Shock septic

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