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

Abstract

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. 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. Day1 fluid was grouped into categories 1L wide,starting with 1-1.99L up to ≥9L,to examine the effect of day1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5L of fluids on day1, 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 (1-5L day1 fluids) and the high fluid range (5 to ≥9L day1 fluids) categories,using weighted linear regression controlling for the effects of sample size and variation within the day1 fluid category. Day1 fluid administration averaged 4.4L being lowest in the group with no mechanical ventilation and no shock (3.6L) and highest (5.4L) in the group receiving mechanical ventilation and in shock. The administration of day1 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 9.1days, respectively. In the entire cohort, low volume resuscitation (1-4.99L) 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 ≥9L),the mortality increased by 2.3% (95% CI 2.0, 2.5%; p=0.0003) for each additional litre above 5L. Total hospital cost increased by $999 for each litre of fluid above 5L (adjusted R 2=92.7%, p=0.005). 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 5L of fluid during the first ICU day is associated with a significantly increased risk of death and significantly higherhospital costs.