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Fluid resuscitation is the cornerstone of resuscitation in patients with severe sepsis and septic shock.
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Fluids should be considered as medications; it is imperative to consider the type, dose, and duration of intravenous fluid therapy in sepsis.
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Crystalloids remain the intravenous fluid of choice in sepsis resuscitation. Balanced solutions may be preferred to normal saline and colloids.
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It is important to know the difference between empiric fluid loading and a fluid challenge in the assessment of
Fluid Resuscitation in Severe Sepsis
Section snippets
Key points
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
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Cited by (31)
Initial fluid resuscitation (30 mL/kg) in patients with septic shock: More or less?
2021, American Journal of Emergency MedicineAcidosis predicts mortality independently from hyperlactatemia in patients with sepsis
2020, European Journal of Internal MedicineCitation 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 SurgeryIntravenous Fluid Administration: Improving Patient Outcomes With Evidence-based Care
2018, Journal for Nurse PractitionersEarly Administration of Intravenous Fluids in Sepsis: Pros and Cons
2018, Critical Care Nursing Clinics of North AmericaCitation 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
Disclosure: The authors have nothing to disclose.