SCCM Resource Library-Impact of Fluid Resuscitation in End-Stage Renal Disease Patients With Septic Shock

Video Transcription

Hello everyone. Thank you for joining in today. My name is Katie Chernoby and I'm currently a critical care clinical pharmacist at the University of New  Mexico Hospital in Albuquerque, New Mexico. Today I will be presenting my research that was completed during my PGY-2 residency at Spectrum Health in  Grand Rapids, Michigan, titled Impact of Fluid Resuscitation in End-stage Renal Disease Patients with Septic Shock. The 2016 Surviving Sepsis Campaign recommends  initial fluid resuscitation of at least 30 mls per kilo of crystalloid fluid within the first hour of presentation. Septic patients, including those with  end-stage renal disease or ESRD, are at increased risk of fluid overload, which is associated with poor outcomes. Currently there are no studies to show  if less than 30 mls per kilo of initial fluid resuscitation improves sepsis outcomes in the ESRD population. The purpose of the study was to determine  the clinical efficacy and safety of initial fluid resuscitation in ESRD patients who receive greater than or equal to 30 mls per kilo of fluid versus  less than 30 mls per kilo fluid within the first three hours of septic shock recognition. This was a multi-center retrospective cohort study that was  conducted between December 1st of 2012 through April 30th of 2020. Data was collected from six institutions across the country, with Spectrum Health,  Butterworth, and Bladgett Hospitals being the primary sites. Lists were generated at each center through ICD-9 and 10 codes for septic shock and ESRD, along  with medication orders for vasopressors during hospital admission. Patients were included in the study if they were between the ages of 18 to 89 years of  age with a known history of end-stage renal disease. End-stage renal disease was defined as patients requiring hemodialysis or peritoneal dialysis as  an outpatient. They were also included if they had a diagnosis of septic shock and were admitted to a medical intensive care unit. Patients had to receive a  initial fluid bolus of at least 250 ml and had vasopressors initiated within the first 12 hours of the fluid bolus. Patients were excluded if they  were pregnant, incarcerated, transferred from an outside hospital, admitted from an operating room or hospital floor, or if they had Comfort Care or ACLS  performed within six hours of admission. The primary outcome of this study was in hospital mortality. Our secondary outcomes included time to hemodynamic  stability, duration of mechanical ventilation, duration of renal replacement therapy, fluid intake at 24, 48, and 72 hours, fluid balance on day one, day three,  and day seven in ICU and hospital length of stay. Septic shock was defined as suspected or confirmed infection plus vasopressor support for at least  60 minutes. Time to hemodynamic stability was defined as time from the initiation of vasopressor support until vasopressors were discontinued for a  continuous 24 hours. Continuous data was analyzing using either students t-tests or Mann-Whitney tests. Categorical data was analyzed through chi-squared or  Fisher's exact tests. We also completed a multivariable logistic regression to adjust for age, hepatity 2 score, appropriateness of antibiotics based on  culture data and diagnosis, and type of dialysis that the patient received on admission. Our estimated sample size was calculated using two-tailed sample  proportion with the hypothesis that in-hospital mortality would be higher in the greater than or equal to 30 mils per kilo group. The initial proportion of 0.28  was used as previous literature reported a mortality between 25 to 30 percent with the second proportion being estimated at 0.4. The ratio of 1.5 was  allocated under the assumption that groups were split 60 to 40. Power was also set at 0.8 with an alpha 0.05. A total of 511 patients with 204 being in  the greater than or equal to 30 mils per kilo group and 307 in the less than 30 mils per kilo group were estimated to be needed to detect a statistical  difference. Between the six institutional sites, a total of 1,167 patients were screened. A total of 1,011 patients were excluded from the study, mainly from  being transferred from an outside hospital, being admitted from the operating room or the floor, or vasopressors not being started within 12  hours of the fluid bolus. 156 patients were included in the analysis with 126 patients receiving less than 30 mils per kilo of initial fluid resuscitation and  the remaining 30 receiving greater than or equal to 30 mils per kilo of fluid. Between the two groups, baseline characteristics were overall very similar  with the exception of weight and BMI being significantly higher in the less than 30 mils per kilo group. Of note, almost half of the patients in both  groups had congestive heart failure. Time the last hemodialysis session prior to admission was also similar between both groups at about two days. Initial fluid  resuscitation within the first three hours was higher in the greater than or equal to 30 mils per kilo group. The most common type of fluid administered in  both groups was normal saline. There was no difference in time to antibiotics between the two groups and appropriateness of antibiotics was  relatively high. The most common vasopressors that were initiated were norepinephrine and vasopressin in both groups. Interestingly, hemodialysis was  the most common first renal replacement therapy initiated in both groups with continuous renal replacement therapy being initiated in approximately 40% of  patients in each group. The primary outcome of in-hospital mortality was not statistically significantly different between the two groups. In each group  there was about 35% of patients that experienced in-hospital mortality, which is similar to the existing sepsis literature. For our secondary outcomes,  time to hemodynamic stability and duration of mechanical ventilation was not statistically different between the two groups. Median duration of continuous  renal replacement therapy was 73.7 hours in the less than 30 mils per kilo group compared to 43.9 hours in the greater than or equal to 30 mils per kilo group,  which was not statistically significant. Fluid intake and fluid balance at 24 hours were statistically significant. However, ICU length of stay and hospital  length of stay were not statistically significant. Based on the differences in weight in the baseline characteristics, a subgroup analysis was also performed to  divide them further to less than 15 mils per kilo of fluid, 15 to 30 mils per kilo of fluid, and greater than 30 mils per kilo of fluid. There is no statistical  difference in in-hospital mortality or time to hemodynamic stability. Similar to the primary groups, there were differences of fluid intake and fluid  balance at 24 hours. ICU length of stay and hospital length of stay were similar between the three groups. To identify any factors associated with the primary  outcome of in-hospital mortality, a multivariable logistic regression analysis was also performed. Based on the analysis, the odds of in-hospital  mortality were significantly higher if a patient did not receive appropriate antibiotics or if a patient required continuous renal replacement therapy.  Age and Hepatitis 2 scores were not associated with in-hospital mortality in this study. Our study had several limitations. One limitation to our study  is the retrospective nature of the chart review and relying on accuracy of nursing documentation for fluids and medication administration. Another limitation is the  relatively small sample size, with a larger percentage of patients receiving less than 30 mils per kilo of initial fluid resuscitation. Because of the small  sample size, our study did not meet power for our primary outcome of in-hospital mortality. Although we included days since last hemodialysis session, we were  unable to truly evaluate emission fluid balance. This emission fluid balance could have impacted how a provider determined how much initial fluid to  administer. Throughout the study period, there were updates in the surviving sepsis campaign guideline recommendations for initial fluid  resuscitation, which could have impacted the amount of fluid that patient received. In addition, the 2021 surviving sepsis campaign guidelines were  recently published, which now suggest the administration of 30 mils per kilo crystalloid fluid as a weak recommendation as opposed to a strong  recommendation that was in the 2016 guidelines. In this study, there was no difference in in-hospital mortality between end-stage renal disease patients  with septic shock who received less than 30 mils per kilo of fluid versus those who received greater than or equal to 30 mils per kilo of fluid. There was also no  difference in other clinical outcomes such as duration of mechanical ventilation or time to hemodynamic stability. Prospective studies are  warranted to confirm optimal fluid resuscitation in end-stage renal disease patients with septic shock. I would like to thank the colleagues listed on this  slide for their contributions to this research project. Thank you again for joining in and I would be happy to answer any questions.

