What is the appropriate intravenous (IV) fluid resuscitation strategy for a 70 kilogram (kg) person with sepsis?

From the Guidelines

For IV fluid resuscitation in a 70 kg person with sepsis, administer an initial bolus of 30 mL/kg of crystalloid fluid, which equates to approximately 2100 mL, as recommended by the Surviving Sepsis Campaign guidelines 1. The choice of crystalloid fluid is crucial, and balanced crystalloids such as Lactated Ringer's or Plasma-Lyte are preferred over normal saline to reduce the risk of hyperchloremic metabolic acidosis 1. After the initial bolus, reassess the patient's hemodynamic status, including:

• Blood pressure
• Heart rate
• Urine output
• Signs of tissue perfusion If the patient remains hypotensive or shows signs of inadequate perfusion, administer additional 500 mL boluses, reassessing after each bolus. Continue fluid resuscitation until hemodynamic goals are met or signs of fluid overload develop. Typical goals include:
• Mean arterial pressure (MAP) ≥ 65 mmHg
• Urine output > 0.5 mL/kg/hour
• Improved mental status and peripheral perfusion Monitor closely for signs of fluid overload, such as worsening respiratory status or peripheral edema. If the patient remains hypotensive despite adequate fluid resuscitation, initiate vasopressor therapy, typically starting with norepinephrine 1. This aggressive fluid resuscitation approach is crucial in sepsis to counteract the vasodilation and increased vascular permeability that lead to hypovolemia and tissue hypoperfusion. The rapid administration of fluids helps to quickly restore intravascular volume and improve tissue perfusion, which is essential in preventing organ dysfunction in sepsis.

From the Research

IV Fluid Resuscitation Strategy for Sepsis

• The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients 2.
• Complications of fluid over-resuscitation can further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality 2.
• The use of vasopressors seems to be a more appropriate strategy, with very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, potentially leading to lower morbidity and mortality in the management of septic patients 2.
• International consensus guidelines suggest the administration of at least 30mL/kg of isotonic crystalloid fluid, but there is a paucity of high-level evidence to support this strategy 3.
• Evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation 3.
• Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation 3.
• A multicenter observational study found that patients with sepsis who received ≥30 mL/kg bolus fluid within three hours experienced more severe clinical outcomes, but it was not associated with the increased odds of the 28-day mortality 4.
• Research on the best treatment strategies for sepsis has provided insights on the optimal timing, dose, and type of fluid to treat patients with sepsis, with recent research supporting the use of smaller volumes 5.
• 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 a measure in clinical care remains limited 5.
• Current data support the use of balanced crystalloids, rather than saline, and the use of crystalloids, rather than semisynthetic colloids 5.
• The role for albumin administration in sepsis remains uncertain, and future research should focus on determining the optimal volume of fluid during sepsis resuscitation 5.
• A review of the scientific evidence for a weight-based fluid resuscitation approach found that there is no credible evidence to support the recommendation of rapidly administering a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock 6.
• Accumulating evidence suggests that aggressive fluid resuscitation is harmful, and an individualized, conservative and physiologic guided approach to fluid resuscitation is recommended 6.

Considerations for a 70 kg Person with Sepsis

• For a 70 kg person, the recommended 30 ml/kg fluid would be 2100 ml, but this may not be appropriate for all patients 2, 3.
• A more conservative approach to fluid resuscitation may be beneficial, with consideration of the patient's individual needs and response to treatment 3, 5, 6.
• The use of vasopressors and other supportive therapies should be considered in addition to fluid resuscitation 2.