Fluid Balance Group Research Articles

Preload responsiveness–guided fluid removal in mechanically ventilated patients with fluid overload: A comprehensive clinical–physiological study

This study investigated fluid removal strategies for critically ill patients with fluid overload on mechanical ventilation. Traditionally, a negative fluid balance (FB) is aimed for. However, this approach can have drawbacks. Here, we compared a new approach, namely removing fluids until patients become fluid responsive (FR) to the traditional empiric negative balance approach.Twelve patients were placed in each group (n = 24). FR assessment was performed using passive leg raising (PLR). Both groups maintained stable blood pressure and heart function during fluid management. Notably, the FR group weaned from the ventilator significantly faster than negative FB group (both for a spontaneous breathing trial (14 h vs. 36 h, p = 0.031) and extubation (26 h vs. 57 h, p = 0.007); the difference in total ventilator time wasn't statistically significant (49 h vs. 62 h, p = 0.065). Additionally, FR group avoided metabolic problems like secondary alkalosis and potential hypokalemia seen in the negative FB group.FR-guided fluid-removal in fluid overloaded mechanically ventilated patients was a feasible, safe, and maybe superior strategy in facilitating weaning and disconnection from mechanical ventilation than negative FB-driven fluid removal. FR is a safe endpoint for optimizing cardiac function and preventing adverse consequences during fluid removal.

Coexistence of a fluid responsive state and venous congestion signals in critically ill patients: a multicenter observational proof-of-concept study

BackgroundCurrent recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission.MethodsMulticenter, prospective cross-sectional observational study conducted in three medical–surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected.ResultsNinety patients were included. Median age was 63 [45–71] years old, and median SOFA score was 9 [7–11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR−). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR− groups (53% vs. 57%, p = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals.ConclusionsVenous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.

Time-related association between fluid balance and prognosis in sepsis patients: a cohort study based on MIMIC-IV database

To investigate time-related association between fluid balance and prognosis in sepsis patients. A retrospective cohort study was conducted based on the data of sepsis patients in the Medical Information Database for Intensive Care-IV 2.0 (MIMIC-IV 2.0) from 2008 to 2019. Sepsis patients aged ≥ 18 years who were admitted to intensive care unit (ICU) for at least 2 days were included. The daily fluid balance and cumulative fluid balance (CFB) were calculated from days 1 to 7 after ICU admission. According to CFB,the patients were divided into negative fluid balance group (CFB% < 0%), fluid balance group (0% ≤ CFB% ≤ 10%), and fluid overload group (CFB% > 10%). In-hospital mortality was the primary outcome. Multifactorial Logistic regression was used to analyze time-related association between different CFB and the risk of in-hospital mortality in patients with sepsis during 7 days after ICU admission. In addition, subgroup analysis was performed on patients with septic shock and patients with sepsis who stayed in the ICU for 7 days or longer. A total of 11 437 patients with sepsis were included, of which 6 595 were male and 4 842 were female. The mean age was (64.4±16.4) years. A total of 10 253 patients (89.6%) survived and 1 184 patients (10.4%) died during hospitalization. Compared with the survival group, patients in the death group were older, lighter, had higher sequential organ failure assessment (SOFA), simplified acute physiology score II (SAPS II), longer ICU stay, higher incidence of septic shock, and higher proportion of invasive mechanical ventilation, renal replacement therapy (RRT) and vasoactive drugs. In terms of comorbidities, congestive heart failure, renal disease, liver disease, and malignancy were more common in the death group. The death group had a higher daily fluid balance than the survival group during 7 days after ICU admission, the CFB in the two groups gradually increased with length of ICU stay. After adjusting variables such as age, gender, race, SOFA score, SAPS II score, comorbidities, and the use of invasive mechanical ventilation, RRT and vasoactive drugs, multivariate Logistic regression analysis showed that fluid overload on day 1 after ICU admission was a protective factor for the reduced risk of in-hospital mortality in sepsis patients [odds ratio (OR) = 0.74, 95% confidence interval (95%CI) was 0.64-0.86, P = 0.001]. However, fluid overload on day 3 was a risk factor for in-hospital mortality in sepsis patients (OR = 1.70, 95%CI was 1.47-1.97, P < 0.001) and the risk of in-hospital mortality was significantly increased from day 4 to day 7. Furthermore, the same results were obtained in patients with septic shock and sepsis patients who stayed in the ICU for 7 days or longer. Fluid overload on day 1 was associated with reduced in-hospital mortality. However, from the third day, fluid overload increases the risk of in-hospital mortality. Thus, managing fluid balance at different times may improve prognosis.

Impact of Negative Fluid Balance on Mortality and Outcome of Patients with Confirmed COVID-19.

