Objective In septic patients, multiple retrospective studies show an association between large volumes of fluids administered in the first 24 h and mortality, suggesting a benefit to fluid restrictive strategies. However, these studies do not directly estimate the causal effects of fluid-restrictive strategies, nor do their analyses properly adjust for time-varying confounding by indication. In this study, we used causal inference techniques to estimate mortality outcomes that would result from imposing a range of arbitrary limits (“caps”) on fluid volume administration during the first 24 h of intensive care unit (ICU) care. Design Retrospective cohort study Setting ICUs at the Beth Israel Deaconess Medical Center, 2008–2012 Patients One thousand six hundred thirty-nine septic patients (defined by Sepsis-3 criteria) 18 years and older, admitted to the ICU from the emergency department (ED), who received less than 4 L fluids administered prior to ICU admission Measurements and main results Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC-III). We employed a dynamic Marginal Structural Model fit by inverse probability of treatment weighting to obtain confounding adjusted estimates of mortality rates that would have been observed had fluid resuscitation volume caps between 4 L–12 L been imposed on the population. The 30-day mortality in our cohort was 17%. We estimated that caps between 6 and 10 L on 24 h fluid volume would have reduced 30-day mortality by − 0.6 to − 1.0%, with the greatest reduction at 8 L (− 1.0% mortality, 95% CI [− 1.6%, − 0.3%]). Conclusions We found that 30-day mortality would have likely decreased relative to observed mortality under current practice if these patients had been subject to “caps” on the total volume of fluid administered between 6 and 10 L, with the greatest reduction in mortality rate at 8 L.

中文翻译：

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ICU 脓毒症患者的液体限制治疗策略：回顾性因果分析

目的 在脓毒症患者中，多项回顾性研究表明，在最初 24 小时内给予大量液体与死亡率之间存在关联，这表明限制液体策略是有益的。然而，这些研究并没有直接估计液体限制策略的因果效应，他们的分析也没有针对适应症随时间变化的混杂因素进行适当调整。在这项研究中，我们使用因果推断技术来估计由于在重症监护病房 (ICU) 护理的前 24 小时内对输液量施加一系列任意限制（“上限”）而导致的死亡率结果。设计 回顾性队列研究 在贝斯以色列女执事医疗中心设置 ICU，2008-2012 年 患者 1639 名 18 岁及以上的脓毒症患者（由 Sepsis-3 标准定义），从急诊科 (ED) 入住 ICU，在入住 ICU 之前接受的液体少于 4 L 测量和主要结果数据来自重症监护 III (MIMIC-III) 医疗信息集市。我们采用了动态边际结构模型拟合，通过治疗加权的逆概率来获得对死亡率的混杂调整估计值，如果对人群强加 4 升至 12 升的液体复苏容量上限，则会观察到死亡率的混杂调整估计值。我们队列中的 30 天死亡率为 17%。我们估计 24 小时液体量的上限为 6 至 10 L 可使 30 天死亡率降低 - 0.6 至 - 1.0%，8 L 时降低最大（- 1.0% 死亡率，95% CI [- 1.6%， − 0.3%])。