Intravenous fluid therapy in sepsis

Abstract

Sepsis is the dysregulated immune response to severe infection that is common and lethal among critically ill patients. Fluid administration is a common treatment for hypotension and shock in early sepsis. Fluid therapy can also cause edema and organ dysfunction. Research on the best treatment strategies for sepsis has provided insights on the optimal timing, dose, and type of fluid to treat patients with sepsis. Initial research on early goal-directed therapy for sepsis included an initial bolus of 30 ml/kg of fluid, but more recent research has supported use of smaller volumes. After initial fluid resuscitation, minimizing additional fluid administration may be beneficial, but no single measure has been established as the best method to guide ongoing fluid management in sepsis. Dynamic measures of "fluid responsiveness" can predict which patients will experience an increase in cardiac output from a fluid bolus. Use of such a measure in clinical care remains limited by applicability to patient populations and uncertainty regarding the effect on clinical outcomes. Recent research informs the effect of fluid composition on outcomes for patients with sepsis. Current data support the use of balanced crystalloids, rather than saline, and the use of crystalloids, rather than semisynthetic colloids. The role for albumin administration in sepsis remains uncertain. Future research should focus on determining the optimal volume of fluid during sepsis resuscitation, the effectiveness of measures of "fluid responsiveness" in improving outcomes, the optimal composition of crystalloid solutions, the role of albumin, and the effects of "deresuscitation" after septic shock.

Keywords: albumin; colloids; critical illness; crystalloid solutions; fluid resuscitation; intravenous fluid; sepsis.

Figure 1.. Fluid administration in Early Goal Directed Therapy trials.

Volume of IV fluid administered from hospital arrival to 6 hours after enrollment in the Rivers et al, ProCESS, ARISE, and ProMISe trials comparing the use of Early Goal-Directed Therapy (EGDT) protocol to usual care (UC) for early sepsis treatment. Average volume in each group is presented as mean except ProMISe which is a median. Mortality values are through 90 days except for Rivers et al which is through 60 days. For the ProCESS trial, data from both the EGDT and Protocol-Based Standard Treatment (PBST) trial groups are reported.

Figure 2.. Risk of death with use of balanced crystalloids versus saline for ICU patients with sepsis.

For the SPLIT, SALT, SMART, BASICS, and PLUS randomized trials comparing the use of balanced crystalloids versus saline among critically ill adults, the relative risk of 90-day mortality with 95% confidence intervals are displayed. Overall, the relative risk of death was 0.93 (95% CI, 0.86 to 1.01).