New Insights into the Fluid Management in Patients with Septic Shock

Abstract

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The “one size fits all” approach may be “convenient” but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.

Sepsis Management in the Cardiac Intensive Care Unit

“…Until recently, most guidelines have recommended aggressive resuscitation with crystalloids in sepsis, with a 30 mL/kg of body weight initial bolus to be followed by maintenance fluids with the goal of achieving a consistent MAP > 65 mmHg [53]. However, contemporary meta-analyses of large RCTs have demonstrated that lower crystalloid resuscitation volumes did not lead to worse outcomes, raising doubt about the ideal fluid volume for sepsis management [54,55]. Thus, the current 2021 Surviving Sepsis guidelines cite insufficient evidence to make a recommendation about a liberal vs. restrictive fluid strategy in the first 24 h of resuscitation [49].…”