What is the recommended fluid administration strategy for patients with sepsis who are fluid-restricted?

From the Guidelines

For patients with sepsis who are fluid-restricted, a conservative fluid administration strategy is recommended, starting with small, controlled fluid boluses of 250-500 mL of balanced crystalloids, such as Lactated Ringer's or PlasmaLyte, and closely monitoring hemodynamic parameters after each bolus. This approach is supported by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, which recommends using a fluid challenge technique where fluid administration is continued as long as hemodynamic factors continue to improve 1. The guidelines also suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock, with a weak recommendation and low quality of evidence 1.

Some key points to consider in this strategy include:

• Using crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock, with a strong recommendation and moderate quality of evidence 1
• Avoiding the use of hydroxyethyl starches for intravascular volume replacement in patients with sepsis or septic shock, with a strong recommendation and high quality of evidence 1
• Considering the use 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, with a weak recommendation and low quality of evidence 1
• Early initiation of vasopressors, particularly norepinephrine, to maintain adequate perfusion while minimizing fluid requirements, and considering the addition of vasopressin as a second-line agent in patients with persistent hypotension despite these measures.

The rationale for this conservative approach is to provide adequate tissue perfusion while avoiding the detrimental effects of fluid overload, which can worsen pulmonary edema, prolong mechanical ventilation, and increase mortality in critically ill patients. Continuous hemodynamic monitoring using tools such as echocardiography, passive leg raise tests, or pulse pressure variation can help guide therapy by assessing fluid responsiveness. This approach is particularly important in patients with conditions like acute respiratory distress syndrome, heart failure, or end-stage renal disease, where fluid overload can worsen outcomes.

From the Research

Fluid Administration Strategies

• The recommended fluid administration strategy for patients with sepsis who are fluid-restricted is to use a restrictive fluid approach, as it has been found to be comparable in efficacy to liberal fluid strategies, but with a lower incidence of fluid overload 2.
• Crystalloids are the preferred solution for the resuscitation of patients with severe sepsis and septic shock, with balanced crystalloids being safer and more effective than normal saline 3.
• The use of colloids, such as albumin, may be considered in certain situations, but the evidence for their use is uncertain 2, 4.
• The type, rate, and amount of fluid administration should be individualized based on the patient's specific needs and response to treatment 5.

Phases of Fluid Therapy

• Fluid therapy for sepsis can be conceptualized as four overlapping phases: resuscitation, optimization, stabilization, and evacuation 6.
• During the resuscitation phase, rapid fluid administration is used to restore perfusion, while during the optimization phase, the risks and benefits of additional fluids are evaluated 6.
• In the stabilization phase, fluid therapy is used only when there is a signal of fluid responsiveness, and in the evacuation phase, excess fluid accumulated during treatment is eliminated 6.

Key Considerations

• Clinicians should consider the risks and benefits of fluid administration in each phase of critical illness and avoid the use of hydroxyethyl starch due to its increased incidence of kidney replacement therapy 6.
• Fluid removal should be facilitated for patients recovering from acute respiratory distress syndrome to improve outcomes 6.