The effect of fluid balance on outcomes in patients with sepsis; experience of a tertiary hospital

Abstract

Purpose: Fluid replacement is vital for stabilizing hemodynamic status in sepsis. However, the positive fluid balance may result in pulmonary edema and may be associated with increased mortality.
Materials and methods: This is a single-center, retrospective study in which the patients, supported with mechanical ventilation (MV) due to sepsis, were enrolled. All the data about the demographic features, medications, MV duration, vital signs, blood gas analysis, blood tests, the fluid balance were obtained from the patient files and nursing reports. Patients were subclassed positive, negative and balanced according to fluid balance and compared to each other.
Results: A total of fifty patients with sepsis were included in the study. Twenty-six (52%) of the patients were male and the mean age was 66.58±3.25 years. The mortality rate was 90%. The mean fluid intake and output were 3481.8±1002.7, 1877.6±921.3 milliliters, respectively. Forty-two (84%) were in positive fluid balance, 6 (12%) in negative fluid balance, and 2 (4%) in balance. There was no significant difference between the fluid balance subgroups in terms of length of stay in the ICU, duration of mechanical ventilation, and mortality. The use of diuretics was significantly higher in patients with positive fluid balance (p=0.023). CRP was significantly higher while serum albumin was lower in patients with positive fluid balance (respectively, p=0.003, p=0.034). There was no difference between the mean GCS, SOFA scores of survivors and nonsurvivors but the mean APACHE II scores in nonsurvivors were significantly higher than in survivors (p=0.026).
Conclusion: Our study showed that positive fluid balance did not affect the length of stay in the ICU, duration of mechanical ventilation and mortality, and that APACHE II was better than SOFA and GCS in predicting mortality.

Keywords

• Fluid therapy
• sepsis
• shock
• mechanical ventilation
• intensive care

Sepsisli hastalarda sıvı dengesinin sonuçlara etkisi; üçüncü basamak bir hastane deneyimi

Abstract

Amaç: Sıvı replasmanı, sepsiste hemodinamik durumu stabilize etmek için hayati öneme sahiptir. Bununla birlikte, pozitif sıvı dengesinin olumsuz etkileri olabilir.
Gereç ve yöntem: Ağustos 2016-Nisan 2017 tarihleri arasında üçüncü basamak bir hastanede sepsise bağlı mekanik ventilasyonla desteklenen hastaları içeren tek merkezli, retrospektif bir çalışmadır. Demografik özellikler, ilaçlar, mekanik ventilasyon süresi, yoğun bakımda kalış süresi, kan biyokimyasal testleri, sıvı dengesi ile ilgili tüm veriler hasta dosyaları ve hemşire çizelgelerinden elde edildi. Hastalar sıvı dengesine göre pozitif, negatif ve dengeli olarak alt sınıflandırılarak birbirleriyle karşılaştırıldı.
Bulgular: Çalışmaya toplam 50 sepsisli hasta alındı. Hastaların yirmi altısı (%52) erkekti ve yaş ortalaması 66,58±3,25 yıl idi. Ölüm oranı %90 idi. Ortalama sıvı alımı ve çıkışı sırasıyla 3481,8±1002,7, 1877,6±921,3 mililitre idi. Kırk ikisi (%84) pozitif sıvı dengesinde, 6'sı (%12) negatif sıvı dengesinde ve 2'si (%4) dengede idi. Sıvı dengesi alt grupları arasında yoğun bakımda kalış süresi, mekanik ventilasyon süresi ve mortalite açısından anlamlı fark yoktu. Pozitif sıvı dengesi olan hastalarda diüretik kullanımı anlamlı olarak daha yüksekti (p=0.023). Pozitif sıvı dengesi olan hastalarda CRP anlamlı olarak daha yüksek, serum albümini ise daha düşüktü (sırasıyla, p=0.003, p=0.034). Sağ kalanların ve sağ kalmayanların ortalama GCS, SOFA skorları arasında fark yoktu ancak sağ kalmayanlarda ortalama APACHE II skorları sağ kalanlardan anlamlı derecede yüksekti (p=0.026).
Sonuç: Çalışmamız, pozitif sıvı dengesinin yoğun bakımda kalış süresi, mekanik ventilasyon süresi ve mortaliteyi etkilemediğini ve APACHE II'nin mortaliteyi öngörmede SOFA ve GKS'ye göre daha iyi olduğunu gösterdi.

