High-Dose Methylprednisolone Pulses for 3 Days vs. Low-Dose Dexamethasone for 10 Days in Severe, Non-Critical COVID-19: A Retrospective Propensity Score Matched Analysis

Corticosteroids are largely recommended in patients with severe COVID-19. However, evidence to support high-dose methylprednisolone (MP) pulses is not as robust as that demonstrated for low-dose dexamethasone (DXM) in the RECOVERY trial. This is a retrospective cohort study on severe, non-critically ill patients with COVID-19, comparing 3-day MP pulses ≥ 100 mg/day vs. DXM 6 mg/day for 10 days. The primary outcome was in-hospital mortality, and the secondary outcomes were need of intensive care unit (ICU) admission or invasive mechanical ventilation (IMV). Propensity-score matching (PSM) analysis was applied. From March 2020 to April 2021, a total of 2,284 patients were admitted to our hospital due to severe, non-critically ill COVID-19, and of these, 189 (8.3%) were treated with MP, and 493 (21.6%) with DXM. The results showed that patients receiving MP showed higher in-hospital mortality (31.2% vs. 17.8%, p < 0.001), need of ICU admission (29.1% vs. 20.5%, p = 0.017), need of IMV (25.9% vs. 13.8, p < 0.001), and median hospital length of stay (14 days vs. 11 days, p < 0.001). Our results suggest that treatment with low-dose DXM for 10 days is superior to 3 days of high-dose MP pulses in preventing in-hospital mortality and need for ICU admission or IMV in severe, non-critically ill patients with COVID-19.

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High-dose versus low-dose haemofiltration for the treatment of critically ill patients with acute kidney injury: an updated systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2016-014171 ◽

2017 ◽

Vol 7 (10) ◽

pp. e014171 ◽

Cited By ~ 7

Author(s):

Peng Li ◽

Li-ping Qu ◽

Dong Qi ◽

Bo Shen ◽

Yi-mei Wang ◽

...

Keyword(s):

Systematic Review ◽

Acute Kidney Injury ◽

Hospital Mortality ◽

Hospital Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Low Dose ◽

Meta Analysis ◽

Kidney Injury ◽

High Dose

ObjectiveThe purpose of this study was to perform a systematic review and meta-analysis to evaluate the effect of high-dose versus low-dose haemofiltration on the survival of critically ill patients with acute kidney injury (AKI). We hypothesised that high-dose treatments are not associated with a higher risk of mortality.DesignMeta-analysis.SettingRandomised controlled trials and two-arm prospective and retrospective studies were included.ParticipantsCritically ill patients with AKI.InterventionsContinuous renal replacement therapy.Primary and secondary outcome measuresPrimary outcomes: 90-day mortality, intensive care unit (ICU) mortality, hospital mortality; secondary outcomes: length of ICU and hospital stay.ResultEight studies including 2970 patients were included in the analysis. Pooled results showed no significant difference in the 90-mortality rate between patients treated with high-dose or low-dose haemofiltration (pooled OR=0.90, 95% CI 0.73 to 1.11, p=0.32). Findings were similar for ICU (pooled OR=1.12, 95% CI 0.94 to 1.34, p=0.21) and hospital mortality (pooled OR=1.03, 95% CI 0.81 to 1.30, p=0.84). Length of ICU and hospital stay were similar between high-dose and low-dose groups. Pooled results are not overly influenced by any one study, different cut-off points of prescribed dose or different cut-off points of delivered dose. Meta-regression analysis indicated that the results were not affected by the percentage of patients with sepsis or septic shock.ConclusionHigh-dose and low-dose haemofiltration produce similar outcomes with respect to mortality and length of ICU and hospital stay in critically ill patients with AKI.This study was not registered at the time the data were collected and analysed. It has since been registered on 17 February 2017 athttp://www.researchregistry.com/, registration number: reviewregistry211.

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Evaluation of low-dose aspirin use among COVID-19 critically ill patients: A Multicenter Propensity Score Matched Study

10.21203/rs.3.rs-872891/v2 ◽

2021 ◽

Author(s):

Abdullah Al Harthi ◽

Khalid Al Sulaiman ◽

Ohoud Aljuhani ◽

Ghazwa B. Korayem ◽

Ali F. Altebainawi ◽

...

