Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study.

OBJECTIVE: We hypothesized that patients with septic shock who achieve negative fluid balance (< or =-500 mL) on any day in the first 3 days of management are more likely to survive than those who do not. DESIGN: Retrospective chart review. PATIENTS: Thirty-six patients admitted with the diagnosis of septic shock. SETTING: Twelve-bed medical ICU of a 300-bed community teaching hospital. METHODS: Medical records of 36 patients admitted to our medical ICU over a 21-month period were examined. Patients with septic shock who required dialysis prior to hospitalization were not included. A number of demographic and physiologic variables were extracted from the medical records. Admission APACHE (acute physiology and chronic health evaluation) II and daily sequential organ failure assessment (SOFA) scores were computed from the extracted data. Variables were compared between survivors and nonsurvivors and in patients who did vs those who did not achieve negative (< or = 500 mL) fluid balance in > or = 1 day of the first 3 days of management. Survival risk ratios (RRs) were used as the measure of association between negative fluid balance and survival. RRs were adjusted for age, APACHE II scores, SOFA scores on the first and third days, and the need for mechanical ventilation, by stratified analyses. RESULTS: Patients ranged in age from 16 to 85 years with a mean (+/- SE) age of 67.4 +/- 3.3 years. The mean admission APACHE II score was 25.4 +/- 1.4, and the day 1 SOFA score was 9.0 +/- 0.8. Twenty patients did not survive; nonsurvivors had higher mean APACHE II scores than survivors (29.8 vs 20.4, respectively) and higher first day SOFA scores than survivors (10.8 vs 6.9, respectively), and they were more likely to require vasopressors and mechanical ventilation compared to patients who survived. Whereas all 11 patients who achieved a negative balance of > 500 mL on > or = 1 of the first 3 days of treatment survived, only 5 of 25 patient who failed to achieve a negative fluid balance of > 500 mL by the third day of treatment survived (RR, 5.0; 95% CI, 2.3 to 10.9; p = 0.00001). At least 1 day of net negative fluid balance in the first 3 days of treatment strongly predicted survival across the strata of age, APACHE II scores, first- and third-day SOFA scores, the need for mechanical ventilation, and creatinine levels measured at admission. CONCLUSION: These results suggest that at least 1 day of negative fluid balance (< or = -500 mL) achieved by the third day of treatment may be a good independent predictor of survival in patients with septic shock. These findings suggest the hypothesis "that negative fluid balance achieved in any of the first 3 days of septic shock portends a good prognosis," for a larger prospective cohort study.

Noninvasive ventilation: experience at a community teaching hospital.

OBJECTIVE: To describe our hospital's experience with noninvasive positive pressure ventilation (bilevel positive airway pressure; BiPAP) for patients with respiratory failure (RF). DESIGN: Retrospective, observational study. SETTING: A 300-bed community teaching hospital. METHODS: Medical records were analyzed for physiologic and outcome variables for all patients who received BiPAP for RF between January 1994 and December 1996. RESULTS: Eighty patients with a mean (+/- S.E.) age of 71.5+/-1.3 years and APACHE II score of 17.2+/-0.6 received BiPAP for RF during the study period. Thirty-one patients received BiPAP for hypoxemic RF, 25 for acute hypercapnic RF, 9 for chronic hypercapnic RF, 10 for postextubation RF and 5 could not be categorized. BiPAP success was defined as no need for invasive ventilation. BiPAP was successful in 47 of 75 cases that could be classified; all BiPAP successes lived whereas 18 of 28 BiPAP failures died. In the overall cohort, BiPAP success was associated with a lower ICU length of stay (5.8+/-0.9 versus 10.6+/-1.4 days, p < 0.01). The duration of BiPAP dependency in successful cases was 35.3+/-6.7 h. BiPAP was successful in 20 of 25 patients with acute hypercapnic RF and in 15 of 31 patients with hypoxemic RF. The risk of BiPAP failure was significantly greater (risk ratio = 2.6, 95% CI = 1.1-6.1) for patients with hypoxemic than for those with hypercapnic RF. BiPAP success was marked by increased PaO2/FIO2 in patients with hypoxemic RF and by increased pH and reduced PCO2 in patients with hypercapnic RF. BiPAP use was also successful in 8 of 10 patients who developed RF within 48 h of endotracheal extubation. CONCLUSIONS: BiPAP is highly effective in selected patients with RF during routine use in a community teaching hospital. The success rate is higher amongst patients presenting with hypercapnic than amongst those with hypoxemic RF and BiPAP failure is associated with an increased likelihood of in-hospital mortality. BiPAP may also be used successfully to temporize patients who develop RF in the period following endotracheal extubation. The duration of BiPAP dependency (35 h in this study) was shorter than in previous trials, and, though this is speculative, may have been minimized by our performing a trial of unassisted breathing each day.

Reduction of homocysteine levels in coronary artery disease by low-dose folic acid combined with vitamins B6 and B12.

An increased plasma homocysteine concentration is a risk factor for atherosclerosis. Folic acid lowers homocysteine but the optimal dose in patients with coronary artery disease (CAD) is unclear. This placebo-controlled, single-blind, dose-ranging study evaluates the effect of low-dose folic acid on homocysteine levels in 95 patients aged 61 +/- 11 years (mean +/- SD) with documented CAD. Patients in each group were given either placebo or 1 of 3 daily supplements of folic acid (400 microg, 1 mg, or 5 mg) for 3 months. Each active treatment arm also received 500 microg vitamin B12 and 12.5 mg vitamin B6. Total plasma homocysteine levels were measured after 30 and 90 days. Folic acid 400 microg reduced homocysteine levels from 13.8 +/- 8.8 to 9.6 +/- 2.0 micromol/L at 90 days (p = 0.001). On 1- and 5-mg folic acid, levels decreased from 13.0 +/- 6.4 to 9.8 +/- 4.0 micromol/L (p = 0.001) and from 14.8 +/- 6.9 to 9.7 +/- 3.3 micromol/L (p < 0.001), respectively. The decrease was similar in all treatment groups. There was no significant change with placebo. Although the sample size is small, these findings suggest that daily administration of 400 microg/day folic acid combined with vitamin B12 and vitamin B6 may be equivalent to higher doses in reducing homocysteine levels in patients with CAD.