Maintaining the proper fluid balance is a fundamental step in the management of hospitalized patients. The current study evaluated the impact of negative fluid balance on outcomes of patients with confirmed COVID-19. We considered the negative fluid balance as a higher output fluid compared to the input fluid. The fluid balance was categorized into four groups (group 4: -850 to -500 ml/day; group 3: -499 to -200 ml/day, group 2: -199 to 0 ml/day, and group 1 : 1 to 1000 ml/day) and included ordinally in the model. The outcomes were all-cause mortality, length of hospitalization, and improvement in oxygen saturation. The fluid balance differed significantly among nonsurvivors and survivors (MD: -317.93, 95% CI: -410.21, -225.69, and p < 0.001). After adjusting for potential confounders, there was a significantly lower frequency of mortality in patients with negative fluid balance compared to the controls (aRR: 0.69, 95% CI: 0.57, 0.84, and p < 0.001). Similarly, the length of hospitalization was significantly shorter in the negative fluid balance group in comparison to the control group (aMD: -1.01, 95% CI: -1.74, -0.28, and p=0.006). We determined that the negative fluid balance was associated with favorable outcomes in COVID-19 patients. The negative fluid balance was associated with the reduced mortality rate and length of hospitalization as well as improvement in oxygen saturation. Moreover, the NT-proBNP >781 pg/mL and fluid balance >-430 mL might be the predictors for positive fluid balance and mortality, respectively.

Early Fluid Balance Is Associated with 90-Day Mortality in Patients Receiving Continuous Renal Replacement Therapy.

Continuous renal replacement therapy (CRRT) is widely used to control fluid balance, but the optimal fluid balance to improve the prognosis of patients remains debated. Appropriate fluid management may depend on hemodynamic status. We investigated the association between 90-day mortality and fluid balance/mean arterial pressure (MAP) in patients receiving CRRT. This single-center retrospective study was conducted between May 2018 and March 2021. Based on the cumulative fluid balance at 72 h after initiation of CRRT, the cases were divided into negative (< 0 mL) and positive (> 0 mL) fluid balance groups. Ninety-day mortality was higher in the positive fluid balance group (p=0.009). At 4 h before and after CRRT initiation, the mean MAP was lower in the positive fluid balance group (p<0.05). After multivariate cox adjustment, 72-h positive fluid balance was independently associated with 90-day mortality (p=0.004). In addition, the cumulative fluid balance was associated with 90-day mortality (p<0.05) in cases without shock, high APACHE II score, sepsis, dialysis dependence, or vasopressor use. A 72-h positive fluid balance was associated with 90-day mortality in patients receiving CRRT.

Impact of Fluid Balance on Intensive Care Unit Length of Stay in Critically Ill Trauma Patients.

There is significant data in the medical and surgical literature supporting the correlations between positive volume balance and negative outcomes such as AKI, prolonged mechanical ventilation, intensive care unit and hospital length of stay and increased mortality. This single-center, retrospective chart review included adult patients identified from a Trauma Registry database. The primary outcome was the total ICU LOS. Secondary outcomes include hospital LOS, ventilator-free days, incidence of compartment syndrome, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT), and days of vasopressor therapy. In general, baseline characteristics were similar between groups with the exception of mechanism of injury, FAST exam, and disposition from the ED. The ICU LOS was shortest in the negative fluid balance and longest in the positive fluid balance group (4 days vs 6 days, P = .001). Hospital LOS was also shorter in the negative balance group than that of the positive balance group (7 days vs 12 days, P < .001). More patients in the positive balance group experienced acute respiratory distress syndrome compared to the negative balance group (6.3% vs 0%, P = .004). There was no significant difference in the incidence of renal replacement therapy, days of vasopressor therapy, or ventilator-free days. A negative fluid balance at seventy-two hours was associated with a shorter ICU and hospital LOS in critically ill trauma patients. Our observed correlation between positive volume balance and total ICU days merits further exploration with prospective, comparative studies of lower volume resuscitation to key physiologic endpoints compared with routine standard of care.

