De-resuscitation in septic shock refers to the process of actively removing excess fluids from a patient after their condition has been stabilized. During the initial phase of septic shock, fluid resuscitation is often necessary to restore tissue perfusion and stabilize the patient's hemodynamic status. However, excessive fluid administration can lead to fluid overload, which is associated with increased morbidity and mortality.
Increased awareness of fluid-overload's (FO) detrimental effects has led to strategies like restrictive fluid administration and active de-resuscitation to minimize FO. De-resuscitation strategies aim to off-load the excess fluid and mitigate the negative effects of fluid overload. These strategies may include the use of diuretics, renal replacement therapy, or other targeted interventions. The primary goal of de-resuscitation is to balance the need for adequate tissue perfusion while minimizing the risk of complications related to fluid overload. Implementing de-resuscitation strategies in septic shock patients is an essential part of optimizing fluid management and improving patient outcomes.
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Restrictive fluid administration has shown potential benefits in patient outcomes, while de-resuscitation strategies have been less studied. In a systematic review and meta-analysis aimed to evaluate the impact of active fluid de-resuscitation on mortality in critically ill patients with septic shock, a comprehensive search was conducted using PubMed, EmBase, and the Cochrane Library databases. Eligible trials were those that examined active fluid de-resuscitation and provided mortality data for patients with septic shock. The primary goal was to determine the effect of active de-resuscitation on short-term mortality in patients with septic shock. Secondary outcomes included assessing whether de-resuscitation resulted in fluid separation and the influence of de-resuscitation on patient-centered outcomes.
The systematic review included thirteen trials involving 8,030 patients, with five randomized-controlled trials (RCTs) incorporated in the meta-analysis. None of the RCTs demonstrated a reduction in mortality associated with active de-resuscitation measures (relative risk (RR) 1.12 [95% CI 0.84 – 1.48]). Fluid separation was achieved in two RCTs. Evidence from non-randomized trials suggests that de-resuscitation strategies may offer a mortality benefit and show a tendency toward a more negative fluid balance. Patient-centered outcomes were not impacted in the RCTs, and only one non-randomized trial showed an effect on the duration of mechanical ventilation and renal replacement therapy (RRT) requirements.
Do you actively perform de-resuscitation in septic shock patients once condition is stabilized?
Yes
No
The review highlights a significant knowledge gap regarding the benefits and potential harm of active de-resuscitation strategies in septic shock patients. Overall, the available data do not support changing current fluid management practices in septic shock for critically ill patients. The first step should be to develop an active fluid de-resuscitation protocol that achieves fluid separation. A combination of restrictive fluid administration and active de-resuscitation might be key to minimizing fluid overload in patients with septic shock and should be further investigated in high-quality clinical trials.
Limitations of this review include the small sample size, observational nature of most trials, low scientific quality of some observational studies, and potential confounders. Furthermore, collinearity of sepsis/septic shock with other diseases, such as AKI, reflects the complexity of critical illness and clinical practice.
In conclusion, this systematic review and meta-analysis found no evidence supporting the superiority of active fluid de-resuscitation over usual care in terms of mortality, fluid balance, or patient-centered outcomes for patients with septic shock. The current evidence is limited by a lack of high-quality RCTs, small sample sizes, and heterogeneous de-resuscitation methods. Furthermore, the validity of most RCTs is significantly undermined by their failure to achieve fluid separation. However, studies in other critical care areas have shown positive results from active fluid de-resuscitation, which may be applicable to septic shock patients. There is a strong need for high-quality research to address the existing knowledge gap concerning fluid minimization and de-resuscitation in patients with septic shock.
REFRENCES
Messmer AS, Dill T, Müller M, Pfortmueller CA. Active fluid de-resuscitation in critically ill patients with septic shock: A systematic review and meta-analysis. Eur J Intern Med. 2023 Mar;109:89-96. doi: 10.1016/j.ejim.2023.01.009. Epub 2023 Jan 11. PMID: 36635127.