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Cited by 1,517Sepsis Diagnosis and TreatmentHemodynamic Monitoring and TherapyAbdominal Surgery and Complications

Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality*

Boyd, John H., Forbes, Jason, Nakada, Taka-aki, Walley, Keith R., Russell, James A.·2011·Critical Care Medicine
DOI 10.1097/ccm.0b013e3181feeb15
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Abstract

OBJECTIVE: To determine whether central venous pressure and fluid balance after resuscitation for septic shock are associated with mortality. DESIGN: We conducted a retrospective review of the use of intravenous fluids during the first 4 days of care. SETTING: Multicenter randomized controlled trial. PATIENTS: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who were receiving a minimum of 5 μg of norepinephrine per minute. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on net fluid balance, we determined whether one's fluid balance quartile was correlated with 28-day mortality. We also analyzed whether fluid balance was predictive of central venous pressure and furthermore whether a guideline-recommended central venous pressure of 8-12 mm Hg yielded a mortality advantage. At enrollment, which occurred on average 12 hrs after presentation, the average fluid balance was +4.2 L. By day 4, the cumulative average fluid balance was +11 L. After correcting for age and Acute Physiology and Chronic Health Evaluation II score, a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased mortality. Central venous pressure was correlated with fluid balance at 12 hrs, whereas on days 1-4, there was no significant correlation. At 12 hrs, patients with central venous pressure <8 mm Hg had the lowest mortality rate followed by those with central venous pressure 8-12 mm Hg. The highest mortality rate was observed in those with central venous pressure >12 mm Hg. Contrary to the overall effect, patients whose central venous pressure was <8 mm Hg had improved survival with a more positive fluid balance. CONCLUSIONS: A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased risk of mortality in septic shock. Central venous pressure may be used to gauge fluid balance ≤ 12 hrs into septic shock but becomes an unreliable marker of fluid balance thereafter. Optimal survival in the VASST study occurred with a positive fluid balance of approximately 3 L at 12 hrs.

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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 [395]

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Authors
Boyd, J. H., Forbes, J., Nakada, T.-A., Walley, K. R., & Russell, J. A.
Affiliations
University of British Columbia (CA)
ORCID
Venue
Critical Care Medicine
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2011-02
Volume
39
Issue
2
Pages
259-265
ISSN
0090-3493 (ISSN-L)
DOI
10.1097/ccm.0b013e3181feeb15
OpenAlex
W2097786723
Cited by
1,517
References
23
Citations by year
2026: 54 · 2025: 61 · 2024: 84 · 2023: 99 · 2022: 88 · 2021: 115 · 2020: 131 · 2019: 105 · 2018: 108 · 2017: 114 · 2016: 137 · 2015: 113 · 2014: 116 · 2013: 102 · 2012: 45
FWCI
39.56
Type
journal article
Language
en
Open access
closed
Locations
  • Critical Care Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
Canadian Institutes of Health Research
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
septic shock, fluid resuscitation, fluid balance, central venous pressure, mortality, norepinephrine, vasopressin, intravenous fluids
MeSH terms
Cause of Death, Central Venous Pressure, Critical Care, Female, Fluid Therapy, Humans, Intensive Care Units, Male, Norepinephrine, Predictive Value of Tests, Resuscitation, Retrospective Studies, Shock, Septic, Time Factors, Water-Electrolyte Balance, Cohort Studies, Survival Analysis, Hospital Mortality, Risk Assessment, APACHE

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