• Niels van Mourik, Bart F Geerts, Jan M Binnekade, Denise P Veelo, BosLieuwe D JLDJDepartment of Intensive Care Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands., W Joost Wiersinga, Tom van der Poll, Olaf L Cremer, Marcus J Schultz, and VlaarAlexander P JAPJDepartment of Intensive Care Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands..
• Department of Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
• Crit Care Explor. 2020 Oct 1; 2 (10): e0219.

ObjectivesPrevious studies demonstrated that extensive fluid loading and consequently positive fluid balances during sepsis resuscitation are associated with adverse outcome. Yet, the association between fluid balance and mortality after reversal of shock, that is, during deresuscitation, is largely unappreciated. Our objective was to investigate the effects of fluid balance on mortality in the days after septic shock reversal.DesignRetrospective observational cohort study.SettingICUs of two university-affiliated hospitals in The Netherlands.PatientsAdult patients admitted with septic shock followed by shock reversal. Reversal of septic shock was defined based on Sepsis-3 criteria as the first day that serum lactate was less than or equal to 2 mmol/L without vasopressor requirement.InterventionsNone.Measurements And Main ResultsReversal of septic shock occurred in 636 patients, of whom 20% died in the ICU. Mixed-effects logistic regression modeling, adjusted for possible confounders, showed that fluid balance in the days after reversal of septic shock (until discharge or death) was an independent predictor of ICU mortality: odds ratio 3.18 (1.90-5.32) per 10 mL/kg increase in daily fluid balance. Similar results were found for 30-day, 90-day, hospital, and 1-year mortality: odds ratios 2.09 (1.64-2.67); 1.79 (1.38-2.32); 1.70 (1.40-2.07); and 1.53 (1.17-2.01), respectively. Positive cumulative fluid balances vs. neutral or negative fluid balances on the final day in the ICU were associated with increased ICU, hospital, 30-day, and 90-day mortality: odds ratios 3.46 (2.29-5.23); 3.39 (2.35-4.9); 5.33 (3.51-8.08); and 3.57 (2.49-5.12), respectively. Using restricted cubic splines, we found a dose-response relationship between cumulative fluid balance after shock reversal and ICU mortality.ConclusionsA higher fluid balance in the days after septic shock reversal was associated with increased mortality. This stresses the importance of implementing restrictive and deresuscitative fluid management strategies after initial hemodynamic resuscitation. Prospective interventional studies are needed to confirm our results.Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.

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