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Association between Initial Fluid Choice and Subsequent In-hospital Mortality during the Resuscitation of Adults with Septic Shock.
Abstract
BACKGROUND: Currently, guidelines recommend initial resuscitation with intravenous
(IV) crystalloids during severe sepsis/septic shock. Albumin is suggested as an alternative.
However, fluid mixtures are often used in practice, and it is unclear whether the
specific mixture of IV fluids used impacts outcomes. The objective of this study is
to test the hypothesis that the specific mixture of IV fluids used during initial
resuscitation, in severe sepsis, is associated with important in-hospital outcomes.
METHODS: Retrospective cohort study includes patients with severe sepsis who were
resuscitated with at least 2 l of crystalloids and vasopressors by hospital day 2,
patients who had not undergone any major surgical procedures, and patients who had
a hospital length of stay (LOS) of at least 2 days. Inverse probability weighting,
propensity score matching, and hierarchical regression methods were used for risk
adjustment. Patients were grouped into four exposure categories: recipients of isotonic
saline alone ("Sal" exclusively), saline in combination with balanced crystalloids
("Sal + Bal"), saline in combination with colloids ("Sal + Col"), or saline in combination
with balanced crystalloids and colloids ("Sal + Bal + Col"). In-hospital mortality
was the primary outcome, and hospital LOS and costs per day (among survivors) were
secondary outcomes. RESULTS: In risk-adjusted Inverse Probability Weighting analyses
including 60,734 adults admitted to 360 intensive care units across the United States
between January 2006 and December 2010, in-hospital mortality was intermediate in
the Sal group (20.2%), lower in the Sal + Bal group (17.7%, P < 0.001), higher in
the Sal + Col group (24.2%, P < 0.001), and similar in the Sal + Bal + Col group (19.2%,
P = 0.401). In pairwise propensity score-matched comparisons, the administration of
balanced crystalloids by hospital day 2 was consistently associated with lower mortality,
whether colloids were used (relative risk, 0.84; 95% CI, 0.76 to 0.92) or not (relative
risk, 0.79; 95% CI, 0.70 to 0.89). The association between colloid use and in-hospital
mortality was inconsistent, and survival was not uniformly affected, whereas LOS and
costs per day were uniformly increased. Results were robust in sensitivity analyses.
CONCLUSIONS: During the initial resuscitation of adults with severe sepsis/septic
shock, the types of IV fluids used may impact in-hospital mortality. When compared
with the administration of isotonic saline exclusively during resuscitation, the coadministration
of balanced crystalloids is associated with lower in-hospital mortality and no difference
in LOS or costs per day. When colloids are coadministered, LOS and costs per day are
increased without improved survival. A large randomized controlled trial evaluating
crystalloid choice is warranted. Meanwhile, the use of balanced crystalloids seems
reasonable. (Anesthesiology 2015; 123:1385-93).
Type
Journal articleSubject
AgedCohort Studies
Female
Fluid Therapy
Hospital Mortality
Humans
Isotonic Solutions
Length of Stay
Male
Middle Aged
Propensity Score
Resuscitation
Retrospective Studies
Shock, Septic
Sodium Chloride
Treatment Outcome
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https://hdl.handle.net/10161/13930Published Version (Please cite this version)
10.1097/ALN.0000000000000861Publication Info
Raghunathan, Karthik; Bonavia, Anthony; Nathanson, Brian H; Beadles, Christopher A;
Shaw, Andrew D; Brookhart, M Alan; ... Lindenauer, Peter K (2015). Association between Initial Fluid Choice and Subsequent In-hospital Mortality during
the Resuscitation of Adults with Septic Shock. Anesthesiology, 123(6). pp. 1385-1393. 10.1097/ALN.0000000000000861. Retrieved from https://hdl.handle.net/10161/13930.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Maurice Alan Brookhart
Professor in Population Health Sciences
M. Alan Brookhart, Ph.D. is a Professor in the Department of Population Health Sciences
at Duke University. He is also an Adjunct Professor at UNC Chapel Hill and an Honorary
Professor of Clinical Epidemiology at Aarhus University, Denmark. Alan did his doctoral
training in biostatistics at UC Berkeley and was on faculty at Harvard Medical School
and UNC Chapel Hill prior to joining the faculty at Duke. Alan has spent his career
developing epidemiologic and statistical methods for
Timothy Ellis Miller
Professor of Anesthesiology
Clinical and research interests are Enhanced Recovery and Perioperative Medicine;
with particular interests in fluid management, and perioperative optimization of the
high-risk non-cardiac surgery patient.
Karthik Raghunathan
Associate Professor of Anesthesiology
Dr. Karthik Raghunathan is an Associate Professor with Tenure in the Department of
Anesthesiology, with a secondary appointment in the Department of Population Health
Sciences, at the Duke University School of Medicine and is a Staff Physician at the
Durham Veterans Affairs Healthcare System.In addition to clinical practice as an anesthesiologist
and intensive care phys
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