Fluid-limiting treatment strategies among sepsis patients in the ICU: a retrospective causal analysis

Shahn, Zach; Shapiro, Nathan I.; Tyler, Patrick D.; Talmor, Daniel; Lehman, Li-wei H.

OBJECTIVE: In septic patients, multiple retrospective studies show an association between large volumes of fluids administered in the first 24 h and mortality, suggesting a benefit to fluid restrictive strategies. However, these studies do not directly estimate the causal effects of fluid-restrictive strategies, nor do their analyses properly adjust for time-varying confounding by indication. In this study, we used causal inference techniques to estimate mortality outcomes that would result from imposing a range of arbitrary limits (“caps”) on fluid volume administration during the first 24 h of intensive care unit (ICU) care. DESIGN: Retrospective cohort study SETTING: ICUs at the Beth Israel Deaconess Medical Center, 2008–2012 PATIENTS: One thousand six hundred thirty-nine septic patients (defined by Sepsis-3 criteria) 18 years and older, admitted to the ICU from the emergency department (ED), who received less than 4 L fluids administered prior to ICU admission MEASUREMENTS AND MAIN RESULTS: Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III). We employed a dynamic Marginal Structural Model fit by inverse probability of treatment weighting to obtain confounding adjusted estimates of mortality rates that would have been observed had fluid resuscitation volume caps between 4 L–12 L been imposed on the population. The 30-day mortality in our cohort was 17%. We estimated that caps between 6 and 10 L on 24 h fluid volume would have reduced 30-day mortality by − 0.6 to − 1.0%, with the greatest reduction at 8 L (− 1.0% mortality, 95% CI [− 1.6%, − 0.3%]). CONCLUSIONS: We found that 30-day mortality would have likely decreased relative to observed mortality under current practice if these patients had been subject to “caps” on the total volume of fluid administered between 6 and 10 L, with the greatest reduction in mortality rate at 8 L.