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Sarah J. Lee, MD, MPH; Kannan Ramar, MBBS, MD; John G. Park, MD, FCCP; Ognjen Gajic, MD, FCCP; Rahul Kashyap, MBBS
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic.

CORRESPONDENCE TO: Rahul Kashyap, MBBS, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: kashyap.rahul@mayo.edu


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):e181. doi:10.1378/chest.14-1712
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To the Editor:

We thank Drs Adrish and Soto for their comments on our recent article in CHEST.1 We agree that electronic medical records, especially progress notes, are subject to human entry error. However, the data in the study were gathered in near real-time entry into the ICU Datamart database as hemodynamics were monitored and fluids were given by providers.2,3 Vital signs, laboratory findings, and medication administration are automatically captured and also validated by ICU nurses at hourly intervals. The study period was selected for completeness and accuracy of the data, which took several years to collect, recheck, and validate against any errors.

We agree that retrospective studies have limitations compared with prospective randomized controlled trials. The weaknesses of the observational study design have been outlined in the discussion of our article.1 It is possible that fluid was conservatively given to some patients per the individual clinician’s decision-making. However, it is unlikely that fluid was systematically withheld to a group of patients with select chronic conditions as that would be inconsistent with the institution’s sepsis resuscitation protocol. Furthermore, we incorporated into the logistic regression analysis age and APACHE (Acute Physiology and Chronic Health Evaluation) and Sequential Organ Failure Assessment (SOFA) scores to account for chronic medical conditions and severity of acute illness. Nevertheless, we cannot exclude potential bias resulting from unmeasured confounders.

In regard to the Protocolized Care for Early Septic Shock (ProCESS) trial, enrollment into the study occurred within (or up to) 2 h of sepsis recognition and within (or up to) 12 h after ED admission. By the time of enrollment into the study, patients had already received 2.2 L or about 29 mL/kg (30.5 ± 22.3 in early goal-directed therapy, 29.2 ± 19.1 in protocol, and 28 ± 21 in usual care group).4 Given that all three groups initially received similar amounts of fluids early in their resuscitation (prior to randomization), ProCESS trial results do not necessarily seem to refute our findings.

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]
 
Herasevich V, Pickering BW, Dong Y, Peters SG, Gajic O. Informatics infrastructure for syndrome surveillance, decision support, reporting, and modeling of critical illness. Mayo Clin Proc. 2010;85(3):247-254. [CrossRef] [PubMed]
 
Herasevich V, Kor DJ, Li M, Pickering BW. ICU data mart: a non-iT approach. A team of clinicians, researchers and informatics personnel at the Mayo Clinic have taken a homegrown approach to building an ICU data mart. Healthc Inform. 2011;28(11):42, 44-45. [PubMed]
 
ProCESS Investigators;Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. [CrossRef] [PubMed]
 

Figures

Tables

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]
 
Herasevich V, Pickering BW, Dong Y, Peters SG, Gajic O. Informatics infrastructure for syndrome surveillance, decision support, reporting, and modeling of critical illness. Mayo Clin Proc. 2010;85(3):247-254. [CrossRef] [PubMed]
 
Herasevich V, Kor DJ, Li M, Pickering BW. ICU data mart: a non-iT approach. A team of clinicians, researchers and informatics personnel at the Mayo Clinic have taken a homegrown approach to building an ICU data mart. Healthc Inform. 2011;28(11):42, 44-45. [PubMed]
 
ProCESS Investigators;Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. [CrossRef] [PubMed]
 
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