Association of active fluid de-escalation timing with clinical outcomes in patients with septic shock: a multicenter cohort study

Background Early fluid resuscitation is a basic therapy for patients with septic shock but may lead to fluid overload associated with poor clinical outcomes. Active de-escalation (accumulated fluid removal using diuretics or ultrafiltration) is a crucial part of fluid management. Methods In this retrospective cohort study, patients were classified as the early group (with septic shock receiving active de-escalation within 24 hours after hemodynamic stability) and late group. The primary outcome was 28-day mortality. Secondary outcomes included use of mechanical ventilation and renal replacement therapy, incidence of kidney injury and hemodynamic deterioration. Landmark analysis and restricted cubic splines based on Cox regression were performed. Results A total of 5,782 patients were included, with 3,255 cases underwent de-escalation within 24 hours after hemodynamic stability and 1,898 pairs of patients were matched after propensity score matching. Patients in the early group were found with lower 28-day mortality (12.6% vs. 18.0%, P  < 0.001), more weaning from mechanical ventilation (32.5% vs. 56.2%, P  < 0.001), lower incidence of AKI (14.6% vs.17.1%, P  = 0.046) and hemodynamic deterioration (11.4 vs. 16%, P  < 0.001) on day 3. Similar outcomes were observed on day 5. A U-shaped association between fluid balance and 28-day mortality was observed. Daily fluid balance of − 1482mL within 3 days is associated with the lowest HR for 28-day mortality and range from − 2814mL to − 445mL represents HR lower than 1 for 28-day mortality. Conclusions Early de-escalation was associated with improved prognosis for patients with septic shock and fluid overload. Maintaining fluid balance in an optimal range could be beneficial and a de-escalation strategy according to fluid balance is recommended. Clinical Trial Number: Not applicable