Resuscitating patients with early severe sepsis: a Canadian multicentre observational study.
BACKGROUND
Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure.


METHODS
A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure.


RESULTS
Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 +/- 16.5 yr and 29.0 +/- 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval (CI)] for 2-4 L 1.67 (1.03-2.70) and > 4 L 2.34 (1.23-4.44) and a reduced risk of renal failure [OR, 95% CI for 2-4 L 0.48 (0.28-0.83) and > 4 L 0.45 (0.22-0.92)] in the first 24 hr of severe sepsis. Administration of colloid and crystalloid fluid as compared to crystalloid fluid alone was associated with a lower risk of renal failure [OR, 95% CI 0.45 (0.26 to 0.76)].


CONCLUSIONS
An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials.
McIntyre
Lauralyn A
LA
Department of Medicine(Critical Care), The Ottawa Hospital, Ottawa Health Research Institute, Ottawa, Ontario, Canada. lmcintyre@ottawahospital.on.ca
Fergusson
Dean
D
Cook
Deborah J
DJ
Nair
Rama C
RC
Bell
Dean
D
Dhingra
Viinay
V
Hutton
Brian
B
Magder
Sheldon
S
Hébert
Paul C
PC
D018806:APACHE; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D015331:Cohort Studies; D003102:Colloids / Q000627:therapeutic use; D000077324:Crystalloid Solutions; D016208:Databases, Factual; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000209:etiology; D007362:Intensive Care Units; D007552:Isotonic Solutions / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology* / Q000517:prevention & control; D012044:Regression Analysis; D012151:Resuscitation / Q000379:methods*; D012189:Retrospective Studies; D018805:Sepsis / Q000150:complications / Q000401:mortality / Q000628:therapy*; D012720:Severity of Illness Index; D013997:Time Factors
D003102:Colloids; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions