Elsevier

Journal of Critical Care

Volume 48, December 2018, Pages 153-159
Journal of Critical Care

Sepsis/Infection
Fluid volume, fluid balance and patient outcome in severe sepsis and septic shock: A systematic review

https://doi.org/10.1016/j.jcrc.2018.08.018Get rights and content

Highlights

  • Patients with a high fluid balance have a 70% increased risk of mortality.

  • Survivors of severe sepsis and/or septic shock received higher fluid volume in the first three hours.

  • Non-survivors received higher volume of fluid in the first 24 h.

  • Low volume resuscitation in the first 24 h had a significant mortality reduction.

Abstract

Purpose

This systematic review and meta-analysis was conducted to evaluate the mortality risk in severe sepsis and septic shock with a low and high fluid volume/balance.

Methods

Cohort studies that compared the mortality of patients with low or high fluid volume/balance were included. Electronic databases: PubMed/Medline PLUS, Embase, Scopus, and Web of Science were searched. Patient mortality at the longest follow-up was the primary outcome measure. The data were analyzed using STATA 14 statistical software.

Results

The current study included fifteen studies with 31,443 severe sepsis and/or septic shock patients. Patients with a high fluid balance have a 70% increased risk of mortality (pooled RR: 1.70; CI: 1.20, 2.41; P = .003). Survivors of severe sepsis and/or septic shock received higher fluid volume in the first three hours. However, fluid volume administered in the first 24 h was higher for non-survivors. Low volume resuscitation in the first 24 h had a significant mortality reduction (P = .02).

Conclusion

High fluid balance from the first 24 h to ICU discharge increases the risk of mortality in severe sepsis and/or septic shock. However, randomized clinical trials should be conducted to resolve the dilemma of fluid resuscitation.

Introduction

Severe sepsis and septic shock are characterized by a deficit in effective vascular volume as a result of vasodilation, vascular leakage and third space loss [1,2]. Therefore, fluid replacement is a core of management. Large fluid resuscitation, 30 mililiter per kilogeram (ml/kg), in the first 6 h was recommended in Early Goal-Directed Therapy [1,3]. However, too much fluid has its own negative consequences. Although positive fluid balance was found to increase mortality and time spent on mechanical ventilation [[4], [5], [6]], too little fluid may also lead to hypoperfusion and aggravate organ dysfunction [7]. The primary goal of resuscitation is to optimize the central venous pressure to 8-12 mmHg for non-ventilated patients and to 12-15 mmHg during mechanical ventilation [1]. Nevertheless, the optimal volume for fluid resuscitation has been debatable.

In spite of progresses made in the development of protocols, severe sepsis and septic shock causes significant morbidity and mortality in the intensive care units [8,9]. Previously, two reviews tried to address the risk of mortality with resuscitation strategy and fluid balance in critically ill patients [10,11]. However, both of these reviews were not specifically designed to deal with severe sepsis and septic shock [10,11]. Therefore, we conducted this systematic review and meta-analysis to evaluate the mortality risk in severe sepsis and septic shock with a low versus high fluid volume/balance.

Section snippets

Methods

This systematic review was done based on PRISMA recommendations [12] and the details of the protocol are registered at PROSPERO (Registration number: CRD42017079560).

Results

The database search revealed of 5191 records of which fifteen articles that fulfilled the inclusion criteria were selected for the current review (Fig. 1). A total of 31,443 severe sepsis and/or septic shock patients were analyzed. The characteristics of the included studies were shown in Table 1.

Discussion

The current review revealed a positive fluid balance recognized at different times from the first 24 h in ICU to cumulative balance at discharge predicts mortality. Patients with a higher fluid balance are 1.70 times as likely to die compared to patients with a lower fluid balance. This result is theoretically appealing when the hemodynamics of septic patients and the associated organ failures are considered. The inflammation-mediated injury on the glycocalyx is responsible for clinical effects

Conclusion

We cautiously conclude that high fluid balance from the first 24 h to ICU discharge increases the risk of mortality in severe sepsis and septic shock. Moreover, high fluid volume resuscitation in the first 3 h and low fluid volume therapy in the first 24 h have survival benefits. We, therefore, strongly recommend that randomized clinical trials should be conducted to determine the cut-off points for fluid volume and fluid balance during fluid therapy in severe sepsis and septic shock management.

Authors' contributions

BMT and MD conceptualize the study, conducted the article review, do the analysis, interpreted the results, and drafted and finalized the manuscript. AK and MM participated in the study designed, conducted the article review and revised the manuscript. BMT, MD, AK and MM revised the manuscript and approved the final manuscript.

Competing interests

The authors declared that they have no conflict of interest.

Funding

Not applicable.

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