What is the difference in fluid administration between sepsis and septic shock?

From the Guidelines

Fluid administration in sepsis should be conservative, with an initial bolus of 30 mL/kg of balanced crystalloids, whereas septic shock requires aggressive fluid resuscitation with an immediate 30 mL/kg crystalloid bolus, followed by additional boluses guided by dynamic assessments of fluid responsiveness, as recommended by the Surviving Sepsis Campaign guidelines 1. The key difference in fluid administration between sepsis and septic shock lies in the timing and aggressiveness of the approach.

• For sepsis without shock, the initial fluid bolus should be administered over the first 3 hours, with reassessment for fluid responsiveness before giving more.
• For septic shock, aggressive fluid resuscitation is essential, starting with an immediate crystalloid bolus within the first hour. Some important points to consider in fluid administration for sepsis and septic shock include:
• The use of crystalloids as the initial fluid of choice for resuscitation 1.
• The recommendation against using hydroxyethyl starches for fluid resuscitation 1.
• The suggestion to use either balanced crystalloids or saline for fluid resuscitation 1.
• The importance of ongoing assessment to avoid fluid overload, which can lead to pulmonary edema, prolonged mechanical ventilation, and increased mortality, particularly in patients with underlying cardiac or renal dysfunction 1. Vasopressors, typically norepinephrine, should be initiated early if fluid resuscitation doesn't restore adequate blood pressure, with a target mean arterial pressure of 65 mmHg 1. It is crucial to note that the management of sepsis and septic shock requires a detailed initial assessment and ongoing reevaluation of the response to treatment, including the use of dynamic measures to assess fluid responsiveness 1.

From the Research

Fluid Administration in Sepsis versus Septic Shock

• The administration of fluids during initial hemodynamic resuscitation in septic shock remains a major therapeutic challenge 2.
• There are four major indications for intravenous fluid administration: resuscitation, maintenance and replacement of total body water and electrolytes, as carriers for medications, and for parenteral nutrition 2.
• The type of fluid to be used for resuscitation in severe sepsis and septic shock has been a topic of ongoing debate, with each fluid type having specific adverse effects 3.
• Research has provided insights on the optimal timing, dose, and type of fluid to treat patients with sepsis, with initial research supporting early goal-directed therapy, but more recent research suggesting the use of smaller volumes 4.
• Dynamic measures of "fluid responsiveness" can predict which patients will experience an increase in cardiac output from a fluid bolus, but the use of such measures in clinical care remains limited 4.
• Current data support the use of balanced crystalloids, rather than saline, and the use of crystalloids, rather than semisynthetic colloids, for fluid resuscitation in sepsis 4, 5.
• Initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, may be associated with improved survival in patients with sepsis-induced hypotension 5.
• The timing, volume, and type of fluid administration in sepsis require further research to determine the optimal approach for achieving positive patient outcomes 6.

Key Considerations

• The four phases of fluid therapy in septic shock: resuscitation, optimization, stabilization, and evacuation 2.
• The four questions to be considered during fluid therapy in septic shock: "When to start intravenous fluids?", "When to stop intravenous fluids?", "When to start de-resuscitation or active fluid removal?", and "When to stop de-resuscitation?" 2.
• The importance of fluid stewardship in critically ill patients, similar to antibiotic stewardship 2.
• The potential benefits and drawbacks of early fluid administration in sepsis, including improved cardiac output and organ perfusion, but also potential adverse effects such as edema and organ dysfunction 6.