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Evaluation and Predictors of Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock

Kuttab, Hani I. MD1; Lykins, Joseph D. MD2; Hughes, Michelle D. MD1; Wroblewski, Kristen MS3; Keast, Eric P. MD1; Kukoyi, Omobolawa MD, MPH1; Kopec, Jason A. MD1; Hall, Stephen MS1; Ward, Michael A. MD4

doi: 10.1097/CCM.0000000000003960
Clinical Investigations
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Objectives: Rapid fluid resuscitation has become standard in sepsis care, despite “low-quality” evidence and absence of guidelines for populations “at risk” for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived “at-risk” volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume “overload” by bedside examination.

Design: Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics.

Setting: Urban, tertiary care center between January 1, 2014, and May 31, 2017.

Patients: Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock.

Interventions: Administration of IV fluids by bolus.

Measurements and Main Results: In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46–0.83), male (odds ratio, 0.66; CI, 0.49–0.87), obese (odds ratio, 0.18; CI, 0.13–0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13–0.40), heart failure (odds ratio, 0.42; CI, 0.29–0.60), or documented volume “overload” (odds ratio, 0.30; CI, 0.20–0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03–2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02–1.99), and increased ICU stay (~2 d) (β = 2.0; CI, 0.5–3.6), without differential effects for “at-risk” groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p < 0.05).

Conclusions: Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation.

1Section of Emergency Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL.

2Department of Emergency Medicine and Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA.

3Department of Public Health Sciences, University of Chicago, Chicago, IL.

4Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI.

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Supported, in part, by grant from the National Center for Advancing Translational Sciences of the National Institutes of Health through Grant Number 5UL1TR002389-02 that funds the Institute for Translational Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: maward@medicine.wisc.edu

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