Rethinking IV Fluid Resuscitation in Sepsis

Summary

• Fluid resuscitation is a key component in the management of sepsis and shock to improve fluid volume.
• The risks of fluid overload may contribute to poorer outcomes.
• Despite widespread support for fluid resuscitation, data supporting large volumes is limited.

Review

• The Surviving Sepsis Campaign recommends patients receive 30 mL/kg crystalloid fluids within 3 hours of sepsis identification.
• This recommendation is also part of the CMS SEP-1 compliance guidelines.
• The determination of 30 mL/kg is based on average fluid volumes administered in previous large sepsis trials.
• The topic remains controversial, with questionable mortality benefit.
• Additional studies demonstrate deleterious effects of large fluid volumes in critically ill patients.
• Patients with end-stage renal disease, heart failure or with advanced age often receive less fluids or have delays in administration with varying degrees of mortality impact.

• There is a paucity of high-quality data to guide clinical practice.
• Table 1 indicates several recent studies demonstrating a benefit to early IV fluid resuscitation.

• Table 2 indicates several recent studies demonstrating limited value or even potential harm with IV fluid resuscitation.

Analysis

• The significant heterogeneity of sepsis makes the generalization of a recommendation difficult.
• Key study weakness in both camps include:
• --- Small underpowered data groups
• --- Often single center studies
• --- High risk of methodologic bias
• --- Wide variances in therapeutic approaches to fluid administration
• --- Inconsistent outcome reporting
• --- Missing data
• --- Missing outcomes other than mortality and length of stay
• Well designed, large multicenter clinical trials are needed
• Plausible current approach:
• --- In patients with evidence of tissue hypoperfusion, fluid administration is most likely beneficial.
• --- If tissue perfusion appears satisfactory, fluid administration may not have a rational role
• --- When fluid administration has failed to improve hypoperfusion, earlier initiation of vasopressor therapy is associated with hemodynamic resuscitation and reduced mortality

Conclusions

• Fluid resuscitation is not without potential harm and may be of questionable value.
• Clinicians should recognize the substantial heterogeneity of sepsis and focus on tailoring fluid resuscitation to the individual needs of the patient based on assessment of clinical responsiveness.
• Earlier use of vasopressors to fluid administration should be considered in unresponsive patients.

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Erkan Hassan?is the Co-Founder?& Chief Clinical Officer?of Sepsis Program Optimization where he?designs & oversees the implementation of solutions to optimize sepsis programs.

Contact Erkan by?phone?(844) 4SEPSIS (844-473-7747),?email ([email protected]), or?video chat.