Abstract
Background
Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure.
Methods
A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure.
Results
Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 ± 16.5 yr and 29.0 ± 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval (CI)] for 2-4 L 1.67 (1.03-2.70) and > 4 L 2.34 (1.23-4.44) and a reduced risk of renal failure [OR, 95% CI for 2-4 L 0.48 (0.28-0.83) and > 4 L 0.45 (0.22-0.92)] in the first 24 hr of severe sepsis. Administration of colloid and crystalloid fluid as compared to crystalloid fluid alone was associated with a lower risk of renal failure [OR, 95% CI 0.45 (0.26 to 0.76)].
Conclusion
An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.
Contexte
La réanimation liquidienne est un facteur crucial pour restaurer la stabilité hémodynamique et la perfusion tissulaire chez les patients en septicémie sévère. Nous avons cherché à examiner les liens entre la quantité et le type de liquide administré durant les six premières heures suivant le diagnostic d’une septicémie sévère et la mortalité hospitalière, la mortalité aux soins intensifs et la défaillance systémique.
Méthode
Une étude de cohorte rétrospective et multi-centrique a été entreprise dans cinq unités de soins intensifs de soins tertiaires au Canada. Nous avons identifié les patients atteints de septicémie sévère admis aux soins intensifs entre le 1er juillet 2000 et le 30 juin 2002, en se fondant sur des bases de données administratives et cliniques. Les critères d’inclusion comprenaient: l’hypotension, la présence d’une source infectieuse, et au minimum deux critères du syndrome de réponse inflammatoire systémique. Nous avons enregistré la quantité totale et le type de liquide administré durant les six premières heures suivant le diagnostic d’une septicémie sévère. Le premier épisode d’hypotension a défini le point de départ pour la récolte des données concernant les liquides administrés. Des analyses de régression multivariées ont été menées afin d’examiner les liens entre la quantité et le type de liquide administré et la mortalité à l’hôpital/aux soins intensifs, ainsi que la défaillance systémique.
Résultats
Parmi les 2 026 dossiers de patients potentiellement éligibles, 496 patients ont présenté les critères d’admissibilité. L’âge moyen et le score APACHE II (Acute Physiology and Chronic Health Evaluation) étaient de 61,8 ± 16,5 ans et 29,0 ± 8,0, respective-ment. Aucun lien entre la quantité ou le type de liquide administré et la mortalité à l’hôpital ou aux soins intensifs n’a été identifié, et nous n’avons pas trouvé de liens statistiquement significatifs entre la quantité ou le type de liquide administré et la défaillance systémi-que. Toutefois, davantage de réanimation liquidienne a été associée a un risque accru de défaillance cardiovasculaire [rapport de cote (OR) et intervalle de confiance (CI) de 95 %] pour 2-4 L 1,67 (1,03-2,70) et> 4L 2,34 (1,23-4,44) ainsi qu’un risque réduit de défaillance rénale [OR, CI 95 % pour 2-4 L 0,48 (0,28-0,83) et> 4L 0,45 (0,22-0,92)] durant les premières 24 h de septicé-mie sévère. L’administration simultanée de colloïde et cristalloïde, comparativement à du cristalloïde seul, a été associée à un risque moindre de défaillance rénale [OR, CI 95 % 0,45 (0,26 à 0,76)].
Conclusion
Aucune association entre la mortalité à l’hôpital et la quantité ou le type de liquide administré durant les six premières heures suivant le diagnostic d’une septicémie sévère n’a pu être identifiée. Ces données devraient être considérées comme génératrices d’hypothèses et exigent leur confirmation ou, au contraire, leur réfutation, par des études randomisées contrôlées.
Article PDF
Similar content being viewed by others
References
Brun-Buisson C. The epidemiology of the systemic inflammatory response. Intensive Care Med 2000; 26(Suppl): S 64–74.
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546–54.
Marik PE, Varon J. Sepsis: state of the art. Dis Mon 2001; 47: 465–532.
Alberti C, Brun-Buisson C, Burchardi H, et al. Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 2002; 28: 525–6.
Rackow EC, Falk JL, Fein IA, et al. Fluid resuscitation in circulatory shock: a comparison of the cardiorespira- tory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 1983; 11: 839–50.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368–77.
Alderson P, Bunn F, Lefebvre C, et al. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev 2004; (4): CD001208.
Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med 2001; 135: 149–64.
Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systematic review of randomized controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ 1998; 317: 235–40.
Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2004; (4): CD000567.
Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med 1999; 27: 200–10.
Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomized trials. BMJ 1998; 316: 961–4.
Wade CE, Kramer GC, Grady JJ, Fabian TC, Younes RN. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies. Surgery 1997; 122: 609–16.
Vincent JL, Navickis RJ, Wilkes MM. Morbidity in hospitalized patients receiving human albumin: a meta-analysis of randomized, controlled trials. Crit Care Med 2004; 32: 2029–38.
Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247–56.
Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992; 101: 1644–55.
Hollenberg SM, Ahrens TS, Annane D, et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med 2004; 32: 1928–48.
Vincent JL, Gerlach H. Fluid resuscitation in severe sepsis and septic shock: an evidence-based review. Crit Care Med 2004; 32(11 Suppl): S451–4.
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354: 2564–75.
Rivers EP. Fluid-management strategies in acute lung injury - liberal, conservative, or both? N Engl J Med 2006; 354: 2598–600.
Shapiro NI, How ell MD, Talmor D, et al. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med 2006; 34: 1025–32.
Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest 2006; 129: 225–32.
Nguyen HB, Corbett SW, Menes K, et al. Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department. Acad Emerg Med 2006; 13: 109–13.
Kortgen A, Niederprum P, Bauer M. Implementation of an evidence-based “standard operating procedure” and outcome in septic shock. Crit Care Med 2006; 34: 943–9.
Sebat F, Johnson D, Musthafa AA, et al. A multidisci-plinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 2005; 127: 1729–43.
Cook D. Is albumin safe? N Engl J Med 2004; 350: 2294–6.
Boldt J, Priebe HJ. Intravascular volume replacement therapy with synthetic colloids: is there an influence on renal function? Anesth Analg 2003; 96: 376–82.
Schortgen F, Lacherade JC, Bruneel F, et al. Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet 2001; 357: 911–6.
Reinhart K, Bloos F, Engell C, et al. Hydroxyethyl starch and Ringer’s lactate for fluid resuscitation in patients with severe sepsis - results from the VISEP study. Intensive Care Med 2006; 32(Suppl 1): S213.
Author information
Authors and Affiliations
Consortia
Corresponding author
Rights and permissions
About this article
Cite this article
McIntyre, L.A., Fergusson, D., Cook, D.J. et al. Resuscitating patients with early severe sepsis: A Canadian multicentre observational study. Can J Anesth 54, 790–798 (2007). https://doi.org/10.1007/BF03021706
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03021706