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Correspondence |

The Flood and Ebb of Septic Shock FREE TO VIEW

Constantine A. Manthous, MD, FCCP
Author and Funding Information

Affiliations: Dr. Manthous is Associate Clinical Professor of Medicine at Bridgeport Hospital and Yale University School of Medicine.

Correspondence to: Constantine A. Manthous, MD, FCCP, Associate Clinical Professor of Medicine Bridgeport Hospital and Yale University School of Medicine, 267 Grant St, Bridgeport, CT 06610; e-mail: Pcmant@bpthosp.org


Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(6):1705. doi:10.1378/chest.09-1723
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To the Editor:

In a recent issue of CHEST (June 2009), Murphy and colleagues1 reported that patients who receive greater attention to achieve adequate filling during early sepsis with acute lung injury, and whose fluid balance is negative during recovery, fare better than those who do not. Alsous and colleagues2 reported in these pages nearly a decade ago the association of negative fluid balance and the survival of patients with septic shock. The observation of Murphy et al1 is additional confirmation in a growing body of literature35 suggesting that fluid balance is associated with outcomes. It remains to be determined whether this is cause or effect. Insofar as the cardiovascular lesion of septic shock includes capillary leak and nitric oxide-mediated vasodilation, resulting in increased vascular capacitance, refilling is required to maintain venous return and systemic pressure. For patients with high-output shock and coincident lung injury, it is not unreasonable to increase venous tone by administering a pressor to permit less fluid administration. If source control (ie, appropriate antibiotic therapy and mechanical drainage when required) is timely, the storm flood abates, vascular tone and impermeability return more quickly, and the amount of exogenously administered fluid required to fill the system slowly decreases.6

In survivors, at some point no more fluid is required (ie, inputs equal outputs), after which the typical patient may be left with a >10-L cumulative net positive fluid balance2 (much less for those with lung injury if pressors are used to reduce fluid needs); it is the cost of success. That fluid MUST return to the vessels and central circulation as a prerequisite and a sign of recovery. Diastolic dysfunction and hypoalbuminemia commonly coincide; so, as venous return increases, the propensity to pulmonary edema increases. The transition to unassisted breathing (the cessation of sedative administration and a drop in mean thoracic pressure during spontaneous breathing trials) further aggravates this “venous return problem.” If the clinician does not keep up with diuresis, the patient's lungs flood with each spontaneous breathing trial (or even before each trial), and the patient remains unnecessarily bound to the ventilator.46 While this model7 awaits confirmation in a prospective randomized study, basic physiology and common sense, like so many recent seminal findings in critical care, are sure to prevail.

Murphy CV, Schramm GE, Doherty JA, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136:102-109. [PubMed] [CrossRef]
 
Alsous F, Khamiees M, DeGirolamo, et al. Negative fluid balance predicts survival in patients with septic shock. Chest. 2000;117:1749-1754. [PubMed]
 
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377. [PubMed]
 
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials NetworkWiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-2575. [PubMed]
 
Upadya A, Tilluckdharry L, Muralidharan V, et al. Fluid balance and weaning outcomes. Intensive Care Med. 2005;31:1643-1647. [PubMed]
 
Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest. 2006;130:1664-1671. [PubMed]
 
Manthous CA. Starling's equation and bedside critical care. J Crit Care. 2008;23:354-356. [PubMed]
 

Figures

Tables

References

Murphy CV, Schramm GE, Doherty JA, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136:102-109. [PubMed] [CrossRef]
 
Alsous F, Khamiees M, DeGirolamo, et al. Negative fluid balance predicts survival in patients with septic shock. Chest. 2000;117:1749-1754. [PubMed]
 
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377. [PubMed]
 
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials NetworkWiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-2575. [PubMed]
 
Upadya A, Tilluckdharry L, Muralidharan V, et al. Fluid balance and weaning outcomes. Intensive Care Med. 2005;31:1643-1647. [PubMed]
 
Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest. 2006;130:1664-1671. [PubMed]
 
Manthous CA. Starling's equation and bedside critical care. J Crit Care. 2008;23:354-356. [PubMed]
 
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