Video Summary

In this presentation, Katie Chernoby, a critical care clinical pharmacist, shares her research on the impact of fluid resuscitation in end-stage renal disease (ESRD) patients with septic shock. The study aimed to determine the clinical efficacy and safety of initial fluid resuscitation in ESRD patients who receive ≥30 ml/kg of fluid versus <30 ml/kg within the first three hours of septic shock recognition. The study was a multi-center retrospective cohort study conducted between December 2012 and April 2020, involving six institutions. The primary outcome, in-hospital mortality, was not statistically different between the two groups, and secondary outcomes such as time to hemodynamic stability and duration of mechanical ventilation were also similar. The study suggests the need for prospective studies to confirm optimal fluid resuscitation in ESRD patients with septic shock.

Asset Subtitle

Sepsis, Renal, Quality and Patient Safety, 2022

Asset Caption

INTRODUCTION:The 2016 Surviving Sepsis Campaign recommends at least 30 mL/kg of initial fluid resuscitation for all patients with septic shock. The guidelines do not address if the initial fluid resuscitation goal should be modified in patients with end-stage renal disease (ESRD). There is limited literature surrounding the optimal fluid resuscitation goal for septic shock patients with ESRD. METHODS:The purpose of this multicenter, retrospective, cohort study was to determine the clinical efficacy and safety of initial fluid resuscitation in ESRD patients who received >30 mL/kg vs < 30 mL/kg within the first three hours of septic shock recognition. All patients included in the analysis had to have a past medical history of ESRD, admitted to a medical intensive care unit and require vasopressor support for at least 60 minutes. The primary outcome was in-hospital mortality. Secondary outcomes included time to hemodynamic stability, duration of mechanical ventilation and renal replacement therapy, fluid intake, fluid balance, and ICU and hospital length of stay. A multivariable logistic regression was used to identify factors associated with in-hospital mortality. RESULTS:A total of 156 patients were included with 126 (80.8%) patients receiving < 30 mL/kg and 30 (19.2%) patients receiving >30 ml/kg of initial fluid. Average initial volume administered was 14 mL/kg vs 36 mL/kg. No difference was observed in the primary outcome of in-hospital mortality between groups (32.5% vs 36.7%; p=0.667). Secondary outcomes, including time to hemodynamic stability, duration of mechanical ventilation, and length of stay were similar between groups. In a multivariable regression analysis both appropriateness of antibiotics (p=0.03) and continuous renal replacement therapy (p=0.008) were significant predictors of in-hospital mortality. CONCLUSIONS:In-hospital mortality and other clinical outcomes were not different in ESRD patients with septic shock who received < 30 mL/kg compared to those who received >30 mL/kg of initial fluid resuscitation. Prospective studies are warranted to determine the optimal initial fluid resuscitation needed to experience the best patient outcomes in septic shock patients with ESRD.

Meta Tag

Content Type Presentation

Knowledge Area Sepsis

Knowledge Area Renal

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Sepsis Resources

Membership Level Select

Tag Shock

Tag Renal

Tag Evidence Based Medicine

Year 2022

Keywords

fluid resuscitation

end-stage renal disease

ESRD patients

septic shock

clinical efficacy

Sepsis

Renal

Quality and Patient Safety

Shock

Renal

Evidence Based Medicine

Presentation

Select

2022

Foundational

Intermediate

Advanced

Sepsis Resources

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.