Association between fluid balance and mortality for heart failure and sepsis: a propensity score-matching analysis

BackgroundFluid resuscitation is necessary to correct the sepsis-induced hypoperfusion, which is contradictory to the treatment of heart failure. This study explored the association between fluid balance (FB) of the first 24 h after ICU admission and mortality in critically ill patients with heart failure and sepsis.MethodsData were extracted from the Medical Information Mart for Intensive Care database. The locally weighted scatterplot smoothing (Lowess) method was used to demonstrate the relationship between FB and in-hospital mortality. Groups were divided into high FB (≥ 55.85 ml/kg) and low FB (< 55.85 ml/kg) according to the cut-off value of FB using Receiver operating characteristic analysis and Youden index method. The primary outcome was in-hospital mortality. Subgroup analyses, multivariable logistic regression analyses, and Kaplan-Meier curves were used to detect the association and survival difference between groups. Inverse probability treatment weighting (IPTW) and propensity score matching (PSM) were performed to minimize the bias of confounding factors and facilitate the comparability between groups.ResultsA total of 936 patients were included. The Lowess curve showed an approximate positive linear relationship for FB and in-hospital mortality. In the multivariable logistic regression adjusted model, high FB showed strong associations with in-hospital mortality (OR 2.53, 95% CI 1.60–3.99, p < 0.001) as compared to the low FB group. In IPTW and PSM models, high FB consistently showed higher in-hospital mortality (IPTW model: OR 1.94, 95% CI 1.52–2.49, p < 0.001; PSM model: OR 2.93, 95% CI 1.75–4.90, p < 0.001) and 30-day mortality (IPTW model: OR 1.65, 95% CI 1.29–2.10, p < 0.001; PSM model: OR 2.50, 95% CI 1.51–4.15, p < 0.001), compared with the low FB group.ConclusionFor critically ill patients with heart failure and sepsis, high FB within the first 24 h after ICU admission could serve as an independent risk factor for in-hospital mortality and 30-day mortality. The avoidance of fluid overload exerts important effects on reducing mortality in such patients.

Clinical effect of fluid resuscitation guided by intra-abdominal pressure and oxygenation index for severe acute pancreatitis patients

To investigate the effect of the liquid resuscitation therapy strategy using intra-abdominal pressure (IAP) and oxygenation index (PaO2/FiO2) as the end point in patients with severe acute pancreatitis (SAP). A retrospective study was performed, including 84 patients with SAP in emergency intensive care unit of Qingzhou Hospital Affiliated to Shandong First Medical University from January 2018 to August 2021. According to the status of fluid balance at admission, all patients were divided into the positive fluid balance group (43 cases) and the negative fluid balance group (41 cases). The clinical data including gender, age, etiology, underlying disease, acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) of all patients were collected. Fluid balance, PaO2/FiO2, IAP, compliance rate, new mechanical ventilation rate and overall hospital stay of 1 week after admission were recorded and compared between the two groups. After 72 hours of treatment, the cumulative fluid balance was (5 219.5±1 038.4) mL in the positive fluid balance group; IAP was higher than that before treatment [mmHg (1 mmHg ≈ 0.133 kPa): 11.9±2.0 vs. 11.7±2.1], but no significant difference was found (P > 0.05); PaO2/FiO2 was significantly higher than that before treatment (mmHg: 299.8±51.4 vs. 220.5±50.4, P < 0.05). After 72 hours of treatment, the cumulative fluid balance in negative fluid balance group was (-3 542.4±1 310.6) mL; IAP was significantly lower than before treatment (mmHg: 11.4±1.8 vs. 15.2±1.9, P < 0.05); PaO2/FiO2 was significantly higher than that before treatment (mmHg: 309.9±50.9 vs. 215.4±49.7, P < 0.05). In the fluid resuscitation goals, after 72 hours of treatment, the compliance rate in the negative fluid balance group was significantly higher than that in the positive fluid balance group [82.93% (34/41) vs. 62.79% (27/43), P < 0.05]; 1 week after admission, the new mechanical ventilation rate in the negative fluid balance group was significantly lower than that in the positive fluid balance group [21.95% (9/41) vs. 41.86% (18/43), P < 0.05]; however, there was no significant difference in overall hospital stay between the two groups (days: 41.2±10.9 vs. 39.1±11.5, P > 0.05). After treatment, 70 patients survived and 14 patients died (including 9 cases in the positive fluid balance group and 5 cases in the negative fluid balance group). Using IAP and PaO2/FiO2 to guide liquid therapy could result in effective fluid resuscitation in SAP. The treatment strategy effectively improved prognosis of patients with SAP.

