Fluid Resuscitation in Septic Shock

Dr. Perz,

Boyd, J.H., Forbes, J., Nakada, T., Walley, K., Russell, J.A. Fluid Resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Critical Care Medicine: Volume 39, Issue 2 (Feb 2011).

The objective of this study was to determine when central venous pressure (CVP) and fluid balance after resuscitation for septic shock are associated with mortality by doing a retrospective review of the use of IV fluids during the first 4 days of care.  The study concluded that a more positive fluid balance both early in resuscitation and cumulatively over four days is associated with an increased risk of mortality in septic shock.  CVP may be used to gauge fluid balance <12 hours into septic shock but becomes an unreliable indicated of fluid balance thereafter.  The study referenced a VASST study (Vasopressin in Septic Shock Trial), which noted that optimal survival occurred with a positive fluid balance of approximately 3L at 12 hours.

This study was a retrospective review of 778 patients from the VASST, all of whom were in septic shock and receiving at least 5mcg of norepinephrine per minute; they analyzed whether a positive fluid balance in the first 12 hours of resuscitation and during the next 4 days was associated with an increase in 28-day mortality. Using the Surviving Sepsis guidelines from 2008, the study grouped patients into those who fell into the recommended range (CVP = 8-12), those with CVP < 8 and those with a CVP >12 and analyzed whether a CVP of 8-12 had a survival advantage.  In this VASST, the patients at 12 hours with a CVP <8 had a lower mortality over those with CVPs of 8-12 and those with CVPs >12.  However, the study also concluded that there is a point when too little fluid is also detrimental.  It also concluded that CVP may be useful along with other measures to gauge adequacy of fluid resuscitation <12 hours into septic shock but becomes an unreliable marker of fluid balance thereafter.  Optimal survival in the VASST study occurred with a positive fluid balance of appx. 3L at 12 hours.