Keyword(s):

Propensity Score ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Low Dose ◽

P Value ◽

Icu Stay ◽

Dose Aspirin ◽

Low Dose Aspirin ◽

Anti Inflammatory

Abstract BackgroundMultiple medications with anti-inflammatory effects have been used to manage the hyper-inflammatory response associated with COVID-19. Aspirin is used widely as a cardioprotective agent due to its antiplatelet and anti-inflammatory properties. Its role in hospitalized COVID-19 patients has been assessed and evaluated in the literature. However, no data regards its role in COVID-19 critically ill patients. Therefore, this study aims to evaluate the use of low-dose aspirin (81-100 mg) and its impact on outcomes in COVID-19 critically ill patients. MethodThis is a multicenter, retrospective cohort study for all adult critically ill patients with confirmed COVID-19 admitted to Intensive Care Units (ICUs) between March 1, 2020, and March 31, 2021. Eligible patients were classified into two groups based on aspirin use during ICU stay. The primary outcome is the in-hospital mortality; other outcomes were considered secondary. Propensity score-matched used based on patient’s age, SOFA score, MV status within 24 hours of ICU admission, prone position status, ischemic heart disease (IHD), and stroke as co-existing illness. We considered a P value of < 0.05 statistically significant.ResultsA total of 1033 patients were eligible; 352 patients were included after propensity score matching (1:1 ratio). The in-hospital mortality (HR (95%CI): 0.73 (0.56, 0.97), p-value=0.03) were lower in patients who received aspirin during hospital stay. On the other hand, patients who received aspirin have a higher risk of major bleeding compared to the control group (OR (95%CI): 2.92 (0.91, 9.36), p-value=0.07); but was not statistically significant.ConclusionAspirin use in COVID-19 critically ill patients may have a mortality benefit; nevertheless, it may be linked with an increased risk of significant bleeding. The benefit-risk evaluation for aspirin usage during an ICU stay should be tailored to each patient.

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Delta Shock Index During Emergency Department Stay Is Associated With in Hospital Mortality in Critically Ill Patients

Frontiers in Medicine ◽

10.3389/fmed.2021.648375 ◽

2021 ◽

Vol 8 ◽

Author(s):

Yi-Syun Huang ◽

I-Min Chiu ◽

Ming-Ta Tsai ◽

Chun-Fu Lin ◽

Chien-Fu Lin

Keyword(s):

Emergency Department ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Early Mortality ◽

Hospital Length Of Stay ◽

Shock Index ◽

Hospital Outcomes ◽

Icu Admission ◽

Delta Shock

Background: Delta shock index (SI; i.e., change in SI over time) has been shown to predict mortality and need for surgical intervention among trauma patients at the emergency department (ED). However, the usefulness of delta SI for prognosis assessment in non-traumatic critically ill patients at the ED remains unknown. The aim of this study was to analyze the association between delta SI during ED management and in-hospital outcomes in patients admitted to the intensive care unit (ICU).Method: This was a retrospective study conducted in two tertiary medical centers in Taiwan from January 1, 2016, to December 31, 2017. All adult non-traumatic patients who visited the ED and who were subsequently admitted to the ICU were included. We calculated delta SI by subtracting SI at ICU admission from SI at ED triage, and we analyzed its association with in-hospital outcomes. SI was defined as the ratio of heart rate to systolic blood pressure (SBP). The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (HLOS) and early mortality. Early mortality was defined as mortality within 48 h of ICU admission.Result: During the study period, 11,268 patients met the criteria and were included. Their mean age was 64.5 ± 15.9 years old. Overall, 5,830 (51.6%) patients had positive delta SI. Factors associated with a positive delta SI were multiple comorbidities (51.2% vs. 46.3%, p < 0.001) and high Simplified Acute Physiology Score [39 (29–51) vs. 37 (28–47), p < 0.001). Patients with positive delta SI were more likely to have tachycardia, hypotension, and higher SI at ICU admission. In the regression analysis, high delta SI was associated with in-hospital mortality [aOR (95% CI): 1.21 (1.03–1.42)] and early mortality [aOR (95% CI): 1.26 (1.07–1.48)], but not for HLOS [difference (95% CI): 0.34 (−0.48 to 1.17)]. In the subgroup analysis, high delta SI had higher odds ratios for both mortality and early mortality in elderly [aOR (95% CI): 1.59 (1.11–2.29)] and septic patients [aOR (95% CI): 1.54 (1.13–2.11)]. It also showed a higher odds ratio for early mortality in patients with triage SBP <100 mmHg [aOR (95% CI): 2.14 (1.21–3.77)] and patients with triage SI ≥ 0.9 [aOR (95% CI): 1.62 (1.01–2.60)].Conclusion: High delta SI during ED stay is correlated with in-hospital mortality and early mortality in patients admitted to the ICU via ED. Prompt resuscitation should be performed, especially for those with old age, sepsis, triage SBP <100 mmHg, or triage SI ≥ 0.9.