Keywords

• Sıvı tedavisi
• sepsis
• şok
• mekanik ventilasyon
• yoğun bakım

References

1. References 1. Napolitano LM. Sepsis 2018: Definitions and Guideline Changes. Surg Infect (Larchmt). 2018 Feb/Mar;19(2):117-125. doi: 10.1089/sur.2017.278. PMID: 29447109.
2. 2. Acheampong A,Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis. Crit Care Med.2015 Jun 15;19:251.
3. 3. Brink A, Alsma J, Verdonschot RJCG, Rood PPM, Zietse R, Lingsma HF, Schuit SCE. Predicting mortality in patients with suspected sepsis at the Emergency Department; A retrospective cohort study comparing qSOFA, SIRS and National Early Warning Score. PLoS One. 2019 Jan 25;14(1):e0211133. doi: 10.1371/journal.pone.0211133. PMID: 30682104; PMCID: PMC6347138.
4. 4. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.
5. 5. Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes. Intensive Care Med. 2005 Dec;31(12):1643-7. doi: 10.1007/s00134-005-2801-3. Epub 2005 Sep 29. PMID: 16193330.
6. 6. Diaz F, Benfield M, Brown L, Hayes L. Fluid overload and outcomes in critically ill children: a single center prospective cohort study. J Crit Care 2017;39:209-213.
7. 7. Lasen HC. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special reference to the treatment of acute respiratory insufficiency. Lancet 1953;1:37-42.
8. 8. Lee J, de Louw E, Niemi M, Nelson R, Mark RG, Celi LA, et al. Association between fluid balance and survival in critically ill patients. J Intern Med. 2015;277:468–77.

9. 9. Yang PH, Hung JY, Yang CJ, Tsai JR, Wang TH, Lee JC et all. Successful weaning predictors in a respiratory care center in Taiwan. Respir Med. 2009 Aug;103(8):1189-95.
10. 10. Miranda AC, de Menezes IAC, Junior HC, Luy AM, do Nascimento MM. Monitoring peripheral perfusion in sepsis associated acute kidney injury: Analysis of mortality. PLoS ONE 15(10): e0239770.
11. 11. Rezende E, Silva Junior JM, Isola AM, Campos EV, Amendola CP, Almeida SL. Epidemiology of severe sepsis in the emergency department and difficulties in the initial assistance. Clinics. 2008;63:457-64.
12. 12. Yu-ming W, Yan-jun Z, Ying C, Yun-chuan H, Wei-wei C, Ran J, et al. Effects of fl uid balance on prognosis of acute respiratory distress syndrome patients secondary to sepsis. World J Emerg Med, Vol 11, No 4, 2020.
13. 13. Oliveira F. S. V, Freitas F. G. R, Ferreira E. M, Castro I, Bafi A. T, Azevedo L. C. P, et al. Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock. J Crit Care. 2015;30(1):97-101.
14. 14. Liborio A. B, Barbosa M. L, Sa V. B, Leite T. T. Impact of loop diuretics on critically ill patients with a PFB. Anaesthesia 2020, 75 (Suppl. 1), e134–e142.
15. 15. Dasgupta A, Rice R, Mascha E, Litaker D, Stoller JK. Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation. Chest. 1999 Aug;116(2):447-55.
16. 16. Modawal A, Candadai NP, Mandell KM, Moore ES, Hornung RW, Ho ML, Tsevat J. Weaning success among ventilator-dependent patients in a rehabilitation facility. Arch Phys Med Rehabil. 2002 Feb;83(2):154-7. doi: 10.1053/apmr.2002.29614. PMID: 11833016.
17. 17. Carlsen S, Perner A, East Danish Septic Shock Cohort I. Initial fluid resuscitation of patients with septic shock in the intensive care unit. Acta Anaesthesiologica Scandinavica. 2011;55(4):394-400.
18. 18. Smith SH, Perner A. Higher vs. lower fluid volume for septic shock: Clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort. Critical Care. 2012;16(3).
19. 19. Ivor S. D, Philip M. A, Keith A. C, Matthew CE, Lui GF, Andre LH, et al. Fluid Response Evaluation in Sepsis Hypotension and Shock A Randomized Clinical Trial. CHEST 2020; 158(4):1431-1445.
20. 20. Niels M, Bart FG, Jan MB, Denise PV, Lieuwe DJB, Joost W, et al. A Higher Fluid Balance in the Days After Septic Shock Reversal Is Associated With Increased Mortality: An Observational Cohort Study. Crit Care Expl 2020; 2:e0219.
21. 21. Tsering D, Jong-Chie T, Alberto M, Cassie CK, Ognjen G, Kianoush BK. Association of Negative Fluid Balance during the De-escalation Phase of Sepsis Management on Mortality: A Cohort Study. J Crit Care. 2020;55:16-21.