Is fluid management in sepsis leading to an increase in Acute Kidney Injury? As September is recognized by the CDC as Sepsis Awareness Month, it is a good time to evaluate your sepsis protocol.
Approximately 5 to 6 percent of ICU patients will develop acute kidney injury (AKI) and 60 percent of these patients will die in the hospital. Of these patients, 47.5 percent also had sepsis. 1
When treating sepsis, fluid resuscitation is often a necessity in the treatment of sepsis. The Surviving Sepsis Campaign, a joint collaboration of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, recommends the following guidelines for initial resuscitation:
A. Initial Resuscitation
- Protocolized, quantitative resuscitation of patients with sepsis-induced tissue hypoperfusion (defined in this document as hypotension persisting after initial fluid challenge or blood lactate concentration ≥ 4 mmol/L). Goals during the first 6 hrs of resuscitation:
- Central venous pressure 8–12 mm Hg
- Mean arterial pressure (MAP) ≥65 mm Hg
- Urine output ≥ 0.5 mL/kg/hr
- Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%, respectively (grade 1C).
- In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C).
Fluid resuscitation should be provided early and in well-defined boluses, (i.e. 500 ml). However, because AKI most commonly occurs four to six days after admission, we may need to think about fluid management not just during the first six hours, but also from hours 7 to 72.
Patients with fluid overload (an increase of more than 10 percent of their body weight) showed an increase in mortality and were more likely to develop acute kidney injury. Many patients receive three to five liters of fluids for resuscitation, equating six to 11 pounds during the first six hours. 2
When resuscitation is complete fluids should be reduced or stopped, yet many patients continue to receive significant maintenance fluids. The goal of treatment should be to achieve a neutral or negative fluid balance. Patients who were treated conservatively had a cumulative seven day fluid balance of negative 136 +/- 491 ml; those who were treated liberally with fluids had a balance of positive 6992 +/- 502 ml. The conservatively treated patients had CVP closer to 8 mm Hg; those treated liberally were closer to CVP 12 mm Hg.2
When normal saline is continued at rates of 75, 100 or 125 ml/hr post resuscitation are you also seeing rising chloride levels and acute kidney injury?
Does your hospital sepsis protocol cover only the first 6 hours or does it extend through the first 7 days and cover fluid management post resuscitation? Adjusting fluid management practices could be an opportunity to improve patient outcomes.
About Janet Blackmere, PharmD
Janet Blackmere, PharmD is a Pharmacy Clinical Program Manager for Pharmacy OneSource. Janet has more than 15 years of experience in pharmacy informatics, pharmacy workflow optimization, automation and clinical decision support. She also has 10 years of consulting experience. She is a member of American Society of Health-System Pharmacists (ASHP) and the Florida Society of Health-System Pharmacists (FSHP).
Janet received her PharmD from the University of Florida and completed a specialty Residency in Computer Applications to foster Pharmaceutical Care.
1 Uchino, S., Kellum J. A., Bellomo, R., Doig, G. S., Morimatsu, H., Morgera, S., Schetz, M., Tan, I., Bouman, C., Macedo, E., Gibney, N., Tolwani, A., Ronco, C. Acute Renal Failure in Critically Ill Patients: a multinational, multicenter study. JAMA. 2005 Aug 17;294(7):813-8.
2 Schrier, R.W. Fluid administration in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol. 2010 Apr;5(4):733-9. doi: 10.2215/CJN.00060110.
3 The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006 Jun 15;354(24):2564-75.
4 O’Malley, C. M. N. Intravenous Fluids and Renal Failure. Transfusion Alternatives in Transfusion Medicine. June2008; 5(4):416 - 423.
5 ASHP 2014 Summer Meeting Professional Poster Abstracts. www.ashp.org/DocLibrary/SM2014/Poster-Abstracts.pdf
6 Bufano, P. Smaller Is Better For Cutting Costs Of Fluid Overload. Pharmacy Practice News. 2014 August; Vol 41.
7 Yerram P., Karuparthi P. R., Misra M. Fluid overload and acute kidney injury. Hemodial Int. 2010 Oct;14(4):348-54.