Comparison of two fluid-management strategies in acute lung injury

Abstract

Conclusion: A conservative strategy of fluid management in patients with acute lung injury shortens duration of mechanical ventilation without increasing nonpulmonary organ failure. Summary: There is debate about optimal fluid management of patients with acute lung injury. Limiting fluids or inducing diuresis may improve lung function but at the expense of impaired perfusion of other organs. In this randomized study, a conservative or liberal strategy of fluid management in patients with acute lung injuries was used. The protocol was applied for 7 days in 1000 patients with acute lung injury. The primary end point was death at 60 days. Ventilator-free days and organ-failure-free days and measures of lung physiology were secondary end points. There was no difference between the two groups in the primary end point at 60 days. In the conservative strategy group, 25.5% of the patients died, and 28.4% of the patients died in the liberal strategy group (P < .30; 95% confidence interval for a difference, −2.6% to 8.4%). The cumulative fluid balance in the first 7 days in the conservative strategy group was −136 ± 491 mL. The cumulative fluid balance in the first 7 days in the liberal strategy group was +6992 ± 502 mL (P < .001). The conservative strategy group had an improved oxygenation index, lung injury score, and an increased number of ventilator-free days (14.6 ± 0.5 vs 12.1 ± 0.5, P < .001) vs the liberal strategy group. The conservative strategy group also had more days not spent in the intensive care unit (13.4 ± 0.4 vs 11.2 ± 0.4, P < .001) during the first 28 days. There was no difference between the conservative and liberal strategy groups with respect to prevalence of shock during the course of the study or the use of dialysis during the first 60 days (10% vs 14%, P < .06). Comment: A conservative fluid management strategy did not decrease death at 60 days vs a liberal fluid management strategy in patients with acute respiratory distress syndrome. However, intensive care unit days were reduced and lung function was improved with the conservative fluid management posture. The results are consistent with other recent reports suggesting improved overall patient outcome with conservative fluid management in acute respiratory distress syndrome. The days of essentially drowning patients with acute lung injury to preserve distal organ perfusion should be over.