What maintains Intravenous Fluid (IVF) therapy for a patient with septic shock?

From the Guidelines

For a patient with septic shock, aggressive intravenous fluid (IVF) resuscitation is essential, beginning with crystalloids at 30 mL/kg within the first 3 hours, as recommended by the Surviving Sepsis Campaign guidelines 1.

Key Recommendations

• The initial fluid of choice for resuscitation should be crystalloids, with balanced crystalloids like lactated Ringer's or Plasma-Lyte preferred over normal saline 1.
• Fluid administration should be guided by dynamic parameters such as passive leg raise tests, pulse pressure variation, or ultrasound assessment of inferior vena cava collapsibility 1.
• Ongoing fluid needs should be reassessed frequently, typically every 30-60 minutes during the acute phase, to avoid fluid overload and ensure adequate tissue perfusion 1.
• If the patient remains hypotensive despite adequate fluid resuscitation (MAP <65 mmHg), vasopressors should be initiated, with norepinephrine as the first-line agent (starting at 0.05-0.1 mcg/kg/min, titrated to effect) 1.

Rationale

The goal of fluid management in septic shock is to restore tissue perfusion while avoiding fluid overload, which can lead to pulmonary edema, prolonged mechanical ventilation, and increased mortality 1.

Important Considerations

• Early identification of sepsis and prompt administration of intravenous fluids and vasopressors are crucial for improving outcomes in patients with septic shock 1.
• The definition of sepsis has evolved to include organ dysfunction attributed to an infection, and septic shock is defined as a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities 1.

From the FDA Drug Label

Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. Septic shock: 0.01 to 0. 07 units/minute Titrate up by 0.005 units/minute at 10-to 15-minute intervals until the target blood pressure is reached.

Vasopressin can be used to maintain IVF (intravenous fluids) for a patient with septic shock. The recommended starting dose is 0.01 units/minute, and it can be titrated up by 0.005 units/minute at 10-to 15-minute intervals until the target blood pressure is reached, with a maximum dose of 0.07 units/minute 2 2.

From the Research

Maintaining IVF for Patients with Septic Shock

• The initial resuscitation of septic shock involves early and effective fluid resuscitation and vasopressor administration to maintain tissue perfusion 3.
• Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock, with balanced crystalloids potentially improving patient-centered outcomes 4.
• The optimal composition and volume of fluid resuscitation for patients with septic shock are unknown, but a combination of crystalloids, colloids, and blood products is often used 5.

Fluid Resuscitation Strategies

• International consensus guidelines suggest the administration of at least 30mL/kg of isotonic crystalloid fluid for initial resuscitation 6.
• However, there is uncertainty about the optimal fluid strategy, with some advocating for a more conservative approach coupled with earlier introduction of vasopressors for haemodynamic support 6.
• The type, rate, and amount of fluid administration for severe sepsis and septic shock are crucial, and providers should choose the right fluid for the right patient at the right time 7.

Key Considerations

• Delays in diagnosis and initiation of treatment of septic shock are associated with increasing risk for mortality 3.
• A low diastolic arterial pressure correlates with severity of arteriolar vasodilation and can be used to identify septic shock patients who may benefit from earlier vasopressor therapy 3.
• The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain, and semi-synthetic colloids may decrease survival and should be avoided 4.