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Evaluation of low-dose aspirin use among COVID-19 critically ill patients: A Multicenter Propensity Score Matched Study

10.21203/rs.3.rs-872891/v1 ◽

2021 ◽

Author(s):

Abdullah Al Harthi ◽

Khalid Al Sulaiman ◽

Ohoud Aljuhani ◽

Ghazwa B. Korayem ◽

Ali F. Altebainawi ◽

...

Keyword(s):

Propensity Score ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Low Dose ◽

P Value ◽

Dose Aspirin ◽

Increased Risk ◽

Low Dose Aspirin ◽

Anti Inflammatory

Abstract BackgroundMultiple medications with anti-inflammatory effects have been used to manage the hyper-inflammatory response associated with COVID-19. Aspirin is used widely as a cardioprotective agent due to its antiplatelet and anti-inflammatory properties. Its role in hospitalized COVID-19 patients has been assessed and evaluated in the literature. However, no data regards its role in COVID-19 critically ill patients. Therefore, this study aims to evaluate the use of low-dose aspirin (81-100 mg) and its impact on outcomes in COVID-19 critically ill patients. MethodThis is a multicenter, retrospective cohort study for all adult critically ill patients with confirmed COVID-19 admitted to Intensive Care Units (ICUs) between March 1, 2020, and March 31, 2021. Eligible patients were classified into two groups based on aspirin use during ICU stay.The primary outcome is the in-hospital mortality; other outcomes were considered secondary. Propensity score-matched used based on patient’s age, SOFA score, MV status within 24 hours of ICU admission, prone position status, ischemic heart disease (IHD), and stroke as co-existing illness. We considered a P value of < 0.05 statistically significant.ResultsA total of 1033 patients were eligible; 352 patients were included after propensity score matching (1:1 ratio). The in-hospital mortality (HR (95%CI): 0.73 (0.56, 0.97), p-value=0.03) were lower in patients who received aspirin during hospital stay. On the other hand, patients who received aspirin have a higher risk of major bleeding compared to the control group (OR (95%CI): 2.92 (0.91, 9.36), p-value=0.07); but was not statistically significant.ConclusionAspirin use in COVID-19 critically ill patients may have a mortality benefit; nevertheless, it may be linked with an increased risk of significant bleeding. The benefit-risk evaluation for aspirin usage during an ICU stay should be tailored to each patient.

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Clinical Significance of Bioimpedance Spectroscopy in Critically Ill Patients

Journal of Intensive Care Medicine ◽

10.1177/0885066617702591 ◽

2017 ◽

Vol 34 (6) ◽

pp. 495-502 ◽

Cited By ~ 3

Author(s):

Shang-Feng Yang ◽

Ching-Min Tseng ◽

I-Fan Liu ◽

Shin-Hung Tsai ◽

Wein-Shung Kuo ◽

...

