In this episode, I’ll discuss moderate vs low and high volume IV fluid resuscitation in sepsis and septic shock.
In an effort to bring clarity to the relationship between fluid resuscitation volume and sepsis mortality, a group of authors recently published in the journal Critical Care Medicine a retrospective database analysis study.
The database used in the analysis draws from over 600 US hospitals. Patient data from the beginning of 2016 to the end of 2019 was analyzed, resulting in a study population of over 190,000 patients with sepsis and septic shock admitted from the emergency department to the ICU.
The primary outcome focused on the volume of resuscitative IV fluid administered before the end of hospital day 1 and mortality. As a secondary goal, the authors wanted to determine the reasons, if any, for variations in predicted vs actual IV resuscitation fluid volume prescribed to patients with sepsis and septic shock.
After taking patient characteristics and illness severity into consideration, the study authors predicted that IV fluid should have been prescribed within a relatively narrow range of 3.6 to 4.5 liters for 95% of the patients in the study population. However the actual 95% range for IV resuscitation fluids in the study population was 1.7 to 7.4 liters.
For further analysis the patients were split into five groups based upon attending physician practice of the amount of resuscitation fluids prescribed: very low, low, moderate, high, and very high. Then, the moderate group was compared against the 2 groups at the extremes – very low and very high.
The moderate resuscitation fluid group received an average of 4 liters, the very low group received 1.6 liters, and the very high group received 6.1 liters.
The authors observed a 2.5% reduction in risk-adjusted mortality compared with either the very low or the very high groups – a difference that was statistically significant.
When the authors applied a “within and between hospital differences” analysis to determine the reason for the variation in predicted vs actual IV resuscitation fluid volume prescribed, they determined that it was physician behavior and not patient characteristics that accounted for the majority of the variation in predicted vs actual fluid volumes.
Importantly, during this within and between hospital differences analysis, the mortality benefit for the moderate IV fluid group was preserved.
These findings highlight that there likely is an IV fluid resuscitation amount that is “just right”. This provides important context to the 2023 CLOVERS study published in NEJM that found no difference between a conservative and liberal fluid resuscitation strategy, because while there is no difference between extremes there is a mortality benefit when the fluid volume is moderate.
Finally, the study highlights that difficult discussions may need to be had at the provider level, because it was specifically determined that being treated by a physician who on average administers a moderate amount of IV fluids on day 1 is associated with decreased mortality.
The authors concluded:
Unless clinical circumstances dictate a different practice, our data suggest adopting a moderate approach to IV fluid resuscitation, one that avoids either extreme of tightly restricting or aggressively administering IV fluid for patients with sepsis and septic shock.
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