Impact of Cumulative Fluid Balance During Continuous Renal Replacement Therapy on Mortality in Patients With Septic Acute Kidney Injury: A Retrospective Cohort Study

Background: The clinicians often use continuous renal replacement therapy (CRRT) for the fluid management of patients with septic acute kidney injury (AKI). However, there is limited knowledge of the effects of changes in fluid balance (FB) on CRRT and its association with outcomes in patients with septic AKI.Objective: This study aimed to determine the association of cumulative FB (CFB) during treatment with 28-day all-cause mortality in the patients with septic AKI who require CRRT.Methods: This retrospective observational study examined patients who received CRRT due to septic AKI in a mixed intensive care unit (ICU) of a tertiary teaching hospital between January 2015 and December 2018. The patients were divided into three groups—negative FB, even FB, and positive FB—based on the CFB during CRRT. The primary outcome was 28-day all-cause mortality.Results: We examined 227 eligible patients and the mean age was 62.4 ± 18.3 years. The even FB group had a significantly lower 28-day mortality (43.0%, p = 0.007) than the positive FB group (72.7%) and the negative FB group (54.8%). The unadjusted and adjusted Cox regression models indicated that the positive FB group had an increased risk for 28-day all-cause mortality relative to the even FB group. A restricted cubic splines model indicated a J-shaped association between the CFB and 28-day all-cause mortality in the unadjusted model.Conclusion: Among the critically ill patients with septic AKI who require CRRT, those with positive FB had a higher mortality rate than those with even FB.

Prospective Cohort Study on Cumulative Fluid Balance and Outcome in Critically Ill Children Using a Restrictive Fluid Protocol.

To study the association of cumulative fluid balance and clinical outcomes in a pediatric intensive care unit (PICU) practicing restrictive fluid protocol. In this prospective cohort study, children aged less than 13 y admitted for more than 48h were screened. Children with unstable hemodynamics throughout the stay were excluded. Fluid balance was calculated by percentage fluid overload (%FO) for the first 7 d. Patients were divided into positive fluid and negative fluid balance groups. The primary outcome was all-cause 28-d mortality. A total of 888 patients (positive fluid balance group = 531, negative fluid balance group = 357) were analyzed. Mean (SD) cumulative %FO was 1.52 (0.67) vs. -1.18 (0.71), p = < 0.001, and minimum and maximum cumulative %FO were -3.0% and 3.1%, respectively. There was no significant difference in all-cause 28-d mortality between the two groups (n = 104/531, 19.6% vs. n = 60/357, 16.8%, RR = 1.17, 95% CI 0.87 to 1.55; p = 0.29). There was no difference in organ dysfunction [mean (SD) sequential organ failure assessment (SOFA) score 3.3 (0.7) vs. 3.3 (0.6)], acute kidney injury (65% vs. 63.6%), need for renal replacement therapy (14% vs. 13%), and duration of ventilation (median, IQR 4, 2-6 vs. 4, 2-6 d). Longer stay in PICU (5, 3-9 vs. 4, 3-7 d; p = 0.014) and in hospital (8, 5-11 vs. 7, 4-10 d; p = 0.007) were noted in the positive fluid balance group. Cumulative fluid balance within 3% using restrictive fluid protocol was not associated with a significant difference in PICU mortality and morbidity.

Association between postoperative fluid balance and mortality and morbidity in critically ill patients with complicated intra-abdominal infections: a retrospective study.

BackgroundPostoperative fluid overload may increase the risk of developing pulmonary complications and other adverse outcomes. We evaluated the impact of excessive fluid administration on postoperative outcomes in critically ill patients.MethodsWe reviewed the medical records of 320 patients admitted to intensive care unit (ICU) after emergency abdominal surgery for complicated intra-abdominal infection (cIAI) between January 2013 and December 2018. The fluid balance data of the patients were reviewed for a maximum of 7 days. The patients were grouped based on average daily fluid balance with a cutoff value of 20 ml/kg/day. Propensity score matching was performed to reduce the underlying differences between the groups.ResultsPatients with an average daily fluid balance of ≥20 ml/kg/day were associated with higher rates of 30-day mortality (11.8% vs. 2.4%; P=0.036) than those with lower fluid balance (<20 ml/kg/day). Kaplan-Meier survival curves for 30-day mortality in these groups also showed a better survival rate in the lower fluid balance group with a statistical significance (P=0.020). The percentage of patients who developed pulmonary consolidation during ICU stay (47.1% vs. 24.7%; P=0.004) was higher in the fluid-overloaded group. Percentages of newly developed pleural effusion (61.2% vs. 57.7%; P=0.755), reintubation (18.8% vs. 10.6%; P=0.194), and infectious complications (55.3% vs. 49.4%; P=0.539) showed no significant differences between the two groups.ConclusionsPostoperative fluid overload in patients who underwent emergency surgery for cIAI was associated with higher 30-day mortality and more frequent occurrence of pulmonary consolidation. Postoperative fluid balance should be adjusted carefully to avoid adverse clinical outcomes.

Perioperative fluid balance and 30-day unplanned readmission after lung cancer surgery: a retrospective study.

