Elsevier

Journal of Critical Care

Volume 26, Issue 6, December 2011, Pages 613-619
Journal of Critical Care

Outcomes
Interaction between fluid balance and disease severity on patient outcome in the critically ill,☆☆,

https://doi.org/10.1016/j.jcrc.2011.02.008Get rights and content

Abstract

Purpose

There is evidence in literature regarding the benefits of immediate aggressive fluid resuscitation together with conservative fluid management approach after initial stabilization. This retrospective study assesses the relationship between fluid balance during intensive care unit (ICU) stay and outcomes among general critically ill patients. In addition, we also aim to see the effect of fluid gain among patients with different disease severity.

Methods

A total of 639 patients admitted into ICU who stayed for 3 days or more were evaluated. Fluid balances during ICU stay were recorded. A logistic regression analysis was performed to identify significant factors associated with hospital mortality.

Results

Acute Physiology and Chronic Health Evaluation IV predicted risk of death, fluid balance on the second plus third ICU days, and total fluid balance during ICU stay were positively associated with hospital death. Significant positive fluid balance on first ICU day, in contrast, was negatively associated with hospital mortality. The positive correlation between standardized mortality ratio (Acute Physiology and Chronic Health Evaluation IV) and fluid gain on the second plus third ICU days increases with disease severity.

Conclusion

Early adequate fluid resuscitation together with conservative late fluid management may provide better patient outcomes. The effect of fluid management strategy on patient outcome may depend on the underlying disease severity.

Introduction

Fluid therapy is a fundamental component of treatment in critically ill patients. Interestingly, fluid balance has recently emerged as a potential biomarker for survival in critically ill patients [1]. Appropriate initial fluid administration is vital for those critically ill. In patient with severe sepsis and septic shock, early goal–directed therapy (EGDT) with aggressive initial fluid resuscitation clearly improved clinical outcomes [2]. A similar study published in 2009 also reported the significant benefits of adequate initial fluid resuscitation within 6 hours after the onset of therapy with vasopressors and vice versa for groups receiving conservative late fluid treatment [3]. The Protocolized Care for Early Septic Shock study (NCT00510835) is a multicenter study currently being conducted in the United Status with its purpose to confirm the beneficial effects of EGDT.

However, over the last decade, multiple clinical studies documented an association of a positive fluid balance with morbidity and mortality. There is clear evidence suggesting that fluid overload may be detrimental in many conditions. Brandstrup and colleagues [4] found that restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduced postoperative complications after elective colorectal resection. In acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), Sakr et al [5] found that positive fluid balance was associated with worse intensive care unit (ICU) outcome, whereas Wiedemann [6] showed that conservative strategy of fluid management improved lung function and shortened the duration of mechanical ventilation and intensive care. In severe sepsis, fluid gain was among the strongest prognostic factors for patient's mortality [7]. Upadya and colleagues [8] also found that positive fluid balance (in 24, 48, and 72 hours and cumulatively from the onset of hospital admission) was associated with ventilator weaning failure. It seems that a threshold in time may exist where aggressive fluid therapy would be detrimental to a patient's survival.

The main purpose of this retrospective cohort study is to assess the relationship between fluid balance during ICU stay and outcomes among general critically ill patients. In addition, this study also aims to see the effect of fluid gain among patients with different disease severity.

Section snippets

Methods

This study was approved by the hospital ethics committee and registered with Hong Kong University Clinical Trial Register (ref: HKCTR-1135). Written informed consent was waived.

This study was a retrospective, single-centered, cohort study conducted at the ICU of Pamela Youde Nethersole Eastern Hospital, a 2300-bed acute care tertiary hospital that provides comprehensive care except cardiothoracic surgery, transplant surgery, and burns. The ICU is a 20-bed closed mixed medical-surgical unit with

Results

Among 1386 patients admitted into our ICU in 2009, only 639 patients stayed in ICU for 3 or more days. Table 1 shows the baseline characteristics of patients stratified based on their hospital outcome. Hospital nonsurvivors were older, more likely to be emergency cases on admission to ICU, had higher APACHE IV scores, had longer ICU length of stay (LOS), and had significantly more fluid gain. In the logistic regression analysis (Table 2; Hosmer and Lemeshow goodness-of-fit test χ2 = 4.67, df =

Discussion

The findings from this observational study demonstrate the impact of fluid gain on the survival of critically ill patients. Fluid balance on the second plus third ICU days and total fluid gain during ICU stay were positively associated with hospital mortality, whereas positive fluid balance on the first ICU day gave reversed findings. Also, the importance of fluid gain on patient's outcome correlated with disease severity.

Rivers and colleagues [2] evidently showed the importance of initial

References (18)

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Financial support/ funding: None.

☆☆

Declaration of interests: Nil for all authors.

Trial registration: HKU clinical trial register (www.HKClinicalTrials.com, Ref: HKCTR-1135).

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