After excluding 62 patients aged less than 16 years or of unknown age, a total of 5,274 patients were included. Table shows the contributing countries and within each of these the number of contributing ICUs, patients and fluid resuscitation episodes. Overall 37.1% (1,955) of patients received fluid resuscitation during the 24-hour study period. This percentage was higher in patients for whom the study period coincided with their admission date to ICU; specifically 55% and 40% of patients who were surveyed on respectively Day 0 or Day 1 in the ICU received fluid resuscitation (Figure ). Of the patients who received fluid, 848 (43.4%) received fluid in one hour only, 495 (25.3%) in two separate hours and 612 (31.3%) in three separate hours or more. Among those receiving fluid, the median number of hours where fluid was administered was two (mean two, inter-quartile range one to three).
Countries/territories, intensive care units and patients included in the survey
Proportion of study participants receiving fluid resuscitation according to the number of days in the ICU.
Figures and show by country the proportion of fluid resuscitation episodes given as crystalloid, colloid and blood product, and the types of colloid as a proportion of all episodes where colloid was given, respectively. Overall crystalloid was administered during 33% of resuscitation episodes, colloid during 48% of episodes and blood products during 28%. Between countries the percentage of episodes where crystalloid was administered ranged from 9 to 58%, colloid from 13 to 76% and blood products from 18 to 42%. The type of colloid used for fluid resuscitation in the contributing ICUs also differed between countries (Figure ); overall starch was administered in 44% of colloid resuscitation episodes, albumin in 30%, gelatin in 25% and dextran in 3%.
Figure 2 Percentage of fluid resuscitation episodes given as crystalloid, colloid or blood product according to country*. Crystalloid; Colloid; Blood: *Difference in proportions given crystalloid, colloid or blood between countries, respectively P < 0.001, (more ...)
Type of colloid used as a percentage of all colloid episodes by country. Albumin; starch; gelatin; dextran
The characteristics of the 1,955 patients who received fluid resuscitation during the study are shown in Table . Of the 4,488 episodes of fluid resuscitation, 39.2% were for the indication of impaired perfusion or low cardiac output. The majority of other fluid resuscitation episodes were for abnormal vital signs in the absence of impaired perfusion (28.5%) or for anaemia, bleeding or coagulopathy (18.5%). Considering only episodes where crystalloid or colloid were administered (n = 3,419), the main indications were impaired perfusion or low cardiac output (44.6%), or to correct abnormal vital signs in the absence of impaired perfusion or low cardiac output (34.8%).
Characteristics of 1,955 patients who received fluid resuscitation and indications for the 4,488 episodes of fluid resuscitation
The patient characteristics, clinical signs and prescriber factors associated with administration of crystalloid, colloid or blood products, are shown by patient and by episode of fluid resuscitation in Tables and respectively. After adjusting for factors that were found by univariate analysis to be associated (P < 0.1) with the administration of crystalloid, colloid or blood product, significant associations remained (Table ). The type of fluid prescribed in the contributing ICUs differed significantly between countries. Compared to Canada (where the proportion of all fluid episodes prescribed as crystalloid, colloid and blood products was 35.5%, 40.6% and 28.3% respectively, and the distribution most closely resembled that of all contributing ICUs combined) crystalloid was less likely to be administered to patients in contributing ICUs in China, Great Britain and Sweden, but more likely to be administered to patients in contributing ICUs in Italy, New Zealand and the USA; there was no significant difference in crystalloid prescription to patients in contributing ICUs between Canada and Australia, Denmark, France, Germany, Hong Kong and Switzerland. Conversely, compared to Canada, colloid was more likely to be administered to patients in contributing ICUs in China and Great Britain and less likely to be administered to patients in contributing ICUs in New Zealand and the USA. Blood was significantly more likely to be prescribed in contributing ICUs in China, Denmark, Sweden and the USA compared to contributing ICUs in Canada.
Characteristics of 1,955 study participants who received crystalloid, colloid or blood products (patients who recevied more than one fluid type are included more than once)
Comparison of indication for fluid, seniority of fluid prescriber and patient characteristics present in relation to administration of crystalloid, colloid or blood by episode for 4,488 fluid resuscitation episodes in 1,955 study participants
Multivariate analysis of factors associated with the use of crystalloid, colloid or blood for fluid resuscitation episodes*
Other than country of location of the contributing ICUs, few factors were independently associated with the administration of crystalloid. Elective post-operative patients were more likely to receive colloid than crystalloid (67.3% versus 38.5%). Compared to this group, those admitted after emergency surgery or from the emergency department were more likely to be resuscitated with crystalloid (OR = 1.57, 95% CI 1.12 to 2.20 and OR = 2.16, 95% CI 1.56 to 2.99 respectively). Among the 514 patients who were admitted to the ICU on the study day, colloid was also more commonly prescribed than crystalloid (622/1,395 episodes (44.6%) versus 561/1,395 (40.2%)). Compared to this group, those who had been in the ICU for longer were less likely to receive crystalloid (OR = 0.70, 95% CI 0.56 to 0.87). In patients where the indication for fluid was impaired perfusion or low cardiac output, colloid was administered more commonly than crystalloid (899/1,743 (51.6%) versus 739/1,743 (42.4%)) and compared to this group, colloid was more likely to be administered as part of a unit protocol (OR 1.65, 95% CI 1.21 to 2.25) and for correction of abnormal vital signs (OR 1.34, 95% CI 1.12 to 1.60). For episodes where the indication was anaemia, bleeding or coagulopathy, administration of crystalloid or colloid was less likely (OR = 0.15, 95% CI 0.12 to 0.20 and OR = 0.13, 95% CI 0.10 to 0.17 respectively) and blood products more likely (OR = 26.7, 95% CI 20.2 to 35.4). The likelihood of receiving colloid increased significantly with a lower mean arterial pressure (OR = 1.16, 95% CI 1.11 to 1.21 per 10 mmHg decrease).
The administration of blood products was predominantly determined by two factors, a reported indication of 'anaemia, bleeding or coagulopathy' (OR 26.7, 95% CI 20.2 to 35.4 compared to 'impaired perfusion or low cardiac output') and haemoglobin concentration (OR 1.24, 95% CI 1.18 to 1.30 per 10 g/L decrease). Patients being treated with renal replacement therapy (OR 1.86, 95% CI 1.29 to 2.68) and with hyperlactaemia (OR 1.59, 95% CI 1.21 to 2.08) were also more likely to receive blood products. Blood products were less likely to be prescribed if the patient had severe sepsis diagnosed in the 24 hours prior to the survey (OR 0.67, 95% CI 0.51 to 0.89). Compared to patients admitted to the ICU following elective surgery, blood was less likely to be prescribed in those admitted from the hospital floor, the operating theatre after emergency surgery or the emergency room.