CHEST Guidelines-Higher-Fluids-in-the-First-Three-Hours-of-Sepsis-R

Higher-Fluids-in-the-First-Three-Hours-of-Sepsis-R

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The correspondence in the November 2014 issue of CHEST addresses a retrospective study by Lee et al., which suggests that early fluid resuscitation within the first three hours of sepsis onset reduces hospital mortality. The authors, Muhammad Adrish and Graciela J. Soto, express concerns about the study’s methodology and draw attention to several critical issues that may impact the validity of the findings.<br /><br />Firstly, the study relied on electronic medical records (EMRs) to identify patients with severe sepsis and septic shock, determining the "sepsis onset time" using fluid-resistant hypotension, vasopressor use, or lactate levels. However, the accuracy of EMRs is questioned, citing a study that found frequent input errors in a highly standardized EMR system. This inherent error rate in data could introduce significant biases that affect study outcomes.<br /><br />Additionally, the correspondence highlights potential selection bias and confounding inherent in observational studies using EMRs. Nonsurvivors in Lee et al.'s study were older, with higher illness severity and more organ dysfunction. The study did not exclude patients with conditions like congestive heart failure or chronic kidney disease, which could hinder liberal fluid use, thus possibly contributing to outcome discrepancies. Furthermore, treatment bias from limiting aggressive care in advanced illnesses could skew results.<br /><br />Adrish and Soto compare this with the ProCESS trial, a randomized study that found no significant outcome differences despite varying fluid volumes administered to participants. They emphasize the need for prospective studies to validate the results observed by Lee et al., as the retrospective nature of the study limits its ability to fully account for treatment selection and confounding biases.<br /><br />In conclusion, while the findings on early fluid resuscitation are promising, the authors advise caution and suggest further prospective research to ascertain the study's claims accurately.

Keywords

sepsis

early fluid resuscitation

hospital mortality

retrospective study

electronic medical records

methodology concerns

selection bias

ProCESS trial

prospective research

treatment bias