Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock

Abstract

Sepsis results in disruption of the endothelial glycocalyx layer and damage to the microvasculature, resulting in interstitial accumulation of fluid and subsequently edema. Fluid resuscitation is a mainstay in the initial treatment of sepsis, but the choice of fluid is unclear. The ideal resuscitative fluid is one that restores intravascular volume while minimizing edema; unfortunately, edema and edema-related complications are common consequences of current resuscitation strategies. Crystalloids are recommended as first-line therapy, but the type of crystalloid is not specified. There is increasing evidence that normal saline is associated with increased mortality and kidney injury; balanced crystalloids may be a safer alternative. Albumin is similar to crystalloids in terms of outcomes in the septic population but is costlier. Hydroxyethyl starches appear to increase mortality and kidney injury in the critically ill and are no longer indicated in these patients. In the trauma population, the shift to plasma-based resuscitation with decreased use of crystalloid and colloid in the treatment of hemorrhagic shock has led to decreased inflammatory and edema-mediated complications. Studies are needed to determine if these benefits also occur with a similar resuscitation strategy in the setting of sepsis.

Figure 1

Effects of severe sepsis, septic shock, and resuscitation strategy on the microvasculature. Panel A. Homeostasis prior to infection. Panel B. Infection products (LPS) and the immune response (TNF-α and reactive oxygen species) cause shedding of the EGL and vascular permeability. Panel C. Normal saline, a commonly used fluid, increases inflammation. Other fluids increase hydrostatic pressure without mitigating endothelial injury, generating edema. Panel D. An ideal resuscitative fluid which repairs the EGL and normalizes the endothelium would mitigate endothelial permeability and edema. TNF-α, tumor necrosis factor-alpha; ROS, reactive oxygen species; LPS, lipopolysaccharide; NS, normal saline. Adapted from J Trauma 2010;69(Suppl 1):S55-63. Used with permission.