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Fluid Management ◽

Laboratory Data ◽

Acute Stage ◽

Volume Control ◽

Hospital Death ◽

Icu Admission ◽

The Third

Background: Early fluid resuscitation is a key aspect in the successful management of critically ill patients, but the optimal goal for volume control after the acute stage of critical illness remains unclear. This study aimed to evaluate the prognostic value of bioimpedance spectrometry for fluid management in critically ill patients. Methods: In this prospective observational study, patients who consented to participate were screened within the first 24 hours of admission to a medical intensive care unit (ICU) from February 4, 2015, to January 31, 2016. Information on demographics, comorbidities, primary reasons for admission, baseline laboratory data, and ventilator or inotropic use were documented. Data of fluid intake, fluid output, and body weight were recorded for the first 3 days of ICU admission. Bioimpedance spectrometry was performed on the first and third days after ICU admission. All participants were followed until death or hospital discharge. Results: Of the 140 enrolled patients (median age: 70 years, interquartile range: 60-77 years), 23 (16.4%) patients died during hospitalization. Independent predictors of hospital mortality were Acute Physiology and Chronic Health Evaluation II scores (per 1 point increase, odds ratio [OR]: 1.101) and overhydration (OH) volume on the first day (per 1 L increase, OR: 1.216). Compared to normal OH status (OH volume between −1 and 1 L), hyper OH status (OH volume < −1 L) on the third day after ICU admission was an independent predictor of hospital death (OR: 7.609). Normal OH status on the third day was associated with greater numbers of ICU-free and ventilator-free days. Conclusion: Bioimpedance spectrometry can be used to predict outcomes in critically ill patients. Increased OH volume on day 1 and hyper OH volume on day 3 of ICU admission are associated with a greater risk of hospital mortality. Volume status on day 3 is associated with durations of ventilator use and ICU stay.

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Intubation is Safe in Respiratory Failure Associated with Septic Shock: An Observational Study

10.21203/rs.3.rs-127681/v1 ◽

2020 ◽

Author(s):

Ting Yang ◽

Yongchun Shen ◽

John G. Park ◽

Phillip J Schulte ◽

Andrew C Hanson ◽

...

Keyword(s):

Septic Shock ◽

Respiratory Failure ◽

Propensity Score ◽

Hospital Mortality ◽

Propensity Score Matching ◽

Medical Center ◽

Invasive Mechanical Ventilation ◽

Hospital Length Of Stay ◽

Hemodynamic Deterioration ◽

The Impact

Abstract BackgroundAcute respiratory failure associated with sepsis contributes to higher in-hospital mortality. Intubation and invasive mechanical ventilation is a common rescue procedure. However, the 2016 International Guidelines for Management of Sepsis and Septic Shock does not provide any recommendation on indication nor timing of intubation. Timely intubation may improve outcome. The decision to intubate those patients is often hampered by the fear of further hemodynamic deterioration following intubation. MethodsThis study aimed at evaluating the impact of timely intubation on outcome in sepsis associated respiratory failure. We conducted an ancillary analysis of a prospective registry od adult ICU patients with septic shock admitted to the medical ICU in a tertiary medical center, between April 30th, 2014 and December 31st, 2017. All cases of sepsis with lactate >4 mmol/L, mean arterial pressure <65 mmHg, or vasopressor use after 30 mL/kg fluid boluses and suspected or confirmed infection. Patients who remained hospitalized at 24 hours following sepsis onset were separated into intubated and non-intubated groups. The primary outcome was hospital mortality. Univariate and multivariable analyses were used, adjusted for admission characteristics and stabilization of shock within 6 hours. In a secondary analysis, time-dependent propensity score matching was used to match intubated and non-intubated patients.ResultsWe identified 345 (33%) patients intubated within 24 hours and 707 (67%) not intubated. Intubated patients were younger, transferred more often from an outside facility, had higher severity of illness scores, more lung infection, achieved blood pressure goals more often but less often lactate normalization within 6 hours. The crude in-hospital mortality was higher, 89 (26%) vs. 82 (12%), p<0.001, as were ICU mortality, and ICU and hospital length of stay. After adjustment, intubation showed no effect on hospital mortality but fewer hospital-free days through day 28. After 1:1 propensity score matching, there was no difference in hospital mortality, but fewer hospital-free days in the intubated group. ConclusionsIntubation within 24 hours of sepsis onset was safe and not associated with hospital mortality, but was associated with less 28-day hospital-free days. Intubation should not be discouraged in appropriate patients with septic shock.

