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174 The actual fluid accumulation status is quite sim‐ ilar between these patients, while according to the current study, patient B had a significantly higher risk of death than patient A (odds ratio, 1.8; 95% CI, 1.1–2.8). Second, according to other studies,2,3 posi‐ tive FB had a dose ‐related impact on clinical outcomes. Thus, simply converting FB to a di‐ chotomous variable could reduce statistical ef‐ ficacy to detect a true association. For instance, according to the current study, we only know that achieving an FB of more than 1000 ml per day within 72 hours is associated with high‐ er ICU mortality rates, compared with an FB of less than 1000 ml. However, what is the bal‐ ance point: stable FB, more negative FB? In‐ terestingly, in a retrospective study including 18 084 critically ill patients, Balakumar et al4 reported that compared with stable FB, expo‐ sure to either positive or negative FB was asso‐ ciated with higher 1‐year mortality. To explore the true association between FB and morality in these patients, we performed a crude analy‐ sis using data from the MIMIC database. Only patients admitted to cardiac or cardiac surgical care unit were screened and patients with an ICU length of stay of less than 72 hours were exclud‐ ed. A total of 4565 patients were included, and we used the LOWESS smoothing method to in‐ vestigate the crude association between FB and ICU mortality (FIGURE 1). We noticed that the curve slope was much steeper on the side with an FB of more than 0, compared with the curve on the other side, which indicated different asso‐ ciations between an FB higher than 0, FB lower than 0, and mortality. However, more research is needed to validate these findings. Third, in clinical practice, the volume of FB may be affected by numerous factors, especial‐ ly disease severity. In patients with severe in‐ fection or under vasopressor support, a large To the editor We read with interest the paper by Dr. Trejnowska et al,1 investigating the im‐ pact of positive fluid balance (FB) on clinical out‐ comes in critically ill patients with cardiovas‐ cular disorders. They concluded that achieving a positive FB of more than 1000 ml during each 24 hours within 3 days was significantly asso‐ ciated with increased intensive care unit (ICU) mortality. This study filled the gap in knowledge about the association between FB and mortal‐ ity in critically ill patients with cardiovascular disorders; however, it is not free of limitations. First, the novelty of the study is that the dai‐ ly FB was analyzed in 24‐hour intervals with‐ in 72 hours, using a cutoff value of 1000 ml. In clinical practice, fluid management is a continu‐ ous, dynamic process, while simply dividing FB by a 24‐hour interval can lead to a biased con‐ clusion. For instance, hypothetical patient A had a 24‐hour FB of 1200 ml, 800 ml, and 1100 ml, and patient B reached 1100 ml, 1100 ml, and 1100 ml within the first 72 hours after ICU admission. L E T T E R T O T H E E D I T O R

Impact of fluid balance on intensive care unit mortality in critically ill patients with cardiovascular disorders