Fluid resuscitation in septic shock: A positive ﬂuid balance and elevated central venous pressure are associated with increased mortality
John H. Boyd, MD, FRCP(C); JasonForbes, MD; Taka-aki Nakada, MD, PhD; Keith R. Walley, MD, FRCP(C); James A. Russell, MD, FRCP(C)
Objective: To determine whether central venous pressure and ﬂuid balanceafter resuscitation for septic shock are associated with mortality. Design: We conducted a retrospective review of the use of intravenous ﬂuids during the ﬁrst 4 days ofcare. Setting: Multicenter randomized controlled trial. Patients: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock and who werereceiving a minimum of 5 g of norepinephrine per minute. Interventions: None. Measurements and Main Results: Based on net ﬂuid balance, we determined whether one’s ﬂuid balancequartile was correlated with 28-day mortality. We also analyzed whether ﬂuid balance was predictive of central venous pressure and furthermore whether aguideline-recommended central venous pressure of 8 –12 mm Hg yielded a mortality advantage. At enrollment, which occurred on average 12 hrs after presentation, the average ﬂuid balance was 4.2L. By day 4, the cumulative average ﬂuid balance was 11 L. After correcting for age and Acute Physiology and Chronic Health Evaluation II score, a more positive ﬂuidbalance at both at 12 hrs and day 4 correlated signiﬁcantly with increased mortality. Central venous pressure was correlated with ﬂuid balance at 12 hrs, whereas on days 1– 4,there was no signiﬁcant correlation. At 12 hrs, patients with central venous pressure 12 mm Hg. Contrary to the overall effect, patients whose central venous pressure was
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