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Published by: Mahmoud Diaa on Aug 12, 2011
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05/21/2012

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research is still needed.
Crit Care Med 
2010;38:683–6848. Machado FR, Mazza BF: Improving mortalityin sepsis: Analysis of clinical trials.
Shock
2010;34(Suppl 1):54–589. Jones AE, Brown MD, Trzeciak S, et al: Theeffect of a quantitative resuscitation strategyon mortality in patients with sepsis: A meta-analysis.
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Stop filling patients against central venous pressure, please!*
I
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
DOI: 10.1097/CCM.0b013e318205c375
396 Crit Care Med 2011 Vol. 39, No. 2

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