Fluid balance and cardiac function in septic shock as predictors of hospital mortality

Scott T Micek, Colleen McEvoy, Matthew McKenzie, Nicholas Hampton, Joshua A Doherty, Marin H Kollef, Scott T Micek, Colleen McEvoy, Matthew McKenzie, Nicholas Hampton, Joshua A Doherty, Marin H Kollef

Abstract

Introduction: Septic shock is a major cause of morbidity and mortality throughout the world. Unfortunately, the optimal fluid management of septic shock is unknown and currently is empirical.

Methods: A retrospective analysis was performed at Barnes-Jewish Hospital (St. Louis, Missouri). Consecutive patients (n = 325) hospitalized with septic shock who had echocardiographic examinations performed within 24 hours of shock onset were enrolled.

Results: A total of 163 (50.2%) patients with septic shock died during hospitalization. Non-survivors had a significantly larger positive net fluid balance within the 24 hour window of septic shock onset (median (IQR): 4,374 ml (1,637 ml, 7,260 ml) vs. 2,959 ml (1,639.5 ml, 4,769.5 ml), P = 0.004). The greatest quartile of positive net fluid balance at 24 hours and eight days post-shock onset respectively were found to predict hospital mortality, and the greatest quartile of positive net fluid balance at eight days post-shock onset was an independent predictor of hospital mortality (adjusted odds ratio (AOR), 1.66; 95% CI, 1.39 to 1.98; P = 0.004). Survivors were significantly more likely to have mild left ventricular dysfunction as evaluated by bedside echocardiography and non-survivors had slightly elevated left ventricular ejection fraction, which was also found to be an independent predictor of outcome.

Conclusions: Our data confirms the importance of fluid balance and cardiac function as outcome predictors in patients with septic shock. A clinical trial to determine the optimal administration of intravenous fluids to patients with septic shock is needed.

Figures

Figure 1
Figure 1
Box plots depicting daily cumulative fluid balance for survivors (white boxes) and non-surviviors (hatched boxes). The lines within the boxes represented the 50th percentile, the lines at the bottom and top of the boxes represent the 25th and 75th percentiles, and the whisker lines represent the 5th and 95th percentiles.
Figure 2
Figure 2
Cox survival curves, adjusted for age, APACHE II scores, and the use of vasopressin are shown for fluid balance quartiles, 24 hours (Top) and at Day 8 (Bottom). Quartile 4 has significantly decreased survival risk compared to quartiles 1 and 2 at 24 hours and 8 days, respectively.
Figure 3
Figure 3
Box plots depicting cumulative fluid balance at 24 hours (Top) and 8 days (Bottom) following shock onset for patients with and without cardiac dysfunction demonstrated by echocardiographic examinations. LV, left ventricle; RV, right ventricle.

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