Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Liquidos en el paciente septico

364 views

Published on

manejo hidrico

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Liquidos en el paciente septico

  1. 1. Original Contribution Fluid balance in sepsis and septic shock as a determining factor of mortality Josep-Maria Sirvent, MD, PhD a, ⁎, Cristina Ferri, MD b , Anna Baró, MD a , Cristina Murcia, MD a , Carolina Lorencio, MD a a Department of Intensive Care (ICU), University Hospital of Girona Doctor Josep Trueta, IDIBGI, CIBERES, Girona, Spain b Department of Intensive Care (ICU), University Hospital of Tarragona Joan XXIII, Tarragona, Spain a b s t r a c ta r t i c l e i n f o Article history: Received 11 October 2014 Received in revised form 25 October 2014 Accepted 7 November 2014 Objective: The objective was to assess whether fluid balance had a determinant impact on mortality rate in a cohort of critically ill patients with severe sepsis or septic shock. Design: A prospective and observational study was carried out on an inception cohort. Setting: The setting was an intensive care unit of a university hospital. Patients: Patients admitted consecutively in the intensive care unit who were diagnosed with severe sepsis or septic shock were included. Interventions: Demographic, laboratory, and clinical data were registered, as well as time of septic shock onset, illness severity (Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment), and comorbidi- ties. Daily and accumulated fluid balance was registered at 24, 48, 72, and 96 hours. Survival curves representing 28-day mortality were built according to the Kaplan-Meier method. Results: A total of 42 patients were included in the analysis: men, 64.3%; mean age, 61.8 ± 15.9 years. Septic shock was predominant in 69% of the cases. Positive blood cultures were obtained in 17 patients (40.5%). No age, sex, Sepsis-related Organ Failure Assessment, creatinine, lactate, venous saturation of O2, and troponin differences were observed upon admission between survivors and nonsurvivors. However, higher Simplified Acute Physiol- ogy Score II was observed in nonsurvivors, P = .016. Nonsurvivors also showed higher accumulated positive fluid balance at 48, 72, and 96 hours with statistically significant differences. Besides, significant differences (P = .02) were observed in the survival curve with the risk of mortality at 72 hours between patients with greater than 2.5 L and less than 2.5 L of accumulated fluid balance. Conclusions: Fluid administration at the onset of severe sepsis or septic shock is the first line of hemodynamic treatment. However, the accumulated positive fluid balance in the first 48, 72, and 96 hours is associated with higher mortality in these critically ill patients. © 2014 Elsevier Inc. All rights reserved. 1. Introduction In severe sepsis and septic shock, the main elements of treatment are intravenous fluids, appropriate antibiotics, source control, vasopressors, and ventilatory support [1]. For more than 10 years, the administration of intravenous fluids has been known as a key in the initial stages of sepsis resuscitation, as proven by a classic article on goal-based treat- ments [2]. Anyway, it is now recognized that the administration of excess fluid in sepsis may lead to worsened respiratory function, increased intraabdominal pressure, worsened coagulopathy, and increased probability of cerebral edema [3]. Some authors observed dif- ficulty in fluid balance management in critically ill patients, and positive fluid balance is associated with increased mortality rates in patients with acute lung injury and septic shock [4,5]. For all these reasons, the present observational study was designed to assess whether fluid balance has a determinant impact on mortality in a well-defined cohort of patients with severe sepsis or septic shock. 2. Methods 2.1. Population and data collection Our study includes the patients admitted consecutively in the inten- sive care unit (ICU) of a teaching hospital for 4 months (from October 2012 to January 2013) that were diagnosed with severe sepsis or septic shock. It is a prospective and observational study on an inception cohort. Patients with septic shock were identified by a specific team of intensivists. Demographic, laboratory, and clinical data were registered: age, sex, time of septic shock onset, focus of infection, presence of initial acute kidney injury, severity of illness based on the Simplified Acute Physiology Score (SAPS) II score [6], the Sepsis-related Organ Failure American Journal of Emergency Medicine 33 (2015) 186–189 ⁎ Corresponding author. Department of Intensive Care (ICU), University Hospital of Girona Doctor Josep Trueta, Avda de França s/n, E-17007 Girona, Spain. Tel.: +34 972 940 288; fax: +34 972 940 296. E-mail address: jsirvent.girona.ics@gencat.cat (J.-M. Sirvent). http://dx.doi.org/10.1016/j.ajem.2014.11.016 0735-6757/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
