Ultrasound-guided fluid resuscitation versus usual care guided fluid resuscitation in patients with septic shock: a systematic review and meta-analysis

Moderate IV Fluid Resuscitation Is Associated With Decreased Sepsis Mortality

OBJECTIVES

Significant practice variation exists in the amount of resuscitative IV fluid given to patients with sepsis. Current research suggests equipoise between a tightly restrictive or more liberal strategy but data is lacking on a wider range of resuscitation practices. We sought to examine the relationship between a wide range of fluid resuscitation practices and sepsis mortality and then identify the primary driver of this practice variation.

DESIGN

Retrospective analysis of the Premier Healthcare Database.

SETTING

Six hundred twelve U.S. hospitals.

PATIENTS

Patients with sepsis and septic shock admitted from the emergency department to the ICU from January 1, 2016, to December 31, 2019.

INTERVENTIONS

The volume of resuscitative IV fluid administered before the end of hospital day- 1 and mortality.

MEASUREMENTS AND MAIN RESULTS

In total, 190,682 patients with sepsis and septic shock were included in the analysis. Based upon patient characteristics and illness severity, we predicted that physicians should prescribe patients with sepsis a narrow mean range of IV fluid (95% range, 3.6-4.5 L). Instead, we observed wide variation in the mean IV fluids administered (95% range, 1.7-7.4 L). After splitting the patients into five groups based upon attending physician practice, we observed patients in the moderate group (4.0 L; interquartile range [IQR], 2.4-5.1 L) experienced a 2.5% reduction in risk-adjusted mortality compared with either the very low (1.6 L; IQR, 1.0-2.5 L) or very high (6.1 L; IQR, 4.0-9.0 L) fluid groups p < 0.01). An analysis of within- and between-hospital IV fluid resuscitation practices showed that physician variation within hospitals instead of practice differences between hospitals accounts for the observed variation.

CONCLUSIONS

Individual physician practice drives excess variation in the amount of IV fluid given to patients with sepsis. A moderate approach to IV fluid resuscitation is associated with decreased sepsis mortality and should be tested in future randomized controlled trials.