Fluid Overload and Deresuscitation Practices in Michigan ICUS

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Chest

Abstract

PURPOSE: While fluid resuscitation is a core component of sepsis management, fluid overload has been associated with increased mortality. Estimates of the incidence of fluid overload in sepsis vary and are largely based on single-center studies. Furthermore, approaches to de-resuscitation—active fluid removal with dialysis and/or diuretics—are not well-studied. We sought to understand incidence of fluid overload and variation in de-resuscitation practices in ICU patients with sepsis across Michigan hospitals. METHODS: Retrospective cohort study of patients hospitalized with community-acquired sepsis from 12/2021-12/2023 at 66 hospitals in the Michigan Hospital Medicine Safety Consortium (HMS), a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. The HMS-Sepsis registry includes a random sample of adult sepsis hospitalizations. Data are abstracted by professional abstractors at each site. Data for this period became available 3/2024. We included patients in the HMSSepsis registry who presented to the ED with sepsis-induced hypoperfusion (on vasopressors, SBP <90, MAP <65, or lactate $4 mmol/L within 3 hours), were admitted to the ICU for >24 hours, survived, and were discharged to the floor. Patients were excluded if no weights were documented on admission and ICU-to-floor transfer (last day ICU - floor day 2). Fluid overload was defined by weight gain from admission to ICU-to-floor transfer: <5% weight gain (no overload), 5-10% weight gain (mild overload), >10% weight gain (severe overload). De-resuscitation was defined as receiving renal replacement therapy (RRT) and/or diuretics on the day of ICU-to-floor transfer. We also assessed documentation of volume status at time of ICU-to-floor transfer based on abstractor chart review. Rates of de-resuscitation and documentation were compared using Chi-squared tests. Hospitals with <10 observations were dropped from analyses of hospital variation. RESULTS: Of 26,932 patients in the HMS-Sepsis registry, 1,545 (5.7%) met inclusion criteria. Of these, 941 (60.9%) had no overload, 286 (18.5%) had mild overload, and 318 (20.6%) had severe overload at ICU-to-floor transfer. Rates of fluid overload (combined mild and severe) ranged from 14.3% to 63.2% across hospitals. The proportion of patients receiving de-resuscitation (RRT and/or diuretics) at ICU-to-floor transfer was similar across volume status groups (no overload: 25.7%, mild overload: 25.5%, severe overload: 24.5%, p=0.69). Use of de-resuscitation varied across hospitals, with 0.0% to 50.0% of all patients receiving RRT and/or diuretics at ICU-to-floor transfer. Volume status documentation at ICU-to-floor transfer was also similar regardless of volume status group (no overload: 31.6%, mild overload: 29.7%, severe overload: 25.8%, p=0.15), though volume status was documented more often in patients receiving de-resuscitation (45.0% vs 24.9%, p<0.001). CONCLUSIONS: Over one-third of patients with sepsis-induced hypoperfusion were fluid overloaded at ICU discharge. However, rates of fluid overload and de-resuscitation varied widely across hospitals, and volume status did not correlate with deresuscitation or documentation. CLINICAL IMPLICATIONS: Our findings raise concern that fluid overload may be under-recognized, though our study is limited by potential errors in weights. Existing measures of fluid overload (weight, fluid balance) are subject to documentation error, which remains a major challenge to quantifying fluid overload. More work is needed to identify fluid overload and understand factors driving overload and approaches to de-resuscitation.

Volume

166

Issue

4 Suppl

First Page

A6379

Last Page

A6380

Comments

Chest 2024 Annual Meeting, October 6-9, 2024, Boston, MA

DOI

10.1016/j.chest.2024.07.021

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