Deresuscitation of Patients With Iatrogenic Fluid Overload Is Associated With Reduced Mortality in Critical Illness

Objectives: To characterize current practice in fluid administration and deresuscitation (removal of fluid using diuretics or renal replacement therapy), the relationship between fluid balance, deresuscitative measures, and outcomes and to identify risk factors for positive fluid balance in critical illness. Design: Retrospective cohort study. Setting: Ten ICUs in the United Kingdom and Canada. Patients: Adults receiving invasive mechanical ventilation for a minimum of 24 hours. Interventions: None. Measurements and Main Results: Four-hundred patients were included. Positive cumulative fluid balance (fluid input greater than output) occurred in 87.3%: the largest contributions to fluid input were from medications and maintenance fluids rather than resuscitative IV fluids. In a multivariate logistic regression model, fluid balance on day 3 was an independent risk factor for 30-day mortality (odds ratio 1.26/L [95% CI, 1.07–1.46]), whereas negative fluid balance achieved in the context of deresuscitative measures was associated with lower mortality. Independent predictors of greater fluid balance included treatment in a Canadian site. Conclusions: Fluid balance is a practice-dependent and potentially modifiable risk factor for adverse outcomes in critical illness. Negative fluid balance achieved with deresuscitation on day 3 of ICU stay is associated with improved patient outcomes. Minimization of day 3 fluid balance by limiting maintenance fluid intake and drug diluents, and using deresuscitative measures, represents a potentially beneficial therapeutic strategy which merits investigation in randomized trials. A full list of Role of Active Deresuscitation After Resuscitation (RADAR) Investigators is listed in Appendix 1. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by a doctoral fellowship award to Dr. Silversides from the Northern Ireland Health and Social Care Research and Development Division. Dr. Silversides' institution received funding from British Journal of Anaesthesia (BJA)/Royal College of Anaesthetists (RCoA) project grant WKR0-2017-0019. Dr. Lapinsky received other support from research grants from the Chest Foundation and Ontario Lung Association for an unrelated research project. Dr. McAuley's institution received funding from v Division (Doctoral Fellowship grant for Dr. Silversides), BJA/RCoA Project Grant WKR0-2017-0019, National Institute of Health Research Health Technology Assessment grant application pending, and GlaxoSmithKline, and he received other funding from Bayer, Boehringer Ingelheim, Peptinnovate. Dr. Marshall received funding from the Data and Safety Monitoring Board of Asahi-Kasei Pharma, Bristol-Myers Squibb (Advisory Board), and Regeneron. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jon.silversides@belfasttrust.hscni.net Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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