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Stop ﬁlling patients against central venous pressure, please!*
n this issue of
Critical Care Med-icine
, Boyd and colleagues (1)present the results of their studyexamining ﬂuid balance duringresuscitation of patients suffering fromseptic shock.The investigators studied 778 patientsoriginally enrolled in the Vasopressin AndSeptic Shock Trial (2) who had septicshock and who were receiving a mini-mum of 5
g of noradrenaline perminute. The main objective was to deter-mine whether central venous pressureand ﬂuid balance following resuscitationfor septic shock was associated with mor-tality. The study design was a retrospec-tive review of the use of intravenous ﬂu-ids during the ﬁrst 4 days of care in theintensive care unit. After correcting forage and Acute Physiology Assessment andChronic Health Evaluation II score, amore positive ﬂuid balance at both 12 hrsand day 4 correlated signiﬁcantly withincreased mortality. Furthermore, cen-tral venous pressure was found to be anunreliable marker of ﬂuid balance.Boyd and colleagues (1) present pro- vocative data on a hot topic in intensivecare medicine. The current SurvivingSepsis Guidelines (3) are based on theprotocol ﬁrst applied by Rivers et a1 (4), where they aimed to achieve mean arte-rial pressure of
65 mm Hg, central ve-nous pressure of 8–12 mm Hg, urineoutput of
0.5 mL/kg/hr, and a central venous oxygen saturation of
70% dur-ing the early phase of resuscitation. Byadministration of antibiotics and a strictadherence to this early goal-directedtherapy protocol, Rivers et al (4) demon-strated a highly favorable outcome.In this new study, Boyd and colleagues(1) link a negative outcome to those whobecame ﬂuid overloaded. This ﬁnding isalso in line with the results from theEuropean survey of critically ill patients with sepsis, where a positive ﬂuid balance was found to be associated with increasedmortality (5). Furthermore, positive ﬂuidbalance has also been shown to increasetime spent on mechanical ventilation anda trend toward increased mortality in pa-tients with acute lung injury (6). Theseand other studies highlight the need for acloser monitoring and evaluation of cur-rent practice. How should we monitorpatients suffering from severe sepsis andseptic shock? How should we speciﬁcallymonitor ﬂuid balance in septic patientsreceiving early goal-directed therapy, andhow should ﬂuid responsiveness be as-sessed? Current sepsis guidelines focuson targeting an optimum delivery of ox- ygen to the body through preload optimi-zation, initiation of timely and appropri-ate vasopressor and inotropic support (3).For decades central venous pressure hasbeen known to be a poor parameter forﬂuid balance. Dr. Swan’s group presenteddata on this issue nearly 40 yrs ago (7),and experimental and human studieshave consistently conﬁrmed a very poorcorrelation between central venous pres-sure and preload (8). Although central venous pressure is a fairly good estimateof right atrial pressure, it bears little re-lation to right ventricular end-diastolic volume, right ventricular stroke volume,and left ventricular preload (9). Accord-ingly, ﬂuid resuscitation in septic pa-tients must be guided by other parame-ters than central venous pressure alone,as it might mislead clinicians to eitheroverﬁll or underﬁll septic patients (10). Accordingly, the present study shouldurge us to review current guidelines anddiscuss alternatives to central venouspressure as a target parameter for ﬂuidresuscitation.To date no randomized controlled tri-als have been designed to study dosing of intravenous ﬂuids in patients sufferingfrom septic shock. The present data werecorrected for age and Acute Physiology Assessment and Chronic Health Evalua-tion II score, yet this does not necessarilymean that these patients were equally ill.Two patients with identical Acute Physi-ology Assessment and Chronic HealthEvaluation II scores might respond dif-ferently to ﬂuids. One patient may well bereversed by ﬂuids and the other not.Fluid responsiveness could thus serve asa measure of illness, indirectly reﬂectingthe degree of inﬂammation and capillaryleak. Unfortunately, failure to reverseseptic shock with ﬂuids may thus lead usto give even more ﬂuids, leading to fur-ther organ failure and death. The presentstudy links a positive ﬂuid balance andelevated central venous pressure to in-
*See also p. 259.
Key Words: septic shock; severe sepsis; ﬂuid re-suscitation; sepsis guidelinesThe author has not disclosed any potential con-ﬂicts of interest.Copyright © 2011 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins
396 Crit Care Med 2011 Vol. 39, No. 2