  2. 2. Assessment (SOFA) score [7], and comorbidities. The kind of fluids used in the volume resuscitation of patients was always balanced electrolyte solution (Plamasmalyte 148) at the doses proposed by Surviving Sepsis Campaign Guidelines [1]. Daily and accumulated fluid balance was registered at 24, 48, 72, and 96 hours. Initial echocardiogram (within the first 24 hours) was completed on 26 patients to evaluate percentage ejection fraction (EF). Patients were excluded if they had developed septic shock outside hospital requiring fluid management and vasopres- sor drugs before their transfer to ICU. Data collection and patient inclu- sion in the study were performed after obtaining informed consent. 2.2. Definitions Severe sepsis was defined by the presence of acute infection and organ dysfunction. Septic shock was defined by acute organ dysfunction (acute renal failure, respiratory failure) in the presence of an infection and the need of vasopressor treatment for more than 6 hours [1]. The initial time of severe sepsis and septic shock was determined upon ICU admission by this diagnosis. When EF was less than 45%, patients were classified as having cardiac dysfunction. 2.3. Statistical analysis Descriptive statistics of demographic and clinical variables included means and standard deviations for quantitative variables and percent- ages for qualitative variables. For unadjusted comparisons between or among groups, continuous variables were compared by using Student t test in case of normally distributed data or Mann-Whitney U test for nonnormally distributed data. Categorical variables were compared by using the χ2 test or Fisher exact test where appropriate. Comparative variables for mortality at 28 days were studied by means of bivariate analysis. Survival curves representing mortality at 28 days were con- structed according to the Kaplan-Meier method and compared with the Mantel-Haenszel log-rank test. P b .05 was considered statistically significant for all comparisons. Statistical analyses were performed using SPSS (version 12; SPSS Inc, Chicago, IL). 3. Results A total of 42 patients were included in the analysis. Epidemiologic results were as follows: predominance of men (64.3%); mean age was 61.8 ± 15.9 years; cases of septic shock were predominant (69%). Positive blood cultures were obtained in 17 patients (40.5% of the cases). The most frequent initial infectious focus was abdominal (48%), followed by respiratory (17%). Infections were community acquired in almost 70% of the cases. Severity scores upon ICU admission were 44.6 ± 16.1 and 7.1 ± 3.4 points in SAPS II and SOFA, respectively. Besides, 28-day mortality was observed in 15 patients (35.7%), all of them in the septic shock group. Five out of 26 patients (19.2%) were classified as having cardiac dysfunction by EF less than 45% (see popula- tion characteristics in Table 1). Table 2 presents differences in fluid balance and variables between survivors and nonsurvivors. No age, sex, SOFA score, creatinine, lactate, venous saturation of O2 (SatvO2), and troponin T differences were re- ported upon admission between survivors and nonsurvivors. However, higher SAPS II score was observed in nonsurvivors (52.5 ± 15.4 vs 40.2 ± 14.9, P = .016). Nonsurvivors also showed higher accumulated posi- tive fluid balance at 48, 72, and 96 hours with significant differences. Fig. 1 shows a box plot with the greater daily accumulated fluid balance in milliliters at 48, 72, and 96 hours in nonsurvivors, with statis- tically significant differences. Fig. 2 shows the survival curve with the risk of survival at 72 hours between patients with greater than 2.5 L and less than 2.5 L of accumulated fluid balance, compared by log-rank test with significant differences (P = .02). 