Is intravenous (IV) fluid administration necessary in a patient with sepsis who is stable and tolerates oral feedings?

From the Guidelines

In patients with sepsis who are stable and tolerating oral feedings, intravenous (IV) fluids are generally not necessary, as oral hydration is preferred when patients can safely consume adequate fluids by mouth. For septic patients who are hemodynamically stable (normal blood pressure, heart rate, and adequate urine output), have no signs of tissue hypoperfusion, and can meet their fluid requirements orally, continuing oral intake rather than administering IV fluids is appropriate, as recommended by the Surviving Sepsis Campaign guidelines 1. This approach avoids potential complications associated with IV access such as infection, phlebitis, and fluid overload. However, close monitoring remains essential as sepsis can rapidly progress. If the patient develops signs of hemodynamic instability (hypotension, tachycardia, decreased urine output), altered mental status, worsening laboratory values, or inability to maintain adequate oral intake, prompt initiation of IV fluid therapy would be necessary, with a recommended initial fluid challenge of at least 30 mL/kg of IV crystalloid fluid 1.

Some key points to consider in the management of sepsis include:

• The use of crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic shock 1
• The avoidance of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock 1
• The importance of frequent reassessment of hemodynamic status to guide additional fluid administration 1
• The need for close monitoring of patients with sepsis, even if they are initially stable, due to the risk of rapid progression.

The physiological basis for this approach is that adequate tissue perfusion can be maintained through oral hydration in stable patients, while avoiding unnecessary interventions and their associated risks.

From the Research

Fluid Resuscitation in Sepsis

• The provided studies do not directly address the question of whether IV fluids are necessary for a patient with sepsis who is stable and tolerating oral feedings 2, 3, 4, 5, 6.
• However, the studies suggest that fluid resuscitation is an essential aspect of sepsis management, especially in the early stages of the disease 2.
• The choice of fluid type, including crystalloids and colloids, is still a topic of debate, with some studies suggesting that balanced crystalloids may be preferable to saline 3, 4.
• The optimal approach to fluid management in sepsis remains unknown, and excessive fluid administration may contribute to edema and organ dysfunction 5.
• Dynamic variables such as passive leg raise testing can predict a patient's hemodynamic response to fluid administration, but it is unclear whether using measures of "fluid responsiveness" to guide fluid administration improves patient outcomes 5.

Key Findings

• Balanced crystalloids were associated with lower in-hospital mortality compared to saline in patients with sepsis 3, 4.
• Albumin may be beneficial in septic shock, but other colloids such as starches, dextrans, and gelatins appear to increase the risk of death and acute kidney injury 5.
• The initial administration of 20 mL/kg of intravenous balanced crystalloid, followed by consideration of the risks and benefits of subsequent fluid administration, represents a reasonable approach to fluid management in sepsis 5.

Considerations for Fluid Management

• The decision to administer IV fluids should be based on individual patient needs and clinical judgment, taking into account factors such as hemodynamic stability, fluid responsiveness, and the risk of fluid overload 5, 6.
• Further research is needed to define the optimal dose, rate, and composition of intravenous fluid during the management of patients with sepsis and septic shock 5, 6.