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Evaluation of zinc sulfate as an adjunctive therapy in COVID-19 critically ill patients: a two center propensity-score matched study

Critical Care ◽

10.1186/s13054-021-03785-1 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Khalid Al Sulaiman ◽

Ohoud Aljuhani ◽

Abdulrahman I. Al Shaya ◽

Abdullah Kharbosh ◽

Raed Kensara ◽

...

Keyword(s):

Propensity Score ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Adjunctive Therapy ◽

Zinc Sulfate ◽

Statistical Significance ◽

Kidney Injury ◽

Additional Treatment ◽

Icu Stay

Abstract Background Zinc is a trace element that plays a role in stimulating innate and acquired immunity. The role of zinc in critically ill patients with COVID-19 remains unclear. This study aims to evaluate the efficacy and safety of zinc sulfate as adjunctive therapy in critically ill patients with COVID-19. Methods Patients aged ≥ 18 years with COVID-19 who were admitted to the intensive care unit (ICU) in two tertiary hospitals in Saudi Arabia were retrospectively assessed for zinc use from March 1, 2020 until March 31, 2021. After propensity score matching (1:1 ratio) based on the selected criteria, we assessed the association of zinc used as adjunctive therapy with the 30-day mortality. Secondary outcomes included the in-hospital mortality, ventilator free days, ICU length of stay (LOS), hospital LOS, and complication (s) during ICU stay. Results A total of 164 patients were included, 82 patients received zinc. Patients who received zinc sulfate as adjunctive therapy have a lower 30-day mortality (HR 0.52, CI 0.29, 0.92; p = 0.03). On the other hand, the in-hospital mortality was not statistically significant between the two groups (HR 0.64, CI 0.37–1.10; p = 0.11). Zinc sulfate use was associated with a lower odds of acute kidney injury development during ICU stay (OR 0.46 CI 0.19–1.06; p = 0.07); however, it did not reach statistical significance. Conclusion The use of zinc sulfate as an additional treatment in critically ill COVID-19 patients may improve survival. Furthermore, zinc supplementation may have a protective effect on the kidneys.

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The Association between Nutritional Status and In-Hospital Mortality of COVID-19 in Critically-Ill Patients in the ICU

Nutrients ◽

10.3390/nu13103302 ◽

2021 ◽

Vol 13 (10) ◽

pp. 3302

Author(s):

Michał Czapla ◽

Raúl Juárez-Vela ◽

Vicente Gea-Caballero ◽

Stanisław Zieliński ◽

Marzena Zielińska

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Nutritional Status ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Nutritional Risk ◽

Risk Of Death ◽

The Impact

Background: Coronavirus disease 2019 (COVID-19) has become one of the leading causes of death worldwide. The impact of poor nutritional status on increased mortality and prolonged ICU (intensive care unit) stay in critically ill patients is well-documented. This study aims to assess how nutritional status and BMI (body mass index) affected in-hospital mortality in critically ill COVID-19 patients Methods: We conducted a retrospective study and analysed medical records of 286 COVID-19 patients admitted to the intensive care unit of the University Clinical Hospital in Wroclaw (Poland). Results: A total of 286 patients were analysed. In the sample group, 8% of patients who died had a BMI within the normal range, 46% were overweight, and 46% were obese. There was a statistically significantly higher death rate in men (73%) and those with BMIs between 25.0–29.9 (p = 0.011). Nonsurvivors had a statistically significantly higher HF (Heart Failure) rate (p = 0.037) and HT (hypertension) rate (p < 0.001). Furthermore, nonsurvivors were statistically significantly older (p < 0.001). The risk of death was higher in overweight patients (HR = 2.13; p = 0.038). Mortality was influenced by higher scores in parameters such as age (HR = 1.03; p = 0.001), NRS2002 (nutritional risk score, HR = 1.18; p = 0.019), PCT (procalcitonin, HR = 1.10; p < 0.001) and potassium level (HR = 1.40; p = 0.023). Conclusions: Being overweight in critically ill COVID-19 patients requiring invasive mechanical ventilation increases their risk of death significantly. Additional factors indicating a higher risk of death include the patient’s age, high PCT, potassium levels, and NRS ≥ 3 measured at the time of admission to the ICU.

