Should patients meeting sepsis criteria who are on fluid restrictions due to impaired renal function be administered intravenous (IV) fluids beyond their prescribed limit?

From the Guidelines

Patients meeting sepsis criteria who are on fluid restrictions should be given fluids over their limit, as the benefits of adequate fluid resuscitation in sepsis generally outweigh the risks of temporary fluid overload. This approach is supported by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, which recommends a fluid challenge technique where fluid administration is continued as long as hemodynamic factors continue to improve 1. The guidelines suggest using crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock.

Key considerations in managing patients with sepsis and fluid restrictions include:

• Starting with smaller fluid boluses (250-500 ml) and closely monitoring the patient's response, including vital signs, urine output, and signs of fluid overload
• Using balanced crystalloids or saline for fluid resuscitation, as suggested by the guidelines 1
• Considering the use of albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement, although the evidence for this is weaker 1
• Initiating vasopressors like norepinephrine earlier than usual if the patient remains hypotensive despite minimal fluid resuscitation, as recommended by the guidelines 1

The goal of fluid resuscitation in sepsis is to maintain organ perfusion and prevent further deterioration, while minimizing the risks of fluid overload. This requires careful clinical judgment and close monitoring of the patient's response to fluid administration. By prioritizing the patient's immediate need for adequate fluid resuscitation, clinicians can help reduce the risk of morbidity and mortality associated with sepsis.

From the Research

Fluid Administration in Sepsis Patients with Fluid Restrictions

• Patients meeting sepsis criteria who are on fluid restrictions require careful consideration of fluid administration to avoid excessive fluid overload, which is associated with worse outcomes in septic shock 2.
• The decision to administer fluids over the limit should be based on a thorough assessment of the patient's fluid deficit, organ dysfunction, tolerance of additional fluid, and overall trajectory of the shock state 2.
• Dynamic indices, such as those involving the interaction between the cardiovascular and respiratory systems, may be superior to traditional static indices like central venous pressure for assessing fluid responsiveness 2.
• Point-of-care ultrasound can be a useful tool in determining fluid administration in septic shock patients 2.

Risks and Benefits of Fluid Administration

• Fluid therapy can be conceptualized as four overlapping phases: resuscitation, optimization, stabilization, and evacuation 3.
• The risks and benefits of fluid administration should be carefully evaluated in each phase of critical illness, and clinicians should avoid the use of hydroxyethyl starch 3.
• Restricting fluid administration in the absence of severe hypoperfusion may not reduce mortality, but limiting fluid administration and administering diuretics can improve outcomes in certain patients 3.

Optimal Fluid Management

• Optimal fluid management in patients with sepsis remains uncertain, and clinicians should consider the individual patient's needs and response to fluid administration 3, 4, 5.
• The choice of optimal fluid and fluid intake is unclear, and further research is needed to determine the best approach to fluid resuscitation in sepsis patients 5.
• Emerging evidence suggests that a more conservative approach to fluid resuscitation may be necessary, with some recommending earlier use of vasopressors rather than repeated fluid boluses 6.