Fluid resuscitation in sepsis: the great 30 mL per kg hoax

Abstract

Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation.

Keywords: Sepsis; fluid bolus; fluid resuscitation; guideline; septic shock; surviving sepsis campaign (SSC).

Figure 1

Fluid responsiveness over time in patients with septic shock. Adapted with permission from Hernández et al. (24).

Figure 2

Flow diagram of the proposed mechanisms of cardiovascular dysfunction associated with fluid bolus therapy in septic shock. ANP, atrial natriuretic peptide; NO, nitric oxide.