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Early Versus Late Use of Dexamethasone in Critically Ill Patients With COVID-19: A Multicenter, Cohort Study

10.21203/rs.3.rs-349677/v5 ◽

2021 ◽

Author(s):

Khalid Al Sulaiman ◽

Ohoud Al Juhani ◽

Ghazwa B. Korayem ◽

Khalid Eljaaly ◽

Alaa Alhubaishi ◽

...

Keyword(s):

Cohort Study ◽

Propensity Score ◽

Critically Ill ◽

Critically Ill Patients ◽

Positive Outcomes ◽

Multicenter Cohort Study ◽

Mechanically Ventilated ◽

Icu Admission ◽

Early Use ◽

Late Group

Abstract Rationale: It is unclear whether the timing of dexamethasone initiation is associated with positive outcomes. Objectives: To evaluate the appropriate timing of systemic dexamethasone initiation in critically ill patients with COVID-19. Methods: A multicenter, non-interventional cohort study including adults with COVID-19 patients admitted to intensive care units (ICUs) received systemic dexamethasone between March 2020 and January 2021. Patients were divided into two groups based on the timing for dexamethasone use (early vs. late). Early use is defined as the new initiation of dexamethasone within 24 hours of ICU admission. Propensity score matching was used based on the patient’s SOFA score, MV within 24 hours of ICU admission, proning status, and tocilizumab use during ICU stay. Results: A total of 480 patients were included in the study; dexamethasone was initiated early within 24 hours of ICU admission in 367 patients. Among 202 patients matched using propensity score, 101 had received dexamethasone after 24 hours of ICU admission (1:1 ratio). The 30-day mortality (OR [95%CI]: 1.82[1.04, 3.19], P=0.04) and in-hospital mortality (OR [95%CI]: 1.80[1.03, 3.15], P=0.04) were higher in the late group. Among the non-mechanically ventilated patients, late use of dexamethasone was associated with higher odds of developing respiratory failure that required MV (OR [95%CI]: 3.8 [1.41, 10.3], P=0.008). Conclusion: Early use of dexamethasone within 24 hours of ICU admission in critically ill patients with COVID-19 was associated with mortality benefits. Moreover, dexamethasone's early use might be considered a proactive measure in non-mechanically ventilated critically ill patients with COVID-19, to prevent further complications.

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The dose - response association between fluid overload and hospital mortality in critically ill patients: a multicenter, prospective, observational cohort study

10.21203/rs.2.20792/v1 ◽

2020 ◽

Author(s):

Meiping Wang ◽

Bo Zhu ◽

Li Jiang ◽

Ying Wen ◽

Bin Du ◽

...

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Dose Response ◽

Fluid Balance ◽

Critically Ill Patients ◽

Fluid Overload ◽

Fluid Management ◽

Management Strategies ◽

Icu Admission ◽

Increased Risk

Abstract Background Fluid management is important for ensuring hemodynamic stability in critically ill patients but easily leads to fluid overload. However, the optimal fluid balance plot or range for critically ill patients is unknown. This study aimed to explore the dose-response relationship between fluid overload (FO) and hospital mortality in critically ill patients.Methods Data were derived from the China Critical Care Sepsis Trial (CCCST). Patients with sequential fluid data for the first 3 days of admission to the ICU were included. FO was expressed as the ratio of the cumulative fluid balance (L) and initial body weight (kg) at ICU admission as a percentage. Maximum fluid overload (MFO) was defined as the peak FO value during the first 3 days of ICU admission. We used logistic regression models with restricted cubic splines to assess the relationship between MFO and the risk of hospital mortality.ResultsIn total, 3850 patients were included, 929 (24.1%) of whom died in hospital. For each 1% L/kg increase in the FO, the risk of hospital mortality increased by 4% (HR 1.04, 95% CI 1.03 - 1.05, P < 0.001). FO greater than 10% was associated with a 44% increased HR of hospital mortality compared with FO less than 5% (HR 1.44, 95% CI 1.27 - 1.67). Notably, we also found a non-linear dose-response association between MFO and hospital mortality.Conclusions Both higher and lower fluid balance were associated with an increased risk of hospital mortality. Further studies should explore this relationship and seek for the optimal fluid management strategies for critically ill patients.

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