Chest
Volume 159, Issue 4, April 2021, Pages 1437-1444
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Critical Care: Original Research
Sepsis, the Administration of IV Fluids, and Respiratory Failure: A Retrospective Analysis—SAIFR Study

https://doi.org/10.1016/j.chest.2020.10.078Get rights and content

Background

Although resuscitation with IV fluids is the cornerstone of sepsis management, consensus regarding their association with improvement in clinical outcomes is lacking.

Research Question

Is there a difference in the incidence of respiratory failure in patients with sepsis who received guideline-recommended initial IV fluid bolus of 30 mL/kg or more conservative resuscitation of less than 30 mL/kg?

Study Design and Methods

This was a retrospective analysis of prospectively collected clinical data conducted at an academic medical center in Omaha, Nebraska. We abstracted data from 214 patients with sepsis admitted to a single academic medical center between June 2017 and June 2018. Patients were stratified by receipt of guideline-recommended fluid bolus. The primary outcome was respiratory failure defined as an increase in oxygen flow rate or more intense oxygenation and ventilation support; oxygen requirement and volume were measured at admission, 6 h, 12 h, 24 h, and at discharge. Subgroup analyses were conducted in high-risk patients with congestive heart failure (CHF) as well as those with chronic kidney disease (CKD).

Results

A total of 62 patients (29.0%) received appropriate bolus treatment. The overall rate of respiratory failure was not statistically different between patients who received appropriate bolus or did not (40.3% vs 36.8%; P = .634). Likewise, no differences were observed in time to respiratory failure (P = .645) or risk of respiratory failure (adjusted hazard ratio, 1.1 [95% CI, 0.7-1.7]; P = .774). Results were similar within the high-risk CHF and CKD subgroups.

Interpretation

In this single-center retrospective study, we found that by broadly defining respiratory failure as an increase in oxygen requirements, a conservative initial IV fluid resuscitation strategy did not correlate with decreased rates of hypoxemic respiratory failure.

Section snippets

Study Design and Patients

This study was considered exempt research by the Creighton University Institutional Review Board (IRBNet Identification: 1304684-2). We retrospectively identified all hospital admissions between June 2017 and June 2018 to CHI Health Creighton University Medical Center—Bergan Mercy, Omaha, NE, that included an International Classification of Diseases, Ninth or Tenth Revision, diagnosis code for sepsis and septic shock and who qualified for the 30-mL/kg fluid bolus as set forth by the Centers for

Results

A total of 244 eligible admissions were identified in which the patient was 19 years of age or older and met inclusion criteria. We excluded patients missing clinical characteristics (n = 13 [5.3%]), any subsequent admissions during the study period (n = 6 [2.5%]), and patients who were intubated before the initial fluid bolus administration (n = 12 [4.9%]). Our final sample consisted of 214 unique patients, of whom 184 (86.0%) had unspecified sepsis cause (e-Tables 1, 2).

Overall, patients

Discussion

Early, aggressive IV fluid administration has been the cornerstone of sepsis management since the inaugural publication of the SSC guidelines.16 This practice is embraced so widely that compliance with the SSC bundle—including a 30-mL/kg bolus in the first 3 h—is a quality measure and noncompliance is reimbursed punitively by the Centers for Medicare and Medicaid Services,9 although this is a point of contention among clinicians. First, this is because no definitive evidence has established

Acknowledgments

Author contributions: N. J. is the guarantor of the content of the manuscript, including the data and analysis. All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. N. J., L. E. M., R. W. W., R. W. P., T. M. P., K. F. K., J. C. M., E. D. D., A. A. B., A. J. F., D. R. M., and M. A. M. contributed substantially to the study design; data collection,

References (23)

  • A randomized trial of protocol-based care for early septic shock

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    (2014)
  • Cited by (5)

    • Do septic patients with reduced left ventricular ejection fraction require a low-volume resuscitative strategy?

      2022, American Journal of Emergency Medicine
      Citation Excerpt :

      These results suggest that a more conservative approach to IVF administration, with the goal of reducing the likelihood of volume overload, should not be solely based on the presence of rLVEF. Our results are consistent with those of prior studies which have found no relationship between adverse respiratory outcomes and IVF volume in patients with rLVEF [7-9]. Our study, however, utilized LVEF assessed at the time of presentation rather than historical report—a critically important difference given that LVEF is not static.

    FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

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