Chest

Chest

Volume 133, Issue 1, January 2008, Pages 252-263
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Recent Advances in Chest Medicine
Fluid Therapy in Resuscitated Sepsis: Less Is More

https://doi.org/10.1378/chest.07-1496Get rights and content

Fluid infusion may be lifesaving in patients with severe sepsis, especially in the earliest phases of treatment. Following initial resuscitation, however, fluid boluses often fail to augment perfusion and may be harmful. In this review, we seek to compare and contrast the impact of fluids in early and later sepsis; show that much fluid therapy is clinically ineffective in patients with severe sepsis; explore the detrimental aspects of excessive volume infusion; examine how clinicians assess the intravascular volume state; appraise the potential for dynamic indexes to predict fluid responsiveness; and recommend a clinical approach.

Section snippets

Fluids in Early Severe Sepsis

In the first hours of severe sepsis, venodilation, transudation of fluid from the vascular space into tissues, reduced oral intake, and heightened insensible loss combine to produce hypovolemia. Along with ventricular dysfunction, arteriolar dilation, and vascular obstruction, volume depletion contributes to impaired global perfusion, threatening the function of critical organs. Treating hypovolemia is a central tenet of early management of severe sepsis1: fluid should be infused to raise the

Fluids in Resuscitated Sepsis

Initial resuscitation transforms a hypovolemic, hypodynamic circulation into one where oxygen transport is normal or high, at least at the whole-body level, in most septic adults.211 In contrast to the average patient entering the EGDT trial, once fluids, antimicrobials, vasoactive drugs, and perhaps blood have been administered, these resuscitated patients usually display elevated CVP, cardiac output, and Svo2. There is no longer global hypoperfusion as judged by any measure of oxygen

Fluids May Be Harmful in Critical Illness

Fluid infused into the vascular space ultimately equilibrates with other fluid compartments. Unnecessary fluid (ie, fluid that does not enhance perfusion) will cause or exacerbate edema in lungs, heart, gut, skin, brain, and other tissues. At times, this creates clinically obvious organ failure, such as respiratory failure, abdominal compartment syndrome,1314 or cerebral edema and herniation. Further, there is some evidence that excess fluid can be harmful by more subtle means. Multiple studies

Usual ICU Care Leads to Fluid Overload

Critically ill septic patients are often receiving nutrition, sedatives, analgesics, antimicrobials, vasoactive drugs, insulin infusions, and agents to reduce the risk of gastric hemorrhage, all of which contribute to fluid intake. Some ICUs still encourage “maintenance” fluids, an approach that compounds the problem of fluid overload. What is surprising is the amount of fluid comprised by all of these treatments. For example, in a study25 comparing midazolam to lorazepam for ICU sedation, the

Impact of a Fluid Bolus

The most direct means to assess whether additional fluid will raise perfusion is to perform a “fluid challenge”: infuse a fluid bolus and measure cardiac output, Scvo2, or some other clinically relevant parameter reflecting perfusion (BP reflects poorly whether perfusion truly rises26). Fluid challenges are a regular part of ICU management, but there are few data to guide how much of what fluid constitutes an adequate challenge. We will not cover here the continuing debate regarding whether to

Assessing Intravascular Volume and Predicting Fluid Responsiveness

Since fluid challenge fails to help many septic patients and may cause harm, predicting the likelihood of response could be of great clinical value. Historically, clinicians have generally used static hemodynamic values (eg, CVP or PAOP) to judge whether fluids are likely to boost the circulation. As discussed below, however, these measures have almost no ability to distinguish fluid responders from nonresponders. Of more current interest are dynamic indexes, such as pulse pressure variation

CVP or Right Atrial Pressure

CVP is probably the most used parameter for judging whether fluids should be administered.226 Nevertheless, a large number of studies2632424344 show that CVP fails to discriminate responders from nonresponders. When CVP is significantly elevated (> 10 mm Hg), fluids are generally quite unlikely to raise perfusion,26 but there are occasional exceptions. Moreover, these studies have generally failed to consider carefully the effect of mechanical ventilation or high levels of positive

Dynamic Measures To Predict Fluid Responsiveness

As confidence in static preload measures has faded over the last 20 years, interest in dynamic predictors has heightened. Rather than relying on fixed hemodynamic values, these measures utilize changes in the mean systemic pressure, which is the intravascular pressure averaged over the entire circulation,63 or right atrial pressure (Pra) [manipulated during breathing] to infer the position of the heart on the Starling function curve. Since (in steady state) cardiac output equals venous return

A Bedside Approach

We summarize here our recommendations for management of fluids in septic patients (Table 2). In the first 6 h of acute resuscitation, fluids should be infused urgently to restore perfusion, guided by the Scvo2. Although infusing fluid until the Pra reaches 8 to 12 mm Hg is commonly recommended, the only basis for this is expert opinion.1281 We are concerned that excessive focus on Pra will lead to underresuscitation or overresuscitation, emphasize again that Scvo2 should be the target, and

Conclusion

After the initial fluid resuscitation, many septic patients who have traditional indications for a fluid challenge will not actually respond. Such fluid challenges may be not only ineffective, but harmful. While further studies should attempt to confirm and quantify this harm, we think that current knowledge is sufficient to change practice safely. We advocate that fluid boluses be considered critically rather than simply being given reflexively. When a patient has indications for a fluid

References (81)

  • MR Shah et al.

    Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE): design and rationale

    Am Heart J

    (2001)
  • S Kaul et al.

    Value of two-dimensional echocardiography for determining the basis of hemodynamic compromise in critically ill patients: a prospective study

    J Am Soc Echocardiogr

    (1994)
  • S Magder et al.

    Respiratory variations in right atrial pressure predict the response to fluid challenge

    J Crit Care

    (1992)
  • S Preisman et al.

    Predicting fluid responsiveness in patients undergoing cardiac surgery: functional haemodynamic parameters including the respiratory systolic variation test and static preload indicators

    Br J Anaesth

    (2005)
  • H Solus-Biguenet et al.

    Non-invasive prediction of fluid responsiveness during major hepatic surgery

    Br J Anaesth

    (2006)
  • A Kramer et al.

    Pulse pressure variation predicts fluid responsiveness following coronary artery bypass surgery

    Chest

    (2004)
  • JM Brennan et al.

    Radial artery pulse pressure variation correlates with brachial artery peak velocity variation in ventilated subjects when measured by internal medicine residents using hand-carried ultrasound devices

    Chest

    (2007)
  • RP Dellinger et al.

    Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

    Crit Care Med

    (2004)
  • E Rivers et al.

    Early goal-directed therapy in the treatment of severe sepsis and septic shock

    N Engl J Med

    (2001)
  • N Sivayoham

    Management of severe sepsis and septic shock in the emergency department: a survey of current practice in emergency departments in England

    Emerg Med J

    (2007)
  • HB Nguyen 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)
  • JW Kern et al.

    Meta-analysis of hemodynamic optimization in high-risk patients

    Crit Care Med

    (2002)
  • M Yu et al.

    Effect of maximizing oxygen delivery on morbidity and mortality rates in critically ill patients: a prospective, randomized, controlled study

    Crit Care Med

    (1993)
  • MA Hayes et al.

    Elevation of systemic oxygen delivery in the treatment of critically ill patients

    N Engl J Med

    (1994)
  • L Gattinoni et al.

    A trial of goal-oriented hemodynamic therapy in critically ill patients: Svo2Collaborative Group

    N Engl J Med

    (1995)
  • MA Hayes et al.

    Oxygen transport patterns in patients with sepsis syndrome or septic shock: influence of treatment and relationship to outcome

    Crit Care Med

    (1997)
  • MM Parker

    Goals for fluid resuscitation: a real challenge

    Crit Care Med

    (2007)
  • ML Malbrain et al.

    Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study

    Crit Care Med

    (2005)
  • J McNelis et al.

    Predictive factors associated with the development of abdominal compartment syndrome in the surgical intensive care unit

    Arch Surg

    (2002)
  • RS Simmons et al.

    Fluid balance and the adult respiratory distress syndrome

    Am Rev Respir Dis

    (1987)
  • S Uchino et al.

    Pulmonary artery catheter versus pulse contour analysis: a prospective epidemiological study

    Crit Care

    (2006)
  • A Upadya et al.

    Fluid balance and weaning outcomes

    Intensive Care Med

    (2005)
  • CD Epstein et al.

    Weaning readiness and fluid balance in older critically ill surgical patients

    Am J Crit Care

    (2006)
  • B Brandstrup et al.

    Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens; a randomized assessor-blinded multicenter trial

    Ann Surg

    (2003)
  • JP Mitchell et al.

    Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization

    Am Rev Respir Dis

    (1992)
  • HP Wiedemann et al.

    Comparison of two fluid-management strategies in acute lung injury

    N Engl J Med

    (2006)
  • GR Bernard et al.

    The American-European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination

    Am J Respir Crit Care Med

    (1994)
  • AS Pohlman et al.

    Continuous intravenous infusions of lorazepam versus midazolam for sedation during mechanical ventilatory support: a prospective, randomized study

    Crit Care Med

    (1994)
  • S Magder et al.

    The clinical role of central venous pressure measurements

    J Intensive Care Med

    (2007)
  • S Finfer et al.

    A comparison of albumin and saline for fluid resuscitation in the intensive care unit

    N Engl J Med

    (2004)

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    This work was done at the University of Iowa, Carver College of Medicine.

    The authors have no conflicts of interest to disclose.

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    Copyright © 2008 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.