4. Discussion Our observational study shows that the accumulated positive fluid balance at 48, 72, and 96 hours is associated with higher mortality in ICU-admitted patients with sepsis or septic shock. These results are consistent with those by Boyd et al [5], who showed that higher positive fluid balance in resuscitation over the first 4 days was associated with increased risk of mortality in septic shock patients. Other factors such as creatinine, lactate, SatvO2, and Table 1 Characteristics of the study population⁎ Variable All patients (N = 42) Demographics Age, y 61.8 (15.9) Sex, male, n (%) 27 (64.3) SAPS II upon admission, points 44.6 (16.1) SOFA upon admission, points 7.1 (3.4) Coexisting conditions, n (%) Smokers 16 (38.1) Alcohol abuse 9 (21.4) Liver disease 4 (9.5) Congestive heart failure 8 (19.0) Cerebral stroke 4 (9.5) Chronic kidney disease 2 (4.8) Diabetes mellitus 8 (19.0) Immunosuppression 6 (14.3) Clinical data, n (%) Severe sepsis 13 (31.0) Septic shock 29 (69.0) Bacteremia 17 (40.5) Cardiac dysfunction† 5/26 (19.2) Infective focus, n (%) Abdomen 20 (47.6) Respiratory 7 (16.7) Soft tissues 4 (9.5) Urinary tract 3 (7.1) Others 8 (19.1) Outcome Length of ICU stay, d 11.5 (15.4) Length of hospital stay, d 23.2 (20.7) ICU mortality, n (%) 14 (33.3) Mortality at 28 d, n (%) 15 (35.7) Hospital mortality, n (%) 18 (42.9) ⁎ Data are expressed as mean (SD). † Echocardiogram performed in 26 out of 42 patients. Table 2 Fluid balance and variables between survivors and nonsurvivors⁎ Variable Survivors (n = 27) Non-survivors (n = 15) P value† Age, y 58.9 (17.6) 66.9 (11.3) .122 Sex, male, n (%) 17 (62.9) 10 (66.6) .810 SAPS II upon admission, points 40.2 (14.9) 52.5 (15.4) .016 SOFA upon admission, points 6.9 (3.2) 7.6 (3.6) .518 Initial creatinine (mg/dL) 1.5 (1.3) 1.9 (1.7) .452 Initial lactate (mg/dL) 18.9 (14.7) 28.6 (18.6) .072 Initial SatvO2 (%) 77 (9) 72 (9) .118 Troponin T hs (ng/dL) 32.5 (36.3) 115.6 (180.4) .099 Fluid balance (mL) within 24 h 1710.4 (1955.4) 3153.5 (3118.9) .096 Fluid balance (mL) within 48 h 1791.6 (2349.1) 4394.3 (3477.6) .020 Fluid balance (mL) within 72 h 1128.1 (3312.6) 5401.6 (3961.4) .002 Fluid balance (mL) within 96 h 4612.8 (4220.0) 6678.6 (4656.5) .001 Fluid balance 24 h N2.0 L 10 (37.0) 11 (73.3) .024 Fluid balance 48 h N2.5 L 12 (44.4) 11 (73.3) .071 Fluid balance 72 h N2.5 L 11 (40.7) 12 (80.0) .014 Fluid balance 96 h N2.5 L 10 (37.0) 12 (80.0) .008 Severe sepsis 13 (48.1) 0 (0.0) .001 Septic shock 14 (51.8) 15 (100.0) .980 Bacteremia 11 (40.7) 6 (40.0) .963 ⁎ Data are expressed as mean (SD). † χ2 de Pearson or Fisher test for qualitative data and Student t or Mann-Whitney U test for quantitative data. 187J.-M. Sirvent et al. / American Journal of Emergency Medicine 33 (2015) 186–189
  3. 3. troponin showed no statistical differences between survivors and nonsurvivors in our study. Micek et al [8] studied the cardiac function and accumulated fluid balance in septic shock in a recent work and concluded that cumulative fluid balance and cardiac dysfunction predict outcome in septic shock patients. Cardiac function was studied only in 26 out of 42 patients in the present work; and therefore, no conclusions could be drawn on this issue, but these data should be taken as preliminary and analyze in future studies. Cordemans et al [9] observed that fluid balance and extravascular lung water index were mortality predictors in critically ill patients requiring mechanical ventilation. Thus, clinicians treating septic shock patients should carefully assess the need for intravenous fluids both in the immediate resuscitation period and over the subsequent days of treatment. The use of more conservative fluid administration protocols in patients with severe sepsis and septic shock needs further study to determine their relative efficacy compared to standard care therapy [8]. Associations between increased cumulative positive fluid balance and long-term adverse outcomes have been reported in sepsis patients [5]. In tests of liberal vs goal-based treatments or restrictive fluid strate- gies in patients with acute respiratory distress syndrome—particularly in perioperative patients [3,4]—restrictive fluid strategies were associated with reduced morbidity. However, because there is no consensus on the definition of these strategies, high-quality tests in specific patients populations are required [10]. The mechanisms by which