BackgroundPerioperative positive fluid balance (FB) is associated with increased complications after lung resection surgery. However, its impact on the 30-day unplanned readmission rate is unclear. This study aimed to determine whether perioperative FB status during and up to 24 hours after lung resection surgery is associated with the 30-day unplanned readmission rate.MethodsThis retrospective cohort study examined adult patients aged 19 years or older who underwent lung cancer surgery at a single tertiary academic hospital between January 2005 and February 2018. Weight-based cumulative FB (%) was calculated during and up to 24 hours after surgery and was categorized as positive (≥5%), normal (0–5%), or negative (<0%). Univariable and multivariable logistic regression analyses were performed.ResultsThe final analysis included 2,412 patients; 164 patients had unplanned readmission during the first 30 postoperative days (6.9%; 164/2,412). According to the multivariable logistic regression model, the positive FB group had a 2.42-time higher risk of 30-day unplanned readmission compared to the normal FB group [odds ratio (OR): 2.42; 95% confidence interval (CI): 1.20 to 4.89; P=0.014]. However, the risk of the negative FB group did not significantly differ from that of the normal FB group (OR: 1.20; 95% CI: 0.46 to 3.12; P=0.711).ConclusionsPerioperative positive FB (>5%) during and up to 24 hours after surgery was associated with an increased 30-day unplanned readmission rate after lung cancer surgery. Future prospective studies are needed to confirm these findings.

Intraoperative fluid therapy and postoperative complications during minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study.

Compared with open thoracotomy, minimally invasive esophagectomy (MIE) methods, such as transhiatal or thoracoscopic esophagectomy, likely have lower morbidity. However, the relationship between intraoperative fluid management and postoperative complications after MIE remains unclear. Thus, we investigated the association of cumulative intraoperative fluid balance and postoperative complications in patients undergoing MIE. This single-center retrospective cohort study examined patients undergoing thoracoscopic esophagectomy for esophageal cancer in the prone position. Postoperative complications included pneumonia, arrhythmia, thrombotic events and acute kidney injury (AKI). We compared patients with higher and lower intraoperative fluid balance (higher and lower than the median). Multivariable logistic regression analyses were performed to estimate the odds ratio of intraoperative fluid balance status on the incidence of postoperative complications. In total, 135 patients were included in the study. Postoperative complications occurred in 43 (32%), including cardiac arrhythmia (n = 12, 9%), thrombosis (n = 20, 15%), pneumonia (n = 13, 10%), and AKI required hemodialysis (n = 1, 1%). Patients with a higher fluid balance had higher incidence of complications than those with a lower fluid balance (46% vs. 18%, p < 0.001). After adjusting for age, ASA-PS ≥ III, blood loss, and the use of radical surgery, the higher intraoperative fluid balance group was significantly and independently associated with postoperative complications (adjusted OR 5.31, 95% CI 2.26-13.6, p < 0.0001). In patients undergoing thoracoscopic esophagectomy in the prone position, a greater intraoperative positive fluid balance was independently associated with a higher incidence of complications.

FACTORS ASSOCIATED WITH FLUID BALANCE IN SEPSIS AND SEPTIC SHOCK

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: The use of fluids in the management of sepsis is considered a strong recommendation with little evidence to support its use. In recent years, a significant amount of attention has been given to fluid balance over the course of sepsis management and multiple studies have identified correlations between positive fluid balance and increased morbidity and mortality. Our goal is to study mortality and clinical comorbidities that may be associated with having a positive fluid balance in sepsis recovery. METHODS: We performed a retrospective chart review of all patients discharged with a diagnosis of sepsis, severe sepsis or septic shock in 2018 from the 30-bed Medical Intensive Care Unit of Dell Seton Medical Center at the University of Texas at Austin, a Level I Trauma Center and teaching hospital for Dell Medical School. Adult patients admitted to the unit directly from the emergency room were included. We used descriptive statistics to characterize this population, and Fisher’s exact test to compare the proportion of deaths and clinical comorbidities between patients with a positive vs negative fluid balance. The study received IRB approval from the University of Texas at Austin. RESULTS: A total of 24 patients from 170 reviewed charts met inclusion criteria. Mean age of the patients was 58.8 years and 45% were male. Average ICU length of stay was 5.8 days and average ventilator days was 1.73 days. A total of 17% of patients died during ICU admission (N=4). A total of 16 (67%) patients had a positive fluid balance and 8 (33%) had a negative fluid balance. All 4 deaths were in the positive fluid balance group, however the proportion of deaths was not significantly different from the negative fluid balance group (positive: 4/16, negative 0/8, P>0.05). Proportions of CHF, cirrhosis, and ESRD were not different between fluid balance groups (CHF: 3/16 vs 2/8; cirrhosis: 4/16 vs 1/8; ESRD 0/16 vs 2/8; all P>0.05). CONCLUSIONS: The majority of patients admitted to the ICU for sepsis, severe sepsis, or septic shock ended up having a positive fluid balance, and although not statistically significant, there was a higher proportion of death among patients with a positive fluid balance. Further chart review of the 1100 total charts will focus on developing a larger sample size for outcomes analysis including mortality and potential effects of fluid balance on ICU length of stay, ventilator days, organ functionality, laboratory data and clinical comorbidities. CLINICAL IMPLICATIONS: This retrospective study shows that patients discharged from the ICU are on average net fluid positive and will further reveal how fluid balance affects multiple clinical parameters in recovery from sepsis. DISCLOSURES: No relevant relationships by Liwayway Andrade, source=Web Response No relevant relationships by Michael Castellarin, source=Web Response No relevant relationships by Andrea Fekete, source=Web Response No relevant relationships by Oscar Garcia, source=Web Response No relevant relationships by pranay kappera, source=Web Response No relevant relationships by Kanza Muzaffar, source=Web Response No relevant relationships by Zachary Pinchover, source=Web Response No relevant relationships by Koonj Shah, source=Web Response No relevant relationships by John Suder, source=Web Response No relevant relationships by Mohi Syed, source=Web Response No relevant relationships by Victoria Valencia, source=Web Response

