What is the ideal strategy for fluid resuscitation in septic shock?

From the Guidelines

The ideal strategy for fluid resuscitation in septic shock involves prompt administration of crystalloid fluids, primarily balanced solutions like lactated Ringer's or Plasma-Lyte, at an initial dose of 30 mL/kg within the first 3 hours of recognition, as recommended by the Surviving Sepsis Campaign guidelines 1. This approach should be followed by additional fluid boluses guided by frequent reassessment of hemodynamic parameters. For ongoing resuscitation, use dynamic measures of fluid responsiveness such as passive leg raise tests, stroke volume variation, or ultrasound assessment of inferior vena cava collapsibility rather than static measures. Target a mean arterial pressure of at least 65 mmHg, with individualization based on patient characteristics, as supported by the guidelines 1. If patients remain hypotensive despite adequate fluid resuscitation (typically 2-3 liters in adults), vasopressors should be initiated, with norepinephrine (starting at 0.05-0.1 mcg/kg/min) as the first-line agent, as recommended by the guidelines 1. Fluid administration should be de-escalated once hemodynamic stability is achieved to prevent volume overload, which can worsen outcomes through pulmonary edema, prolonged mechanical ventilation, and organ dysfunction. Key points to consider in fluid resuscitation 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 due to their potential harm 1
• The consideration of albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, when patients require substantial amounts of crystalloids 1
• The importance of frequent reassessment of hemodynamic status to guide additional fluid administration 1 This approach balances the need for rapid restoration of tissue perfusion while minimizing the risks associated with excessive fluid administration, ultimately aiming to reduce morbidity, mortality, and improve quality of life for patients with septic shock.

From the FDA Drug Label

To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0. 2 mcg/kg/min, to achieve the desired blood pressure goal. After hemodynamic stabilization, wean incrementally over time, such as by decreasing doses of epinephrine every 30 minutes over a 12- to 24-hour period.

The ideal strategy for fluid resuscitation in septic shock is not directly addressed in the provided drug labels. However, the labels provide information on the use of epinephrine 2 and vasopressin 3 in the management of septic shock.

• The use of these medications is focused on providing hemodynamic support and achieving a desired mean arterial pressure (MAP).
• The labels do not provide a comprehensive strategy for fluid resuscitation, but rather focus on the administration of specific medications.
• It is essential to note that fluid resuscitation is a critical component of septic shock management, but the provided labels do not offer direct guidance on this topic.

From the Research

Ideal Strategy for Fluid Resuscitation in Septic Shock

The ideal strategy for fluid resuscitation in septic shock involves several key considerations, including the type of fluid, volume, and timing of administration.

• Early and effective fluid resuscitation is crucial in maintaining tissue perfusion in septic shock patients 4.
• The choice of fluid is also important, with crystalloids being recommended as the first-line therapy 5, 6.
• Balanced crystalloids may be a safer alternative to normal saline, which has been associated with increased mortality and kidney injury 6.
• Colloids, such as albumin, can be considered in some clinical settings, but hydroxyethyl starches should be avoided due to their potential to increase mortality and kidney injury 5, 6.

Key Considerations

• The optimal composition and volume of fluid resuscitation are unknown, and controversy exists regarding the balance of fluids and vasopressors to maintain target mean arterial pressure 4, 7.
• Patients with septic shock may require a combination of crystalloids, colloids, and blood products, with the more severely shocked patients receiving higher volumes of these fluids 7.
• The type of fluid used can have significant effects on patient outcomes, with some fluids associated with increased risk of adverse effects such as kidney injury and mortality 5, 6.

Fluid Resuscitation Practices

• A study of patients with septic shock found that the mean volume of resuscitation fluid administered during the first 24 hours was 4.9 liters, with patients in the higher volume group receiving more crystalloids, colloids, and blood products 7.
• Another study found that crystalloids should still be considered as the first-choice fluid for volume resuscitation in patients with septic shock, with colloids such as albumin considered in some clinical settings 5.
• The use of hydroxyethyl starches is not recommended due to their potential to increase mortality and kidney injury 5, 6.