positive fluid balance can adversely influence outcomes remain unknown. However, hypervolemia or hyperosmolarity might exacerbate capillary leak in septic shock patients, thus contributing to pulmonary edema. Positive fluid balance could also result in intraabdominal hypertension, thus contributing to organ hypo- perfusion development and subsequent organ failure [11,12]. Acute renal failure coexisting with sepsis may worsen outcomes as well as lead to positive fluid balance [13]. Our study has important limitations. Firstly, it was performed in one only middle-sized and university hospital and may therefore have no external validity for other institutions. Secondly, our observational de- sign and the lower number of studied patients tan other studies of fluid balance, limit our ability to determine a causal relationship be- tween fluid balance and outcomes. And thirdly, the fact that cardiac function was only studied in 26 of the 42 patients leaves out an impor- tant predictor of mortality. Finally, other factors such as antibiotic ther- apy, focus control, and some other unmeasured clinical parameters may have contributed to our findings. Recommendations in the guidelines for sepsis treatment are well known to have recently been questioned, specifically the early goal-directed treatment [14]. The same applies to the recommendations of the type of fluid used for sepsis and septic shock. For all these reasons, it is difficult to standardize a single treat- ment protocol for these critically ill patients, as well as to draw clear conclusions from observational studies. Lastly, selection, timing, doses, and fluid balance in sepsis and septic shock should also be evaluated very carefully with the aim of maximizing efficacy and minimizing iatrogenic toxicity [15]. In conclusion, fluid administration upon the onset of severe sepsis or septic shock is the first line of hemodynamic treatment in this clinical situation. There is no doubt that the study of cardiac function by echo- cardiography helps us better understand the prognosis of these patients. However, the accumulated positive fluid balance in the first 48, 72, and 96 hours is associated with higher mortality in these critically ill, ICU-admitted patients. References [1] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637. [2] Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal- directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. [3] National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS), Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564–75. [4] Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009;136:102–9. [5] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [6] Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270:2957–63. [7] Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996;22:707–10. Accumulated Fluid Balance 72h < or >2,5L Fig. 2. Survival curve with the risk of survival at 72 hours between patients with greater than 2.5 L and less than 2.5 L of accumulated fluid balance. FluidBalance(mL) Fig. 1. Comparative box plot showing accumulated fluid balance in milliliters at 24, 48, 72, and 96 hours between survivors and nonsurvivors. 188 J-M. Sirvent et al. / American Journal of Emergency Medicine 33 (2015) 186–189
  4. 4. [8] Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. Crit Care 2013;17:R246. [9] Cordemans C, De Laet I, Van Regenmortel N, Schoonheydt K, Dits H, Huber W, et al. Fluid management in critically ill patients: the role of extravascular lung water, abdominal hypertension, capillary leak, and fluid balance. Anaesth Intensive Care 2012;2(Suppl. 1). [10] Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 2012;114:640–51. [11] Myburgh JA. Fluid resuscitation in acute illness-time to reappraise the basics. N Engl J Med 2011;364:2543–4. [12] Ke L, Ni HB, Sun JK, Tong ZH, Li WQ, Li N, et al. Risk factors and outcome of intra- abdominal hypertension in patients with severe acute pancreatitis. World J Surg 2012;36:171–8. [13] Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL, SOAP investigators. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008;12(3):R74. [14] Coen D, Cortellaro F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med 2014;32:563–8. [15] Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med 2013;369:1243–51. 189J.-M. Sirvent et al. / American Journal of Emergency Medicine 33 (2015) 186–189

×