Association of perioperative weight-based fluid balance with 30-day mortality and acute kidney injury among patients in the surgical intensive care unit

Perioperative positive fluid balance has negative effects on short-term outcomes, such as surgical complications, although the associations with postoperative mortality remain unclear. This study evaluated the associations of perioperative fluid balance (FB) with 30-day mortality and acute kidney injury (AKI) after postoperative intensive care unit (ICU) admission. This retrospective study evaluated data from adult patients who were admitted to the ICU after surgery during 2012-2016. Weight-based cumulative FB (%) was calculated for 3 time periods [postoperative day (POD) 0 (24h), 0-1 (48h), and 0-2 (72h)] and was categorized as positive (≥ 5%), mild to moderate positive (5-10%), severe positive (> 10%), normal (0-5%), or negative (< 0%). Data from 7896 patients were included in the analysis. The multivariable Cox regression model revealed that increased 30-day mortality was associated with positive FB groups (≥ 5%) compared to normal FB groups (0-5%) during 3 time periods [hazard ratio (HR) on POD 0 (24h): 1.87, HR on POD 1 (48h): 1.91, and HR on POD 2 (72h): 4.62, all P < 0.05]. These trends were more evident in the severe positive FB group across the three time periods. Additionally, similar association was found for incidence of AKI during POD 0-2. Perioperative cumulative weight-based FB was positively associated with increased postoperative 30-day mortality or postoperative AKI in ICU patients; this association was consistent with the positive FB on POD 0 (24h), 0-1 (48h), and 0-2 (72h).

Analysis of the association of fluid balance and short-term outcome in traumatic brain injury

IntroductionA balance of fluid intake and output (fluid balance) influences outcomes of critical illness, but the level of such influence remains poorly understood for traumatic brain injury (TBI) and was quantitatively examined in this study. MethodsWe conducted a retrospective cohort study of 351 moderate and severe TBI patients to associate the degree of fluid balance with clinical outcomes of TBI. Fluid balance and intracranial pressure (ICP) were continuously recorded for 7days on patients admitted to neurocritical care unit (NCCU). The short-term outcome was dichotomized into improvement and deterioration groups based on changes in Glasgow Coma Scale (GCS) measured between admission and 30days after admission. Fluid balance was calculated as: Fluid intake (mL) - fluid outputs (mL)/day×5 and used to group patients in tertiles to study its effect on TBI outcome. ResultsPatients at the low (<637mL) and upper (>3673mL) tertiles of fluid balance were associated with poor outcomes. Those in the upper tertile also had a higher incidence of acute kidney injury (AKI) and refractory intracranial hypertension (RIH). There was a negative correlation between the cumulative fluid balance and the short-term outcome for patients in the low tertile and a positive correlation between the cumulative fluid balance and the short-term outcome in the upper fluid balance group. Levels of fluid balance were also associated with serum creatinine (Cr, r=0.451, P<0.0001) and days in NCCU (r=0.188, P=0.001). More patients in the upper tertile had ICP higher than 20mmHg (P=0.009). A fluid balance in the upper tertile is an independent predictor of poor 30-day clinical outcomes after the adjustment for confounding variables in a multivariable logistic regression model. ConclusionWe found that fluid balance in low and upper tertiles were associated with poor short-term outcomes and ICP variations. Fluid balance in the upper tertile may be an independent predictor for poor 30-day outcome, primarily due to high AKI and RIH.

