Acute Crit Care.  2023 May;38(2):209-216. 10.4266/acc.2022.01550.

Percent fluid overload for prediction of fluid de-escalation in critically ill patients in Saudi Arabia: a prospective observational study

• Alharbi RA
• Aldardeer NF
• Heaphy ELG
• Alabbasi AH
• Albuqami AM
• Hawa H

• KMID: 2543640
• DOI: http://doi.org/10.4266/acc.2022.01550

Abstract

Background
Percent fluid overload greater than 5% is associated with increased mortality. The appropriate time for fluid deresuscitation depends on the patient's radiological and clinical findings. This study aimed to assess the applicability of percent fluid overload calculations for evaluating the need for fluid deresuscitation in critically ill patients. Methods: This was a single-center, prospective, observational study of critically ill adult patients requiring intravenous fluid administration. The study's primary outcome was median percent fluid accumulation on the day of fluid deresuscitation or intensive care unit (ICU) discharge, whichever came first. Results: A total of 388 patients was screened between August 1, 2021, and April 30, 2022. Of these, 100 with a mean age of 59.8±16.2 years were included for analysis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15.4±8.0. Sixty-one patients (61.0%) required fluid deresuscitation during their ICU stay, while 39 (39.0%) did not. Median percent fluid accumulation on the day of deresuscitation or ICU discharge was 4.5% (interquartile range [IQR], 1.7%–9.1%) and 5.2% (IQR, 2.9%–7.7%) in patients requiring deresuscitation and those who did not, respectively. Hospital mortality occurred in 25 (40.9%) of patients with deresuscitation and six (15.3%) patients who did not require it (P=0.007). Conclusions: The percent fluid accumulation on the day of fluid deresuscitation or ICU discharge was not statistically different between patients who required fluid deresuscitation and those who did not. A larger sample size is needed to confirm these findings.

Keyword

critical care; de-escalation; deresuscitation; percent fluid overload

Reference

1. Messmer AS, Zingg C, Müller M, Gerber JL, Schefold JC, Pfortmueller CA. Fluid overload and mortality in adult critical care patients: a systematic review and meta-analysis of observational studies. Crit Care Med. 2020; 48:1862–70.

2. Semler MW, Self WH, Wang L, Byrne DW, Wanderer JP, Ehrenfeld JM, et al. Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial. Trials. 2017; 18:129.

3. Silversides JA, McMullan R, Emerson LM, Bradbury I, Bannard-Smith J, Szakmany T, et al. Feasibility of conservative fluid administration and deresuscitation compared with usual care in critical illness: the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomised clinical trial. Intensive Care Med. 2022; 48:190–200.

4. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017; 45:486–552.

5. Chao WC, Tseng CH, Chien YC, Sheu CC, Tsai MJ, Fang WF, et al. Association of day 4 cumulative fluid balance with mortality in critically ill patients with influenza: a multicenter retrospective cohort study in Taiwan. PLoS One. 2018; 13:e0190952.

6. Hawkins WA, Smith SE, Newsome AS, Carr JR, Bland CM, Branan TN. Fluid stewardship during critical illness: a call to action. J Pharm Pract. 2020; 33:863–73.

7. Zhang L, Chen Z, Diao Y, Yang Y, Fu P. Associations of fluid overload with mortality and kidney recovery in patients with acute kidney injury: a systematic review and meta-analysis. J Crit Care. 2015; 30:860.

8. Teixeira C, Garzotto F, Piccinni P, Brienza N, Iannuzzi M, Gramaticopolo S, et al. Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care. 2013; 17:R14.

9. Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care. 2008; 12:R74.

10. Vaara ST, Korhonen AM, Kaukonen KM, Nisula S, Inkinen O, Hoppu S, et al. Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study. Crit Care. 2012; 16:R197.

11. Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, et al. Cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease. Crit Care Med. 2016; 44:1891–900.

12. Balakumar V, Murugan R, Sileanu FE, Palevsky P, Clermont G, Kellum JA. Both positive and negative fluid balance may be associated with reduced long-term survival in the critically ill. Crit Care Med. 2017; 45:e749–57.

13. González-Castro A, Ortiz-Lasa M, Leizaola O, Salgado E, Irriguible T, Sánchez-Satorra M, et al. Fluid balance and chloride load in the first 24h of ICU admission and its relation with renal replacement therapies through a multicentre, retrospective, case-control study paired by APACHE-II. Rev Esp Anestesiol Reanim. 2017; 64:243–9.

14. Cardoso FS, Pereira R, Laranjo A, Gamelas V, Bagulho L, Germano N, et al. Positive fluid balance was associated with mortality in patients with acute-on-chronic liver failure: a cohort study. J Crit Care. 2021; 63:238–42.

15. Vincent JL, Pinsky MR. We should avoid the term “fluid overload”. Crit Care. 2018; 22:214.

16. Silversides JA, McAuley DF, Blackwood B, Fan E, Ferguson AJ, Marshall JC. Fluid management and deresuscitation practices: a survey of critical care physicians. J Intensive Care Soc. 2020; 21:111–8.

17. Bagshaw SM, Cruz DN. Fluid overload as a biomarker of heart failure and acute kidney injury. Contrib Nephrol. 2010; 164:54–68.

18. Marik PE, Linde-Zwirble WT, Bittner EA, Sahatjian J, Hansell D. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med. 2017; 43:625–32.

19. Sadaka F, Juarez M, Naydenov S, O’Brien J. Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality. J Intensive Care Med. 2014; 29:213–7.

20. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006; 354:2564–75.

21. Meyhoff TS, Hjortrup PB, Wetterslev J, Sivapalan P, Laake JH, Cronhjort M, et al. Restriction of intravenous fluid in ICU patients with septic shock. N Engl J Med. 2022; 386:2459–70.

22. Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017; 43:155–70.