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Cited by 362Sepsis Diagnosis and TreatmentHemodynamic Monitoring and TherapyAbdominal Surgery and Complications

Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database

Marik, Paul E., Linde-Zwirble, Walter T., Bittner, Edward A., Sahatjian, Jennifer, Hansell, Douglas·2017·Intensive Care Medicine
DOI 10.1007/s00134-016-4675-y
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Abstract

Purpose The optimal strategy of fluid resuscitation in the early hours of severe sepsis and septic shock is controversial, with both an aggressive and conservative approach being recommended.Methods We used the 2013 Premier Hospital Discharge database to analyse the administration of fluids on the first ICU day, in 23,513 patients with severe sepsis and septic shock, who were admitted to an ICU from the emergency department. Day 1 fluid was grouped into categories 1 L wide, starting with 1-1.99 L up to ≥9 L, to examine the effect of day 1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5 L of fluids on day 1, using patient age and acute conditions present on admission. Patients were grouped by the requirement for mechanical ventilation and the presence or absence of shock. We assessed trends in the difference between actual and expected mortality, in the low fluid range (1-5 L day 1 fluids) and the high fluid range (5 to ≥9 L day 1 fluids) categories, using weighted linear regression controlling for the effects of sample size and variation within the day 1 fluid category.Results Day 1 fluid administration averaged 4.4 L being lowest in the group with no mechanical ventilation and no shock (3.6 L) and highest (5.4 L) in the group receiving mechanical ventilation and in shock. The administration of day 1 fluids was remarkably consistent on the basis of hospital size, teaching status, rural/urban location, and region of the country. The hospital mortality in the entire cohort was 25.8%, with a mean ICU and hospital length of stay of 5.1 and 9.1 days, respectively. In the entire cohort, low volume resuscitation (1-4.99 L) was associated with a small but significant reduction in mortality, of -0.7% per litre (95% CI -1.0%, -0.4%; p = 0.02). However, in patients receiving high volume resuscitation (5 to ≥9 L), the mortality increased by 2.3% (95% CI 2.0, 2.5%; p = 0.0003) for each additional litre above 5 L. Total hospital cost increased by $999 for each litre of fluid above 5 L (adjusted R 2 = 92.7%, p = 0.005).Conclusion The mean amount of fluid administered to patients with severe sepsis and septic shock in the USA during the first ICU day is less than that recommended by the Surviving Sepsis Campaign guidelines. The administration of more than 5 L of fluid during the first ICU day is associated with a significantly increased risk of death and significantly higher hospital costs.

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Crossref · 10.1007/s00134-016-4675-y

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  • Observational studies have shown an association between high-volume fluid resuscitation and increased mortality, but these studies are likely affected by unmeasured variables such as administering higher amounts of fluids to sicker patients.

    “Data from observational studies have shown an association of high-volume fluid resuscitation and increased mortality, but these studies are likely affected by unmeasured variables (i.e. the administration of higher amounts of fluids to sicker patients) [395, 396].”

    From Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 (2021) · cites this paper as [396]

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Authors
Marik, P. E., Linde-Zwirble, W. T., Bittner, E. A., Sahatjian, J., & Hansell, D.
Affiliations
  • Eastern Virginia Medical School (US)
  • Massachusetts General Hospital (US)
Corresponding author
Marik, Paul E.
ORCID
Venue
Intensive Care Medicine
Publisher
Springer Science and Business Media LLC
Published
2017-01-27
Volume
43
Issue
5
Pages
625-632
ISSN
  • 0342-4642 (ISSN-L)
  • 1432-1238
DOI
10.1007/s00134-016-4675-y
OpenAlex
W2580396496
Cited by
362
References
38
Citations by year
2026: 13 · 2025: 27 · 2024: 29 · 2023: 43 · 2022: 56 · 2021: 43 · 2020: 55 · 2019: 36 · 2018: 35 · 2017: 23 · 2016: 1
FWCI
32.14
Type
journal article
Language
en
Open access
closed
Licence
Locations
  • Intensive Care Medicine (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
  • Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Abdominal Surgery and Complications
Keywords
fluid resuscitation, severe sepsis, septic shock, in-hospital mortality, mechanical ventilation, hospital costs, ICU length of stay, early sepsis management
MeSH terms
Aged, Female, Fluid Therapy, Hospitals, Humans, Intensive Care Units, Length of Stay, Male, Outcome and Process Assessment, Health Care, Respiration, Artificial, Risk, Severity of Illness Index, Shock, Septic, Time Factors, United States, Cohort Studies, Linear Models, Databases, Factual, Hospital Mortality, Sepsis

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