What is the recommended amount of crystalloid (intravenous fluid) to administer in septic shock?

From the Guidelines

The recommended initial crystalloid fluid resuscitation for septic shock is 30 mL/kg of body weight, administered within the first 3 hours of recognition. This typically means giving 2-3 liters of balanced crystalloid solutions such as lactated Ringer's or Plasma-Lyte, rather than normal saline when possible. After this initial bolus, additional fluid should be given based on frequent reassessment of hemodynamic status, including vital signs, urine output, capillary refill, and when available, more advanced hemodynamic parameters. Fluid responsiveness should be evaluated before administering additional boluses, which are typically given in 500 mL increments followed by reassessment. The goal is to restore adequate tissue perfusion while avoiding fluid overload, which can lead to pulmonary edema and other complications. Early fluid resuscitation works by increasing cardiac preload, stroke volume, and ultimately cardiac output, which improves oxygen delivery to tissues and helps reverse the microcirculatory dysfunction characteristic of septic shock. If patients remain hypotensive despite adequate fluid resuscitation, vasopressors should be initiated, with norepinephrine as the first-line agent 1.

Some key points to consider in the management of septic shock include:

• The use of crystalloids as the initial fluid of choice for resuscitation 1
• The avoidance of hydroxyethyl starches for fluid resuscitation due to their potential to cause harm 1
• The consideration of albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients who require substantial amounts of crystalloids 1
• The importance of frequent reassessment of hemodynamic status to guide further fluid administration 1
• The use of dynamic over static variables to predict fluid responsiveness, where available 1

Overall, the management of septic shock requires a multifaceted approach that includes early recognition, rapid initiation of treatment, and careful monitoring of the patient's response to therapy. By following these guidelines and using the best available evidence, clinicians can provide optimal care for patients with septic shock and improve their chances of survival.

From the Research

Recommended Amount of Crystalloid in Septic Shock

The evidence suggests that the optimal amount of crystalloid to administer in septic shock is still a topic of debate. However, some studies provide guidance on this issue:

• A study published in 2021 2 found that an initial fluid resuscitation rate of 20-30 mL/kg within the first hour may be associated with reduced 28-day mortality in septic shock patients.
• Another study from 2020 3 argues that the traditional recommendation of 30 mL/kg of crystalloid solution may be excessive and that a more restrictive approach to fluid resuscitation may be beneficial.
• A 2013 review 4 suggests that crystalloids should still be considered as the first-choice fluid for volume resuscitation in patients with septic shock, but the optimal volume is unclear.
• A 2011 study 5 found that patients with septic shock who received higher volumes of crystalloids, colloids, and blood products had similar mortality rates to those who received lower volumes.

Key Findings

• The 2018 Surviving Sepsis Campaign recommends rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥4 mmol/L in patients with septic shock, but the evidence to support this recommendation is limited 2, 3.
• The type of crystalloid used may also be important, with lactated Ringer's solution potentially being associated with improved survival compared to 0.9% saline 6.
• The optimal approach to fluid resuscitation in septic shock may be individualized and guided by physiological parameters rather than a one-size-fits-all approach 3.

Fluid Resuscitation Strategies

• The evidence suggests that a medium initial fluid volume dose (20-30 mL/kg) may be associated with reduced 28-day mortality in septic shock patients 2.
• A more restrictive approach to fluid resuscitation may be beneficial, with excess fluid administration potentially worsening shock 3.
• The use of balanced crystalloids, such as lactated Ringer's solution, may be preferred over 0.9% saline due to potential benefits in terms of survival and hospital-free days 6.