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Higher Fluids in the First Three Hours of Sepsis Resuscitation? Too Soon to ConcludeHigher Fluids in Sepsis Resuscitation FREE TO VIEW

Muhammad Adrish, MD; Graciela J. Soto, MD
Author and Funding Information

From the Division of Critical Care Medicine (Drs Adrish and Soto) and Jay B. Langner Critical Care Service (Dr Soto), Montefiore Medical Center, Albert Einstein College of Medicine.

CORRESPONDENCE TO: Muhammad Adrish, MD, Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, 1650 Selwyn Ave, Ste 12 F, Bronx, NY 10457; e-mail: aadrish@hotmail.com


Dr Adrish is currently at the Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine (Bronx, NY).

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential 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. See online for more details.


Chest. 2014;146(5):e180. doi:10.1378/chest.14-1256
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To the Editor:

It is with great interest that we read the retrospective study published by Lee et al1 in a recent issue of CHEST (October 2014) that showed a significant decrease in hospital mortality in patients who received early fluid resuscitation within the first 3 h of onset of severe sepsis or septic shock. However, some important points related to this study need to be addressed.

The authors used electronic medical records (EMRs) to identify patients with severe sepsis and septic shock. “Sepsis onset time” was determined by fluid-resistant hypotension, vasopressor use, or a lactate level > 4 mmol/L.1 The reliability and validity of the outcome data in EMR-based interventional studies depend on the accuracy of data collection, entry, and storage. A study conducted on the Veterans Administration’s EMRs, a highly integrated and standardized EMR system, showed that 60% of the patients had one or more input-related errors, with an average of 7.8 errors per patient.2

The use of EMRs in observational studies is subject to selection bias and confounding.3 In the study by Lee et al,1 nonsurvivors were significantly older, had a higher severity of illness, and more organ dysfunction. Nonsurvivors also had lower net-positive fluid balance in the first 3 h of resuscitation. The authors suggested the unavailability of a central venous catheter as a possible explanation for underachieved resuscitation goals. However, the presence of certain medical conditions, such as congestive heart failure or chronic kidney disease, can also limit liberal fluid use. Patients with congestive heart failure and chronic kidney disease were not excluded in the study by Lee et al.1

Physicians may also limit aggressive care when presence of advanced medical illness or prior advance directives precludes this approach, thereby introducing treatment bias. In the recently published Protocolized Care for Early Septic Shock (ProCESS) trial, there were no outcome differences among the study groups despite receiving significantly different fluid volumes.4 In this randomized trial, patients with acute pulmonary edema, do-not-resuscitate status, or those deemed unsuitable for aggressive care were excluded.4

In a retrospective observational study, treatment selection bias can influence both the choice for a particular treatment and the outcome of interest. The confounding introduced by this type of bias cannot be adjusted with traditional logistic regression analyses.5 Adequate adjustment for treatment selection and confounding bias requires inclusion of variables that may be unknown or unavailable in a retrospective cohort. As appropriately indicated by Lee et al,1 their results need to be validated with a prospective study.

References

Lee SJ, Ramar K, Park JG, Gajic O, Li G, Kashyap R. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest. 2014;146(4):908-915. [CrossRef] [PubMed]
 
Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61-67. [PubMed]
 
Paxton C, Niculescu-Mizil A, Saria S. Developing predictive models using electronic medical records: challenges and pitfalls. AMIA Annu Symp Proc. 2013:1109-1115.
 
Yealy DM, Kellum JA, Huang DT, et al; ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. [CrossRef] [PubMed]
 
Dean BB, Lam J, Natoli JL, Butler Q, Aguilar D, Nordyke RJ. Review: use of electronic medical records for health outcomes research: a literature review. Med Care Res Rev. 2009;66(6):611-638. [CrossRef] [PubMed]
 

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References

Lee SJ, Ramar K, Park JG, Gajic O, Li G, Kashyap R. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest. 2014;146(4):908-915. [CrossRef] [PubMed]
 
Weir CR, Hurdle JF, Felgar MA, Hoffman JM, Roth B, Nebeker JR. Direct text entry in electronic progress notes. An evaluation of input errors. Methods Inf Med. 2003;42(1):61-67. [PubMed]
 
Paxton C, Niculescu-Mizil A, Saria S. Developing predictive models using electronic medical records: challenges and pitfalls. AMIA Annu Symp Proc. 2013:1109-1115.
 
Yealy DM, Kellum JA, Huang DT, et al; ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. [CrossRef] [PubMed]
 
Dean BB, Lam J, Natoli JL, Butler Q, Aguilar D, Nordyke RJ. Review: use of electronic medical records for health outcomes research: a literature review. Med Care Res Rev. 2009;66(6):611-638. [CrossRef] [PubMed]
 
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