Continuous renal replacement therapy and negative fluid balance improves renal function and prognosis of patients with acute kidney injury in sepsis

To investigate the influence of fluid balance and model of renal replacement therapy (RRT) on renal function and prognosis of patients suffering from septic acute kidney injury (AKI). A retrospective cohort analysis of 117 septic AKI patients who had undergone RRT between January 2009 and December 2014 was performed in the Second Affiliated Hospital of Nanjing Medical University. The patients were divided into positive fluid balance group (n = 52) and negative fluid balance group (n = 65) according to the total amount of fluid calculated from the difference between fluid administered and fluid lost during the first 1 week of RRT. The incidence of renal recovery and death of the patients by 60 days as the endpoint events were taken to judge the prognosis of two groups. RRT strategies included continuous renal replacement therapy (CRRT) and intermittent renal replacement therapy (IRRT). Multiple factors including estimated glomerular filtration rate (eGFR), sequential organ failure assessment (SOFA) score, RRT model, the accumulation of fluid before initiation of RRT, and negative fluid balance during RRT were analyzed for outcome predictors by Cox proportional hazards model. There were no differences between two groups regarding clinical characteristics. The percentage of receiving CRRT in the negative fluid balance group was slightly higher than that of the positive fluid balance group (52.31% vs. 36.54%, χ² = 2.899, P = 0.089). With Kaplan-Meier survival curves, it was shown that the patients of negative fluid balance group had a higher rate of recovery of renal function (χ² = 4.803, P = 0.028) and significantly lower mortality rate (χ² = 9.505, P = 0.002). The rate of recovery of renal function by 60 days was higher in the negative fluid balance group than that in the positive fluid balance group (47.69% vs. 28.85%, χ² = 3.991, P = 0.046), while the mortality rate was significantly lowered in the negative fluid balance group compared with that of the positive fluid balance group (40.00% vs. 67.31%, χ² = 4.378, P = 0.036). Cox multivariate regression was used for excluding confounding factors. After adjusting for the clinically relevant variables, RRT negative fluid balance was significantly associated with recovery of renal function [ hazard ratios (HR) = 2.440, 95% confidence intervals (95%CI) = 1.089-5.464, P = 0.030] and mortality (HR = 0.443, 95%CI = 0.238-0.822, P = 0.010]. Higher eGFR before RRT and CRRT were independent favorable factors for recovery of renal function (HR = 1.014, 95%CI = 1.003-1.026, P = 0.012; HR = 3.138, 95%CI = 1.765-7.461, P = 0.002), and higher SOFA score was associated with a significantly higher risk of death (HR = 1.115, 95%CI = 1.057-1.177, P < 0.001). Once the patients with septic AKI showed the signs of fluid overload, timely RRT and effective removal of excessive liquid may reverse the adverse prognosis. RRT with negative fluid balance is beneficial for the recovery of renal function, and reduce the mortality in patients with septic AKI, and CRRT model is a good choice.

What happens to the fluid balance during and after recovering from septic shock?

ObjectiveWe aimed to evaluate the cumulative fluid balance during the period of shock and determine what happens to fluid balance in the 7 days following recovery from shock.MethodsA prospective and observational study in septic shock patients. Patients with a mean arterial pressure ≥ 65mmHg and lactate < 2.0mEq/L were included < 12 hours after weaning from vasopressor, and this day was considered day 1. The daily fluid balance was registered during and for seven days after recovery from shock. Patients were divided into two groups according to the full cohort’s median cumulative fluid balance during the period of shock: Group 1 ≤ 4.4L (n = 20) and Group 2 > 4.4L (n = 20).ResultsWe enrolled 40 patients in the study. On study day 1, the cumulative fluid balance was 1.1 [0.6 - 3.4] L in Group 1 and 9.0 [6.7 - 13.8] L in Group 2. On study day 7, the cumulative fluid balance was 8.0 [4.5 - 12.4] L in Group 1 and 14.7 [12.7 - 20.6] L in Group 2 (p < 0.001 for both). Afterwards, recovery of shock fluid balance continued to increase in both groups. Group 2 had a more prolonged length of stay in the intensive care unit and hospital compared to Group 1.ConclusionIn conclusion, positive fluid balances are frequently seen in patients with septic shock and may be related to worse outcomes. During the shock period, even though the fluid balance was previously positive, it becomes more positive. After recovery from shock, the fluid balance continues to increase. The group with a more positive fluid balance group spent more time in the intensive care unit and hospital.

