Fluid resuscitation in patients with sepsis - Part 3

The article was written by Dr. Truong Ngoc Hai - Resuscitation Doctor - Emergency Department - Vinmec Central Park International General Hospital

Fluid overload is a very common problem in patients with sepsis (NKH). Fluid overload increases mortality in patients after cardiac and noncardiac surgery, cancer and acute kidney injury, and patients on invasive and noninvasive mechanical ventilation [6]. Therefore, fluid resuscitation in septic shock should be managed promptly but with appropriate guidance, avoiding overly aggressive, prolonged and uncontrolled fluid resuscitation.

According to the SSC guidelines, “establishing an infusion line and initiating fluid resuscitation are the top priorities when managing patients with septic shock” [20]. It must be recognized that prompt perfusion is one of the most important potentially life-saving treatments in NKH. However, there is increasing evidence that positive fluid balance is associated with higher mortality in patients with NKH [1],[24],[33],[43],[47].
Fluid resuscitation in patients with CKD has a short hemodynamic effect (usually 60 minutes). If the cause of hypotension is vascular dysfunction, increased vascular permeability, and vasodilation, it should be corrected using vasopressors rather than repeated fluid resuscitation. Recognizing this phenomenon early, many studies have been performed to evaluate the effects of positive fluid balance and patient mortality outcomes.
Table 3. Studies on fluid balance and outcomes in patients with NKH

Several observational studies have reported an association between positive fluid balance and increased mortality. In 2000, a study by Alsous et al showed a better survival prognosis in patients with negative fluid balance for at least 1 day during the first 72 h of septic shock (RR 5.0; 95% CI:2, 3 – 10.9; p value < 0.001) [2]. Age and positive fluid balance 72 h after onset of septic shock are strong predictors of mortality in resuscitation. This means that positive fluid balance is the only modifiable risk factor for reducing mortality according to Vincent et al. Boyd et al. [8] performed a retrospective study showing that positive fluid balance during the first 12 h of resuscitation and cumulative fluid after 4 days were independent risk factors for mortality. In the group of NKH patients with lung injury, Murphy et al showed adequate initial fluid resuscitation (defined as 20 ml/Kg after vasopressors and CVP > 8 mmHg) and cautious fluid resuscitation in the phase Late (ie, adequate or negative fluid balance for at least the next 2 days of the first week of septic shock) is independently associated with survival, especially in patients with both of the above criteria. higher survival [36].
On the contrary, some studies show that active infusion is beneficial. Smith et al. [48] performed a prospective multicenter observational study of 164 patients that found that patients with septic shock after 72 h of receiving larger volumes of fluids had a lower 90-day mortality rate, although despite having the same severity score at admission. However, the mean volume of fluid replacement (7.5 L during the first 72 h of shock) was lower than in similar studies [39]. A study by Shen et al. [46] showed that living patients received a higher volume of fluid than dead patients. Note that Shen et al.'s study [46] only included patients with negative fluid balance. Furthermore, mortality benefit was observed in highly resuscitated patients who remained in shock for three or more days as reported by Smith et al [48]. The cut-off points reported in this study were lower than the expected high volume of fluid in clinical trials.
Micek et al. [33], Sakr et al. [44] showed that fluid balance in the first 24 hours and cumulative fluid balance were significantly lower in the surviving group than in the dead group with p = 0.003 and p < 0.001. Sirvent et al [47] also showed a large positive fluid balance in patients who died at 48, 72, and 96 hours. The difference was not statistically significant at 24 h. A study by Boyd et al. [8] showed that patients with low fluid balance at 12 h and day 4 had a lower 28-day mortality rate compared with patients with higher fluid balance.
From the above studies, we can see that positive fluid balance at various times from the first 24 hours in resuscitation to cumulative fluid balance on discharge day has the ability to predict mortality risk. Patients with higher cumulative fluid balance have a higher mortality rate than patients with low cumulative fluid balance. This result seems reasonable considering the hemodynamic aspects and organ dysfunction. However, the studies on fluid resuscitation and fluid balance in the above patients with septic shock/shock are still limited. First, most of the studies included in the analysis were retrospective studies. Second, the timing of fluid balance assessment and subsequent follow-up time varied widely between studies. Third, the cutoff points for volume and fluid balance also varied between studies.

CONCLUSION
In patients with septic shock, fluid administration during initial hemodynamic resuscitation remains an important therapeutic challenge. Physicians face many open questions regarding the choice of type, dose, and duration of intravenous fluids.
Four main indications for infusion: resuscitation with hemodynamically stable fluids, intravenous fluids to maintain and replace total body water - electrolytes, drug preparation (antibiotics) and nutrition through a vein. Fluid management strategies in critically ill patients include the "four D's": drug (Drug), duration (Duration), dose (Dosing), and de-escalation.
During the treatment of patients with septic shock, four phases of treatment include: (1) Life-saving phase, the goal of which is the minimum acceptable blood pressure to maintain life; (2) Optimal phase, with the goal of increasing cardiac output in proportion to organ demand; (3) The stabilization phase, focusing mainly on support and prevention of complications; and (4) The de-escalation phase, when it is assessed that the patient should be released from the ICU. Each stage requires a different treatment attitude regarding infusion.

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