From the Guidelines
Fluid resuscitation for elevated lactate levels should begin immediately with crystalloid solutions at 30 mL/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.
Key Recommendations
- The initial fluid resuscitation should be guided by the patient's hemodynamic status, with a focus on restoring tissue perfusion and oxygen delivery.
- Additional fluids should be administered based on frequent reassessment of hemodynamic parameters, including blood pressure, heart rate, capillary refill, and urine output.
- The use of dynamic variables, such as pulse pressure variation, to predict fluid responsiveness is suggested, although the quality of evidence is low 1.
- An initial target mean arterial pressure of 65 mm Hg is recommended for patients with septic shock requiring vasopressors 1.
- Guiding resuscitation to normalize lactate levels is suggested, although the recommendation is weak and based on low-quality evidence 1.
Rationale
The Surviving Sepsis Campaign guidelines emphasize the importance of early and effective fluid resuscitation in patients with sepsis-induced tissue hypoperfusion or septic shock 1. The guidelines recommend an initial fluid bolus of 30 mL/kg of crystalloid solution within the first 3 hours, with subsequent fluid administration guided by the patient's hemodynamic response. The use of dynamic variables, such as pulse pressure variation, may help predict fluid responsiveness, although the evidence is limited 1. The guidelines also recommend targeting a mean arterial pressure of 65 mm Hg in patients with septic shock requiring vasopressors, and guiding resuscitation to normalize lactate levels, although the evidence for this is weak 1.
Clinical Implications
The guidelines have significant implications for clinical practice, emphasizing the need for prompt and effective fluid resuscitation in patients with sepsis-induced tissue hypoperfusion or septic shock. Clinicians should be aware of the importance of frequent reassessment of hemodynamic parameters and the use of dynamic variables to guide fluid administration. The guidelines also highlight the need for ongoing monitoring of lactate levels to guide resuscitation efforts and adjust treatment as needed. Overall, the guidelines provide a framework for the management of sepsis-induced tissue hypoperfusion and septic shock, with a focus on early and effective fluid resuscitation and ongoing monitoring and adjustment of treatment.
From the Research
Fluid Resuscitation Guidelines for Elevated Lactate
- The management of patients with elevated lactate levels requires an understanding of the various etiologies and contributing factors, as the clinical and prognostic importance of an elevated lactate level varies widely by disease state 2.
- The Surviving Sepsis Campaign (SSC) guidelines recommend rapid administration of a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels, but recent findings suggest that aggressive fluid resuscitation may be harmful 3.
- An individualized, conservative, and physiologic-guided approach to fluid resuscitation is recommended, rather than a weight-based approach 3.
- The choice of crystalloid solution is also important, with balanced crystalloid solutions such as lactated Ringer's and Plasma-Lyte potentially being associated with improved outcomes compared to normal saline 4, 5, 6.
- Lactated Ringer's solution has been shown to be associated with improved survival and more hospital-free days in patients with sepsis-induced hypotension compared to normal saline 4.
- Balanced crystalloid solutions have a sodium, potassium, and chloride content closer to that of extracellular fluid and may have fewer adverse effects on acid-base balance compared to normal saline 5.