Expert statement for the management of hypovolemia in sepsis

Abstract

Hypovolemia is frequent in patients with sepsis and may contribute to worse outcome. The management of these patients is impeded by the low quality of the evidence for many of the specific components of the care. In this paper, we discuss recent advances and controversies in this field and give expert statements for the management of hypovolemia in patients with sepsis including triggers and targets for fluid therapy and volumes and types of fluid to be given. Finally, we point to unanswered questions and suggest a roadmap for future research.

Sepsis associated acute kidney injury

“…Sepsis is associated with up to 50% of AKI, and up to 60% of patients with sepsis have AKI 2527. Independent risk factors or clinical consequences of sepsis and AKI, such as hypovolemia or exposure to nephrotoxic therapies, have confounded the relation between these entities 2829. Although the pathophysiologic mechanism remains incompletely understood, it seems evident that the deleterious inflammatory cascade characteristic of sepsis contributes to the AKI as well 30.…”

Liberal or restricted fluid resuscitation in critical illness: Shifting the needle back towards equipoise

“…Although recent clinical studies have pointed to a more fluid‐restricted approach being preferable, the findings of the RELIEF trial caution against the premature adoption of fluid management strategies based on a limited evidence base. In the meantime, we endorse the recommendations made by the authors of the expert statement and echo their call for high‐quality research in this area . Wherever possible, eligible patients should be enrolled in clinical trials designed to resolve this important question.…”

“…For patients with critical illness and shock, infusion of a bolus of isotonic crystalloid is a universal first‐line treatment. Sepsis, for example, is frequently associated with hypovolaemia because of exogenous fluid losses and volume redistribution from capillary leak and vasodilatation . This can lead to systemic hypotension and, combined with alterations of the microcirculation and cellular function, result in tissue hypoperfusion or septic shock .…”

“…For example, the mechanistic effects of exogenous fluids on the structure and function of the endothelium and endothelial glycocalyx in systemic inflammation remain incompletely understood . A recent expert statement recommends judicious, titrated fluid boluses and earlier vasopressor introduction . Yet for the practising emergency physician, the question of the right amount of volume for an individual patient, and the closely related question of when to introduce vasopressors, remains a dilemma for which there is a paucity of high‐quality evidence to inform practice …”

“…Sepsis, for example, is frequently associated with hypovolaemia because of exogenous fluid losses and volume redistribution from capillary leak and vasodilatation. 1 This can lead to systemic hypotension and, combined with alterations of the microcirculation and cellular function, result in tissue hypoperfusion or septic shock. 2 International consensus guidelines recommend initial volume resuscitation with at least 30 mL/kg of isotonic fluid within 3 h in patients with sepsis and hypoperfusion, with further fluid administration guided by repeated assessment of haemodynamic and perfusion parameters.…”