Fluid Resuscitation in Severe Sepsis

https://doi.org/10.1016/j.emc.2016.08.001Get rights and content

Section snippets

Key points

  • Fluid resuscitation is the cornerstone of resuscitation in patients with severe sepsis and septic shock.

  • Fluids should be considered as medications; it is imperative to consider the type, dose, and duration of intravenous fluid therapy in sepsis.

  • Crystalloids remain the intravenous fluid of choice in sepsis resuscitation. Balanced solutions may be preferred to normal saline and colloids.

  • It is important to know the difference between empiric fluid loading and a fluid challenge in the assessment of

Frank-Starling Curve

Mean arterial blood pressure (MAP) is determined by cardiac output (CO) and systemic vascular resistance (SVR), and can be calculated according to the following equation:MAP = CO ∗ SVR.

The primary determinants of CO are heart rate (HR) and stroke volume (SV). In order to maintain CO, blood ejected from the left ventricle (LV) must traverse the circulatory system, return to the right atrium and right ventricle, and transit the pulmonary circulation. In this way, CO is coupled with venous return

Hemodynamic instability in septic shock

In order to understand the goals of fluid resuscitation in sepsis, it is pertinent to review the pathophysiology of sepsis. Sepsis has recently been defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection.”24 Patients with septic shock are defined as those with a lactate value greater than 2 mmol/L who require vasopressor medications to maintain an MAP greater than or equal to 65 mm Hg despite adequate fluid resuscitation.24 Although dehydration may

Phases of resuscitation

The complex mechanisms that produce hemodynamic alterations in severe sepsis and septic shock make it difficult to recommend a one-size-fits all approach to fluid resuscitation. Importantly, patients with severe sepsis and septic shock can present along a spectrum of illness and the need for fluid therapy may vary for each patient. A recent conceptual model of circulatory shock has been published that identifies 4 phases of resuscitation: rescue, optimization, stabilization, and de-escalation.32

Selection of fluid

In the past, the selection of which fluid to administer to patients with severe sepsis or septic shock has largely been based on geography, marketing, availability, cost, and even the type of provider training (medical vs surgical).37 Fluids can largely be separated into crystalloid and colloid solutions. Crystalloid solutions can be further divided into unbalanced and balanced solutions, whereas colloid solutions primarily include albumin, dextran, and hydroxyethyl starch solutions. The

Empiric Fluid Loading

Empiric fluid loading is the administration of a predetermined volume of fluid with the intent to ensure adequate organ perfusion. In the EGDT by Rivers and colleagues,4 refractory hypotension was defined as a systolic blood pressure less than 90 mm Hg after a 20 to 30 mL/kg fluid bolus. Largely based on the EGDT trial, the Surviving Sepsis Campaign guidelines recommend an initial 30-mL/kg bolus of crystalloids for patients with severe sepsis and septic shock.2 In the 3 most recent studies that

Adverse effects of fluid resuscitation

Excessive and indiscriminate fluid administration can lead to a positive cumulative fluid balance and the potential for patient harm. Fluid overload is a state of excess total body water that is caused by both increased fluid administration and decreased renal elimination in critical illness. Patients with severe sepsis and septic shock are susceptible to fluid overload because of the pathogenesis of sepsis described earlier. It has been traditionally taught that approximately one-third of the

Summary

Fluid therapy is a cornerstone of the resuscitation and management of patients with severe sepsis and septic shock. The complex pathophysiologic processes of sepsis and the various phases of resuscitation make a one-size-fits-all approach to fluid resuscitation impractical. Early fluid administration is necessary in the rescue phase of resuscitation, whereas fluid administration should be guided by dynamic measurements of fluid responsiveness in later stages of resuscitation. Based on current

First page preview

First page preview
Click to open first page preview

References (60)

  • R.P. Dellinger et al.

    Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock

    Crit Care Med

    (2013)
  • R.C. McDermid

    Controversies in fluid therapy: type, dose, and toxicity

    World J Crit Care Med

    (2014)
  • E.P. Rivers et al.

    Early goal-directed therapy in the treatment of severe sepsis and septic shock

    N Engl J Med

    (2001)
  • J.H. Boyd et al.

    Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality

    Crit Care Med

    (2011)
  • D.J. Kelm et al.

    Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death

    Shock

    (2015)
  • F. Sadaka et al.

    Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality

    J Intensive Care Med

    (2014)
  • J.L. Vincent et al.

    Sepsis in European intensive care units: results of the SOAP study

    Crit Care Med

    (2006)
  • P.R. Mouncey et al.

    Trial of early, goal-directed resuscitation for septic shock

    N Engl J Med

    (2015)
  • D.M. Yealy et al.

    A randomized trial of protocol-based care for early septic shock

    N Engl J Med

    (2014)
  • S.L. Peake et al.

    Goal-directed resuscitation for patients with early septic shock

    N Engl J Med

    (2014)
  • D.A. Berlin et al.

    Starling curves and central venous pressure

    Crit Care

    (2015)
  • S. Sondergaard et al.

    Central venous pressure: we need to bring clinical use into physiological context: applied physiology of central venous pressure

    Acta Anaesthesiol Scand

    (2015)
  • A.P. Story

    Venous function and central venous pressure

    Anesthesiology

    (2008)
  • E.H. Starling

    On the absorption of fluids from the connective tissue spaces

    J Physiol

    (1896)
  • B.F. Becker et al.

    Therapeutic strategies targeting the endothelial glycocalyx: acute deficits, but great potential

    Cardiovasc Res

    (2010)
  • C.C. Michel et al.

    Glycocalyx volume: a critical review of tracer dilution methods for its measurement

    Microcirculation

    (2009)
  • M. Rehm et al.

    Changes in blood volume and hematocrit during acute preoperative volume loading with 5% albumin or 6% hetastarch solutions in patients before radical hysterectomy

    Anesthesiology

    (2001)
  • D. Bruegger et al.

    Release of atrial natriuretic peptide precedes shedding of the endothelial glycocalyx equally in patients undergoing on- and off-pump coronary artery bypass surgery

    Basic Res Cardiol

    (2011)
  • D. Bruegger et al.

    Atrial natriuretic peptide induces shedding of endothelial glycocalyx in coronary vascular bed of guinea pig hearts

    Am J Physiol Heart Circ Physiol

    (2005)
  • M. Singer et al.

    The third international consensus definitions for sepsis and septic shock (Sepsis-3)

    JAMA

    (2016)
  • Cited by (31)

    • Acidosis predicts mortality independently from hyperlactatemia in patients with sepsis

      2020, European Journal of Internal Medicine
      Citation Excerpt :

      More aggressive therapeutic approaches targeting specifically acidotic patients with and without concomitant hyperlactatemia could be evaluated in future studies. These aggressive treatment strategies constitute one the one hand of intravenous fluid administration or at least assessment for fluid responsiveness [27,28]. Also, higher vasopressor doses and even blood pressure target might be considered and improve outcomes in some highly selected patients [29–31].

    • Perineal soft tissue infections

      2019, Seminars in Colon and Rectal Surgery
    • Early Administration of Intravenous Fluids in Sepsis: Pros and Cons

      2018, Critical Care Nursing Clinics of North America
      Citation Excerpt :

      Any increases in preload will result in an increase in SV until optimal preload is achieved and a plateau is reached.”12,14 Beyond that plateau point, additional preload, such as that administered as IV fluid will not be able to significantly increase SV leading to fluid overload resulting in impaired cardiac function, pulmonary edema, and interstitial edema.12 Lactate is produced as a result of adrenergic and inflammatory responses seen in sepsis.11

    View all citing articles on Scopus

    Disclosure: The authors have nothing to disclose.

    View full text