Clinical Pearls & Morning Reports
Meyhoff et al. conducted a trial that compared the effects of intravenous fluid restriction with those of standard intravenous fluid therapy in adult intensive care unit (ICU) patients with septic shock. Read the NEJM Original Article here.
Q: What are some of the Surviving Sepsis Campaign guidelines?
A: Septic shock is a leading cause of death worldwide and improvements in care are warranted. To improve circulation in affected patients, the Surviving Sepsis Campaign guidelines suggest an initial fixed volume of 30 ml per kilogram of body weight, although the level of certainty for this evidence is low. Owing to insufficient evidence, no recommendation is currently given with regard to the use of restrictive or liberal fluid strategies in patients who still have signs of hypoperfusion after initial resuscitation measures have been taken.
Q: Why is the use of higher volumes of intravenous fluid for patients with septic shock a concern?
A: The use of higher volumes of intravenous fluid has been associated with harm in observational studies and in randomized trials involving patients with sepsis and septic shock. The adverse effects in these patients include worsening of kidney injury, respiratory failure, and higher risk of death. However, a recent systematic review of meta-analyses of randomized trials that assessed lower intravenous fluid volumes as compared with higher intravenous fluid volumes in adults with sepsis showed that the quantity and quality of evidence was very low.
A: During the 90-day trial period, the median cumulative volume of intravenous fluids administered in the ICU, excluding fluids administered with medication and nutrition, was 1798 ml in the restrictive-fluid group and 3811 ml in the standard-fluid group. The median cumulative volume of all fluids given in the ICU was 10,433 ml in the restrictive-fluid group and 12,747 ml in the standard-fluid group. There were no significant differences in 90-day mortality or serious adverse events among the patients who received restricted fluid therapy and those who received standard therapy. At 90 days after randomization, death had occurred in 323 of 764 patients (42.3%) in the restrictive-fluid group and 329 of 781 patients (42.1%) in the standard-fluid group (adjusted absolute difference, 0.1 percentage points; 95% confidence interval [CI], –4.7 to 4.9; P=0.96). The number of days alive without life support and days alive and out of hospital at 90 days were similar in the two groups.
A: The strengths of the trial include the high completeness of the data and the enrollment of patients who had characteristics and outcomes that were similar to those observed in other trials involving patients with septic shock. Fluid volumes in the standard-fluid group were within the ranges of those observed in recent trials of fluid types used to treat patients in the ICU. It is reasonable to assume that the results are generalizable, at least within Europe, because patients were recruited from 31 university and non-university ICUs in eight European countries, and most patients who were screened were included in the trial. Among the limitations of the trial was that patients and personnel were aware of group assignment. Different results may be obtained in settings where more intravenous fluid is used in standard care.