Fluid resuscitation in sepsis: the great 30 mL per kg hoax. | Semantic Scholar (2024)

This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in septic patients.

Prevention of fluid overload in septic shock patients is extremely important, and requires the careful attention of the entire critical care team.

In septic shock patients, an initial fluid resuscitation rate of 20-30ml/kg within the first 1 h or completion of the initial 30 ml/kg fluid resuscitate between the first1-2 h may be associated with faster organ function recovery and lower 28-day mortality.

The aim of this narrative review is to depict the pathophysiology of hypotension in sepsis, evaluate how common interventions to treat hypotension interfere with physiology, and to give a resume of the results from clinical studies focusing on targets and timing of vasopressor in septic shock.

UTI as an adjuvant therapy for restricting volumes of resuscitation fluid strategy in treating septic shock may decrease the LA level, attenuate the inflammatory response, reduce vascular permeability, prevent pulmonary edema, and restore cardiac and renal functions.

In patients with sepsis and lactate value greater than 4 mmol/L, high or low fluid doses were not associated with better lactate clearance or patient outcomes, and greater than 50 cc/kg IBW dose of fluids within 3 hours is associated with higher mortality.

The challenges with using a weight-based approach to bolus fluid dosing during the early phase of resuscitation of adult, obese patients are discussed.

Reports indicate that adjunctive hydrocortisone can lead to more rapid shock reversal, andconflicting data exist regarding the impact of corticosteroids on mortality in septic shock.

Intensive fluid therapy in the prehospital setting for critically ill patients with sepsis, including considerations regarding a need for early fluid resuscitation and the choice and administration of fluid, as well as monitoring and assessing the patient response to this.

...

...

It is argued that the concept of large fluid bolus resuscitation in sepsis needs to be investigated further and is at odds with emerging observational data in several subgroups of critically ill patients or those having major abdominal surgery.

The historical and physiological rationale for the introduction of fluid resuscitation as treatment for sepsis is reviewed and a number of significant concerns are highlighted based on current experimental and clinical evidence.

The evidence behind the bundles presented by the Surviving Sepsis Campaign is discussed, the introduction of new variables and more dynamic measurements are suggested and why some recommendations may need to be updated are explained.

The adaptive platform trial design may provide the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous.

In patients with septic shock resuscitated according to current guidelines, a more positive fluid balance at 24 hours is associated with an increase in the risk of mortality.

A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased risk of mortality in septic shock.

The conflict between the desire to achieve adequate resuscitation of shock and the need to mitigate the harmful effects of fluid overload is discussed.

In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days and there was no significant difference in survival time, in-hospital mortality, duration of organ support, or length of hospital stay.

Interventions to limit the development of a positive cumulative fluid balance are associated with improved outcomes and in patients not transgressing spontaneously from the Ebb to Flow phases of shock, late conservative fluid management and late goal directed fluid removal (de-resuscitation) should be considered.

...

...