What is the approach to fluid resuscitation in septic (Systemic Inflammatory Response Syndrome) shock?

From the Guidelines

Fluid resuscitation in septic shock should begin immediately with crystalloid solutions, preferably balanced crystalloids like lactated Ringer's or Plasma-Lyte at 30 mL/kg within the first 3 hours. For an average 70 kg adult, this means approximately 2-2.5 liters initially. After this initial bolus, additional fluid should be given based on frequent reassessment of hemodynamic status using dynamic parameters such as passive leg raise tests, pulse pressure variation, or ultrasound assessment of inferior vena cava collapsibility. Ongoing fluid requirements typically range from 4-6 liters in the first 24 hours. If patients remain hypotensive despite adequate fluid resuscitation (MAP <65 mmHg), vasopressors should be initiated, with norepinephrine as the first-line agent at an initial dose of 0.05-0.1 mcg/kg/min, titrated to maintain MAP ≥65 mmHg. Fluid resuscitation works by increasing preload and cardiac output, thereby improving tissue perfusion and oxygen delivery to tissues. However, excessive fluid administration can lead to pulmonary edema, prolonged mechanical ventilation, and increased mortality, so a careful balance must be maintained with frequent reassessment of fluid responsiveness to guide ongoing therapy.

Some key points to consider in fluid resuscitation in septic shock include:

• The use of crystalloids as the initial fluid of choice, with balanced crystalloids preferred over saline 1
• The recommendation against using hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock 1
• The suggestion to use albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, when patients require substantial amounts of crystalloids 1
• The importance of frequent reassessment of hemodynamic status to guide ongoing fluid therapy 1
• The use of dynamic parameters such as passive leg raise tests, pulse pressure variation, or ultrasound assessment of inferior vena cava collapsibility to assess fluid responsiveness 1

Overall, the goal of fluid resuscitation in septic shock is to restore adequate tissue perfusion and oxygen delivery, while avoiding excessive fluid administration that can lead to complications such as pulmonary edema. By following these guidelines and using a careful and balanced approach to fluid resuscitation, clinicians can help improve outcomes for patients with septic shock.

From the FDA Drug Label

Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement Central venous pressure monitoring is usually helpful in detecting and treating occult blood volume depletion

• Fluid resuscitation is essential in the management of septic shock, and it should be done before administering any vasopressor.
• Blood volume depletion should be corrected as fully as possible before administering norepinephrine.
• Norepinephrine can be administered concurrently with blood volume replacement in emergency situations.
• Central venous pressure monitoring can help detect and treat occult blood volume depletion 2

From the Research

Fluid Resuscitation in Septic Shock

• The management of septic shock involves the administration of intravenous (IV) fluids and vasopressors as initial options 3.
• The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients, as complications of fluid over-resuscitation can delay organ recovery and increase mortality 3, 4.
• The use of vasopressors seems to be a more appropriate strategy, with early administration (preferably during the first hour after diagnosis) potentially leading to lower morbidity and mortality in septic patients 3.

Initial Fluid Resuscitation

• A study published in 2021 found that an initial fluid resuscitation rate of 20-30 mL/kg within the first hour may be associated with reduced 28-day mortality in septic shock patients 4.
• The same study found that patients who completed 30 mL/kg initial fluid resuscitation in the first 1-2 hours had the lowest 28-day mortality rate (22.8%) 4.
• Another study published in 2017 recommended crystalloids as the initial fluid solution of choice in the resuscitation of patients with severe sepsis and septic shock 5.

Preferred Resuscitation Fluid

• Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock 5, 6.
• Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 5, 6.
• Semi-synthetic colloids, such as hydroxyethyl starches (HESs), should be avoided due to decreased survival and potential adverse effects 5, 6.