Post Resusicitation Fluid Boluses in Severe Sepsis or Septic Shock

Abstract

Administration of fluid boluses (FBs) beyond initial resuscitation in patients with severe sepsis is common and may contribute to positive fluid balance. Little is known regarding the efficacy and risk profile of this strategy. To estimate the prevalence and efficacy of FBs after initial resuscitation in septic patients. In a prospective study, patients with severe sepsis/septic shock were recruited after initial resuscitation and followed up for 3 days. Number, types, and volumes of FBs; resuscitation goals; and their perceived success rates were recorded. Data are presented as median (interquartile range). Over a 1-year period, 50 patients were recruited, 47 (94%) of them received FBs, with a total of 184 FBs (3 [2-5] per patient) administered over 72 h. On day 1, 2 (1-3) FBs, totaling 750 mL (500-1,720 mL), were administered, which comprised 52.4% (22.1%-124.2%) of the fluid balance. Low blood pressure (mean arterial pressure [MAP]) (76.0%) and increased vasopressor requirement (60.3%) were the two most common indications for FBs. Low filling pressure (70.9%) and clinical signs (79.4%) were perceived as the most successful indications. One hour after these FBs, there was a small increase in MAP (P < 0.01) and central venous pressure (P < 0.01); however, there was also concomitant increase in noradrenaline administered. There was a significant decrease in PaO2/FIO2 ratio, hemoglobin, and temperature, whereas urine output remained unchanged. Factors (Exp[b] [SE], P) (R = 0.296) that affected the increase in MAP were baseline MAP (-0.49 [0.057], P < 0.001) and amount of these FBs (-0.05 [0.01], P = 0.001). Cumulative fluid balance had a weak correlation with delta sequential organ failure assessment score (r = 0.32, P = 0.001) and lung injury score (r = 0.13, P = 0.02) and negative correlation with PaO2/FIO2 ratio (r = -0.28, P = 0.001). Postresuscitation FBs are common in septic patients, meet limited success, and may be harmful.