr level < < 2.0 mg/dL2.0 mg/dL

• Summary estimates using both the Summary estimates using both the Mantel-Mantel-Haenszel testHaenszel test and and precision-based approacprecision-based approacheshes were computed were computed

• small sample sizesmall sample size and and absence of mortalityabsence of mortality in group achieved net negative fluid balancin group achieved net negative fluid balance e meaningful simultaneous adjustment o meaningful simultaneous adjustment of multiple risk factors could not be performf multiple risk factors could not be performeded

ResultsResults

• 44 cases listed in our ICU logbook, 44 cases listed in our ICU logbook, 36 patients met strict inclusion 36 patients met strict inclusion criteria for septic shock and had no criteria for septic shock and had no history of dialysis.history of dialysis.

• 25 patients were admitted through 25 patients were admitted through ER , and 11 patients were ER , and 11 patients were transferred into the ICU from wardtransferred into the ICU from ward

• 20 of 36 patients (56%) did not survive. 20 of 36 patients (56%) did not survive. • 9 patients died within 3 days of hospital 9 patients died within 3 days of hospital

admission, and care was limited (no admission, and care was limited (no code) or withdrawn for all but 1 patient.code) or withdrawn for all but 1 patient.

• 3 patients had 2 days of negative 3 patients had 2 days of negative balance, and 8 patients had 1 day of balance, and 8 patients had 1 day of negative balancenegative balance

• urine outputs were urine outputs were significantly highersignificantly higher in those who achieved negative fluid in those who achieved negative fluid balance over each of first 3 days of balance over each of first 3 days of therapytherapy

• All patientsAll patients who achieved who achieved net negative net negative fluid balancesfluid balances on any of the first 3 days on any of the first 3 days of therapy of therapy livedlived

• only only 5 of 255 of 25 patients who failed to patients who failed to achieve 1 day of net negative fluid achieve 1 day of net negative fluid balance by day 3 livedbalance by day 3 lived

• The mean fluid balance was The mean fluid balance was persistently persistently net positivenet positive for those patients who died. for those patients who died.

• 20 patients who died, 17 never 20 patients who died, 17 never achieved even 1 day of net negative achieved even 1 day of net negative fluid balancefluid balance

• highest estimates of survival RRs for those patients highest estimates of survival RRs for those patients who achieved negative fluid balance on 1 of the firswho achieved negative fluid balance on 1 of the first 3 days of therapy were obtained in categories that 3 days of therapy were obtained in categories that traditionally portend the worst prognosist traditionally portend the worst prognosis

• Even APACHE II scores Even APACHE II scores >= >= 20, those who achieved n20, those who achieved negative fluid balance (egative fluid balance (>= - >= - 22500 mL) on 1 of the firs500 mL) on 1 of the first 3 days of therapy t 3 days of therapy 6 6 times as likely to survive as times as likely to survive as those who did notfirst day those who did notfirst day

• Even first day SOFA scores Even first day SOFA scores >= >= 10, those achieved n10, those achieved net negative fluid balance on et negative fluid balance on >= >= 1 of the first 3 days 1 of the first 3 days of therapy wereof therapy were 6 6 times as likely to survive. times as likely to survive.

DiscussionsDiscussions

• negative fluid balance on any of first 3 negative fluid balance on any of first 3 days after admission is associated witdays after admission is associated with better survival rates than for patienth better survival rates than for patients who do not achieve negative fluid bas who do not achieve negative fluid balance (100% vs 31%, respectively; RR, lance (100% vs 31%, respectively; RR, 5.0; 95% CI, 2.3 to 10.9)5.0; 95% CI, 2.3 to 10.9)

• study is limited by study is limited by small sample sizesmall sample size a and by resulting nd by resulting instabilityinstability of stratum-s of stratum-specific survival RR estimates pecific survival RR estimates cannocannot be said with a high degree of certaintt be said with a high degree of certaintyy

• choice of day 3 as the critical day to assess choice of day 3 as the critical day to assess whether or not a patient had achieved negawhether or not a patient had achieved negative fluid balance (on any day) tive fluid balance (on any day) empiric & empiric & defined defined a prioria priori. . But ¼ patients were alre But ¼ patients were already dead by day 3 …… ady dead by day 3 …… earlier assessmentearlier assessment would be more meaningfulwould be more meaningful

• Ebb phase and flood phaseEbb phase and flood phase• successful resuscitation includes successful resuscitation includes refilling threfilling th

e underfilled systeme underfilled system

• return of normal vascular tone and the retrieval of return of normal vascular tone and the retrieval of fluid from the peripheral circulation and third spacfluid from the peripheral circulation and third space back to the central circulatione back to the central circulation

• Renal failureRenal failure worse clinical outcomes in patients worse clinical outcomes in patients with sepsiswith sepsis

• Negative fluid balance Negative fluid balance resolution of hemodyna resolution of hemodynamic derangements and that the kidneys and heart mic derangements and that the kidneys and heart have not failed by result of septic insult have not failed by result of septic insult good pr good prognosis ognosis effect of successful management of sept effect of successful management of septic shockic shock

• Diuretics?? Diuretics?? No difference No difference

• hypothesis should be reexamined hypothesis should be reexamined and verified in a much larger cohortand verified in a much larger cohort

• if confirmed in prospective studies, if confirmed in prospective studies, fluid balance in any of first 3 days fluid balance in any of first 3 days of septic shockof septic shock could provide a could provide a simple and inexpensive method of simple and inexpensive method of augmenting current augmenting current prognostic prognostic indicatorsindicators obvious benefit to obvious benefit to anxious family members and anxious family members and caretakers caretakers

Thank you for your Thank you for your attentionattention