Assessment of the components of fluid balance in patients with septic shock: a prospective observational study
Avaliação dos componentes do balanço hídrico em pacientes com choque séptico: estudo observacional prospectivo
Maria Aparecida de Souza, Fernando José da Silva Ramos, Bianca Silva Svicero, Nathaly Fonseca Nunes, Rodrigo Camillo Cunha, Flavia Ribeiro Machado, Flavio Geraldo Rezende de Freitas
Abstract
Background
The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours.
Methods
In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness.
Results
We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores.
Conclusions
Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.
Keywords
Resumo
Introdução
A quantidade ideal para a ressuscitação volêmica inicial ainda é controversa na sepse e a contribuição dos fluidos não-reanimação no equilíbrio hídrico não é clara. Nosso objetivo foi investigar os principais componentes da ingestão de líquidos e do equilíbrio hídrico em pacientes sobreviventes e não sobreviventes com choque séptico nas primeiras 72 horas.
Métodos
Neste estudo observacional prospectivo em duas unidades de terapia intensiva, registramos todos os fluidos administrados por via intravenosa, oral ou enteral, e perdas durante intervalos de tempo específicos desde o início do vasopressor: T1 (até 24 horas), T2 (24 a 48 horas) e T3 (48 a 72 horas). A regressão logística e um modelo matemático avaliaram a associação com a mortalidade e a influência da gravidade da doença.
Resultados
Incluímos 139 pacientes. Os principais componentes da ingestão de líquidos variaram em diferentes intervalos de tempo, com fluidos de reanimação e não reanimação, como antimicrobianos e fluidos de manutenção, sendo contribuintes significativos em T1 e terapia nutricional em T2/T3. O balanço hídrico positivo tanto em T1 quanto em T2 foi associado à mortalidade (p=0,049; p=0,003), enquanto o suporte nutricional em T2 foi associado a menor mortalidade (p=0,040). A associação com mortalidade não foi explicada pelos escores de gravidade da doença.
Conclusão
Os fluidos não relacionados à reanimação são os principais contribuintes para um balanço hídrico positivo nas primeiras 48 horas após a reanimação. Um balanço hídrico positivo nas primeiras 24 e 48 horas parece aumentar de forma independente o risco de morte, enquanto uma maior quantidade de nutrição parece protetora. Esses dados podem informar estratégias de administração de fluidos com o objetivo de melhorar os resultados e minimizar complicações na sepse.
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References
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Submitted date:
06/20/2023
Accepted date:
01/03/2024
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