Journal Jam: Association Between Volume of Fluid Resuscitation and Intubation in High Risk Patients with Sepsis, Heart Failure, End-stage Renal Disease, and Cirrhosis
Rizwan A. Khan, MD; Nauman A. Khan, MD; Seth R. Bauer, PharmD; Manshi Li, MS; Abhijit Duggal, MD, MPH; Xiaofeng Wang, PhD; and Anita J. Reddy, MD
How many times has that “Best Practice: This patient may have sepsis” pop-up window plagued you? So, you begin ordering the sepsis panel when you reach for the recommended fluid rate of 30 ml/kg. Volume for fluid resuscitation has been a controversial topic, especially in patients with comorbidities that place them at risk for volume overload. Khan et. al. examine whether the Initial fluid volume in sepsis guidelines is associated with a greater risk of respiratory failure.
Design: Retrospective cohort study
n=208
Patients were included when admitted to the ICU with a diagnosis of sepsis/septic shock with comorbidity of CHF, ESRD, or cirrhosis.
104 patients were in fluid restricted group (<30ml/kg) and the other 104 were in the standard fluid resuscitation group (30ml/kg).
Primary outcome: Respiratory failure resulting in intubation within 72 hours.
Secondary outcomes: Time to Intubation, change in O2 requirement, ventilator days, hospital mortality, “alive ICU-free days.”
Results: No significant difference in intubation incidence was detected between the two groups. 35% of patients in the restricted group were intubated and 32% in the standard fluid group (P=0.64).
No difference in the standard and restricted group in “alive ICU-free days,” duration of mechanical ventilation, or time to intubation.
Limitations: This was a retrospective design which can suffer from bias and the results are descriptive. Furthermore it was limited by not classifying severity of comorbidities (i.e. CHF class), amounts of fluid provided by EMS, and why providers restricted fluids or provided standard 30 ml/kg.
Discussion: It can hypothesized that there was no significant difference in the restricted group vs. standard group due to the vasoplegia caused by sepsis. The drop in effective circulating intravascular volume may be large enough that the 30 ml/kg bolus does not lead to respiratory failure (Although I wonder if the data changes with patients who present with sepsis secondary to pneumonia, complicated by pleural effusions?). This study eases some hesitation I get when I bolus higher risk patients. I will continue to treat my septic patients with the initial recommended 30 ml/kg bolus, while keeping a close eye on volume status.
Khan RA, Khan NA, Bauer SR, et al. Association between volume of fluid resuscitation and intubation in high-risk patients with sepsis, heart failure, end-stage renal disease, and cirrhosis. Chest. 2020; 157(2):286-292. https://journal.chestnet.org/article/S0012-3692(19)34013-9/fulltext. Published October 14, 2019. Accessed October 27, 2021.
(Note: You may require your institutions’ database to access the full article.)