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Stop filling patients against central venous pressure,
please!*
In 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-m um o f 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 Surviving
Sepsis Guidelines (3) are based on theprotocol first applied by
Rivers et a1 (4),
where they aimed to achieve mean arte-
rial pressure of65 mm Hg, central ve-
nous pressure of 812 mm Hg, urineoutput of0.5 mL/kg/hr, and a
central
venous oxygen saturation of70% dur-
ing the early phase of resuscitation. Byadministration of
antibiotics and a strict
adherence to this early goal-directed
therapy 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 who
became fluid overloaded. This finding is
also in line with the results from theEuropean survey of
critically ill patients
with sepsis, where a positive fluid balancewas found to be
associated with increased
mortality (5). Furthermore, positive fluidbalance has also been
shown to increase
time spent on mechanical ventilation and
a trend toward increased mortality in pa-tients with acute lung
injury (6). These
and other studies highlight the need for acloser monitoring and
evaluation of cur-
rent practice. How should we monitorpatients suffering from
severe sepsis and
septic shock? How should we specificallymonitor fluid balance in
septic patients
receiving early goal-directed therapy, andhow should fluid
responsiveness be as-sessed? Current sepsis guidelines focus
on 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 for
fluid balance. Dr. Swans group presented
data on this issue nearly 40 yrs ago (7),and experimental and
human studies
have consistently confirmed a very poor
correlation between central venous pres-
sure and preload (8). Although centralvenous pressure is a
fairly good estimate
of right atrial pressure, it bears little re-
lation to right ventricular end-diastolicvolume, 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 either
overfill or underfill septic patients (10).
Accordingly, the present study shouldurge us to review current
guidelines and
discuss alternatives to central venouspressure as a target
parameter for fluid
resuscitation.To date no randomized controlled tri-
als have been designed to study dosing ofintravenous fluids in
patients suffering
from septic shock. The present data were
corrected for age and Acute PhysiologyAssessment 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 Health
Evaluation II scores might respond dif-ferently to fluids. One
patient may well be
reversed by fluids and the other not.
Fluid responsiveness could thus serve asa measure of illness,
indirectly reflecting
the degree of inflammation and capillaryleak. Unfortunately,
failure to reverse
septic 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 and
elevated 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
Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e318205c375
396 Crit Care Med 2011 Vol. 39, No. 2
