Background Optimal fluid management in patients with acute lunginjury is unknown. Diuresis or fluid restriction may improvelung function but could jeopardize extrapulmonary-organ perfusion.
Methods In a randomized study, we compared a conservative anda liberal strategy of fluid management using explicit protocolsapplied for seven days in 1000 patients with acute lung injury.The primary end point was death at 60 days. Secondary end pointsincluded the number of ventilator-free days and organ-failure–freedays and measures of lung physiology.
Results The rate of death at 60 days was 25.5 percent in theconservative-strategy group and 28.4 percent in the liberal-strategygroup (P=0.30; 95 percent confidence interval for the difference,–2.6 to 8.4 percent). The mean (±SE) cumulativefluid balance during the first seven days was –136±491ml in the conservative-strategy group and 6992±502 mlin the liberal-strategy group (P<0.001). As compared withthe liberal strategy, the conservative strategy improved theoxygenation index ([mean airway pressurexthe ratio of the fractionof inspired oxygen to the partial pressure of arterial oxygen]x100)and the lung injury score and increased the number of ventilator-freedays (14.6±0.5 vs. 12.1±0.5, P<0.001) and daysnot spent in the intensive care unit (13.4±0.4 vs. 11.2±0.4,P<0.001) during the first 28 days but did not increase theincidence or prevalence of shock during the study or the useof dialysis during the first 60 days (10 percent vs. 14 percent,P=0.06).
Conclusions Although there was no significant difference inthe primary outcome of 60-day mortality, the conservative strategyof fluid management improved lung function and shortened theduration of mechanical ventilation and intensive care withoutincreasing nonpulmonary-organ failures. These results supportthe use of a conservative strategy of fluid management in patientswith acute lung injury. (ClinicalTrials.gov number, NCT00281268
[ClinicalTrials.gov]
.)
Source Information
The members of the Writing Committee (Herbert P. Wiedemann, M.D., Cleveland Clinic, Cleveland; Arthur P. Wheeler, M.D., and Gordon R. Bernard, M.D., Vanderbilt University, Nashville; B. Taylor Thompson, M.D., and Douglas Hayden, M.A., Massachusetts General Hospital, Boston; Ben deBoisblanc, M.D., Louisiana State University Health Sciences Center, New Orleans; Alfred F. Connors, Jr., M.D., Case Western Reserve University at MetroHealth Medical Center, Cleveland; R. Duncan Hite, M.D., Wake Forest University Health Sciences Center, Winston-Salem, N.C.; and Andrea L. Harabin, Ph.D., National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Md.) assume responsibility for the integrity of the article. This article was published at www.nejm.org on May 21, 2006.
Address reprint requests to Dr. Wiedemann at the Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, 9500 Euclid Ave., Desk A-90, Cleveland, OH 44195, or at wiedemh{at}ccf.org.
Fluid-Management Strategies in Acute Lung Injury
Schuller D., Schuster D. P., Morizio A., Kupfer Y., Tessler S., Amaral A. C.K.B., Amado V. M., Wiedemann H. P., Wheeler A. P., Hayden D.
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N Engl J Med 2006;
355:1175-1176, Sep 14, 2006.
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