Chest
Volume 100, Issue 4, October 1991, Pages 1068-1075
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Clinical Investigations in Critical Care
Fluid Balance during Pulmonary Edema: Is Fluid Gain a Marker or a Cause of Poor Outcome?

https://doi.org/10.1378/chest.100.4.1068Get rights and content

Study Objective:

To evaluate the importance of fluid balance and changes in extravascular lung water (EVLW) on survival in the ICU and short-term outcome in patients with pulmonary edema.

Design:

Retrospective analysis of data (sorting by survival and “treatment received”) from a recent randomized controlled trial of fluid restriction in this population.

Setting:

Medical ICU of a university-affiliated, tertiary-care medical center.

Patients:

Eighty-nine patients (from the previously mentioned study) requiring pulmonary artery catheterization with abnormally high EVLW (>7 ml/kg).

Measurements and Results:

When analyzed by survival, the survivors had no significant fluid gain or change in EVLW but decreased wedge pressure and body weight, compared to nonsurvivors. When analyzed by fluid balance, patients who gained less than 1 L of fluid by 36 hours into the study had a better rate of survival (74 percent) than the rest (50 percent; p<0.05). Also, the median duration of days on the ventilator, ICU days, and days of hospitalization was approximately half as long for each variable in the group with less than 1 L of fluid gain. Even accounting for baseline differences in the severity of illness, fluid balance was an independent predictor of survival (p<0.05). When analyzed by whether or not EVLW decreased by more than 15 percent between the first and last measurement, only patients with ARDS or sepsis had decreased days on the ventilator and ICU days.

Conclusions:

These data support the concept that positive fluid balance per se is at least partially responsible for poor outcome in patients with pulmonary edema and defend the strategy of attempting to achieve a negative fluid balance if tolerated hemodynamically.

Section snippets

MATERIALS AND METHODS

The data for this study were collected prospectively from June 14, 1987 to June 22, 1989 in the medical ICU of Barnes Hospital, St. Louis. During this time, 302 balloon-flotation pulmonary artery catheters were placed, usually for evaluation of shock or pulmonary edema. Although 201 patients were excluded from entering the study, a post hoc analysis failed to reveal any systematic sources of bias or difference in outcome for these patients vs the patients who actually participated in the study

Analysis by Survival

The baseline characteristics of survivors and non-survivors are shown in Table 1. Not surprisingly, the baseline scores for severity of illness were significantly lower for survivors. A larger fraction of patients in the surviving group also had a clinical diagnosis of CHF. Seven patients did not meet criteria for sepsis syndrome, ARDS, or CHF (ie, four had interstitial pulmonary disease, two had massive gastrointestinal bleeding, and one had cirrhosis). The only significant difference in the

DISCUSSION

The issue of fluid management in pulmonary edema is not new. In both cardiogenic and noncardiogenic pulmonary edema, the intent to limit edema accumulation by reducing the pulmonary microvascular hydrostatic pressure follows directly from the model of capillary fluid dynamics embodied by the familiar Starling equation.15, 16, 17 Experimentally, reducing microvascular pressures consistently limits EVLW accumulation.5,18, 19, 20, 21 In CHF, there is little controversy about management, since the

Reasons for and Outcome of Patients Excluded from Study

Of the 302 patients who underwent PAC over the approximately two-year period of recruiting patients, 201 were excluded for the following reasons (number of patients in parentheses): (1) patient-related technical problems (69), including contraindicated arterial catheter, and PAC performed for preoperative assessment only; (2) patient-unrelated technical problems (42), including investigative staff unavailable or equipment malfunction or supply shortage; (3) technique unreliable (38), including

ACKNOWLEDGMENTS:

We thank Ms. Debra Babcock and Mr. Michael Provence of the Biostatistics Department for their help with statistical considerations; Charles Owen, R.N., and Denise Canfield, R.N., for help with data collection; the pulmonary fellows, medical house staff, and nurses of the Barnes Hospital Medical and Respiratory Intensive Care Units for their help in performing the EVLW measurements; and Ms. Lisa Schomaker for her secretarial assistance.

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    Supported in part by National Institutes of Health grant HL41476.

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