The influence of volume load on prognosis of patients with sepsis induced acute kidney injury

To investigate the influence of volume load on the prognosis of patients with sepsis induced acute kidney injury (AKI). A retrospective study was conducted. Patients with sepsis induced AKI from intensive care unit (ICU) of Binzhou Medical College Hospital from October, 2009 to September, 2011, were studied. 28-day mortality, 28-day renal-recovery rate, ICU stay days and mechanical ventilation rate were compared between negative fluid balance group and positive fluid balance group according to the fluid balance in first 72 hours. The influence of continuous renal replacement therapy (CRRT) on the volume load and the prognosis of patients with sepsis induced AKI were also studied. One hundred and sixty patients were enrolled. Compared with positive fluid balance group (n=79), 28-day-mortality [37.0% (30/81) vs. 68.4% (54/79), P<0.01], ICU stay time (10.1±4.9 days vs. 12.4±8.0 days, P<0.05) and mechanical ventilation rate [50.6% (41/69) vs. 68.4% (54/819), P<0.01] were lower in negative fluid balance group (n=81). According to Acute Kidney Injury Net (AKIN) staging standard, in stage 1, 2, and 3 of AKI (n=49, n=52, n=59), the day volume of first 72 hours of patients undergoing CRRT were lower than that of patients not undergoing CRRT (-10 ml vs. 716 ml, 324 ml vs. 778 ml, 521 ml vs. 1177 ml, all P<0.05). The 28-day mortality of patients undergoing CRRT was lower than that of patients not undergoing CRRT in stage 2 of AKI [38.7% (12/31) vs. 66.7% (14/21), P<0.05]. There is a relationship between fluid balance and prognosis of sepsis induced AKI, and 28-day-mortality can be reduced by negative fluid balance. CRRT can regulate fluid balance and improve the prognosis of sepsis induced AKI.

The impact of early restrictive positive fluid balance strategy on the prognosis of patients with severe trauma

To observe the impact of early restrictive positive fluid balance strategy on the prognosis of patients with trauma. A prospective controlled study was conducted. The patients with severe post-trauma capillary leak syndrome (PTCLS) admitted to department of critical care medicine of the Fifth Center Hospital in Tianjin were considered as study object. Fluid treatment was adjusted according to intra-thoracic blood volume index (ITBVI), mean arterial pressure (MAP), cardiac index (CI) and oxygen saturation of central vein (ScvO2) at leakage stage of PTCLS. Patients were divided into two groups according to different fluid therapy volume, restrictive positive fluid balance group (restrictive group) and non-restrictive positive fluid balance group (non-restrictive group), 30 patients were enrolled into each group. The fluid balance volume and index of prognosis between two groups were analyzed within 7 days of treatment. During the leakage stage of PTCLS, compared with non-restrictive group, fluid positive volume of the restrictive group were decreased at 1-6 days of the treatment (1 day: 5968.8±1818.0 ml/d vs. 7109.7±2186.41 ml/d, 2 days: 3653.7±1525.1 ml/d vs. 6080.3±1538.8 ml/d, 3 days: 1953.6±621.3 ml/d vs. 3223.3±875.1 ml/d, 4 days: -2808.7±888.0 ml/d vs. -4169.9±1302.5 ml/d, 5 days: -5969.1±1470.8 ml/d vs. -6896.5±1619.4 ml/d, 6 days: -1938.1±746.0 ml/d vs. -4964.0±1389.6 ml/d, P<0.05 or P<0.01), ITBVI and extravascular lung water index (EVLWI) were decreased at 2 days and 3 days of the treatment (ITBVI 2 days: 689.2±60.6 ml/m(2) vs. 807.7±67.8 ml/m(2), 3 days: 729.6±43.3 ml/m(2) vs. 825.5±71.5 ml/m(2); EVLWI 2 days: 6.9±2.0 ml/kg vs. 8.3±2.1 ml/kg, 3 days: 7.6±2.0 ml/kg vs. 8.9±1.9 ml/kg, P<0.05 or P<0.01). Compared with non-restrictive group, the occurrence of respiratory dysfunction (46.7% vs. 76.7%), gastrointestinal dysfunction (33.3% vs. 60.0%) and the occurrence of intracranial hypertension (26.7% vs. 56.7%) at 7 days of treatment in restrictive group were decreased (all P<0.05), the time of mechanical ventilation (3.6±1.1 days vs. 5.1±1.5 days) and intensive care unit (ICU) stay time (5.5±1.5 days vs. 7.0±1.9 days) were shortened (both P<0.01). There were no differences in the occurrence of dysfunction of cardiovascular, blood coagulation, hepatic and renal function, the percentage of patients receiving renal-replacement therapy and the number of days with dialysis, as well as the mortality during the first 28 days between two groups (all P>0.05). Using restrictive positive fluid balance strategy in the leakage stage of PTCLS, fluid positive balance volume, occurrence of dysfunction of some organs, mechanical ventilation and ICU stay time can be decreased.