From the Guidelines
The recommended maintenance fluid rate for a patient in septic shock is typically 30 mL/kg of crystalloid fluid administered intravenously within the first 3 hours of recognition, followed by ongoing fluid resuscitation guided by frequent reassessment of hemodynamic status, with maintenance fluids administered at 1.5-2 mL/kg/hour, adjusted based on the patient's clinical response, urine output, and hemodynamic parameters, as recommended by the Surviving Sepsis Campaign guidelines 1.
Key Considerations
- The initial fluid challenge should aim to achieve a minimum of 30 mL/kg of crystalloids, with more rapid administration and greater amounts of fluid potentially needed in some patients 1.
- Crystalloids, such as normal saline or lactated Ringer's solution, are the preferred initial fluid choice for resuscitation of severe sepsis and septic shock 1.
- Albumin may be considered in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients requiring substantial amounts of crystalloids 1.
- Fluid administration should be titrated using dynamic measures of fluid responsiveness, such as passive leg raise tests, pulse pressure variation, or stroke volume variation, when available 1.
- Monitoring for signs of fluid overload, including peripheral edema, pulmonary congestion, or worsening oxygenation, is crucial 1.
Vasopressor Therapy
- If the patient remains hypotensive despite adequate fluid resuscitation, vasopressors, typically norepinephrine as first-line, should be initiated to maintain a mean arterial pressure of at least 65 mmHg 1.
- The goal of vasopressor therapy is to restore adequate organ perfusion pressure, with individualized mean arterial pressure targets based on frequent assessment of end-organ perfusion 1.
From the Research
Maintenance Fluid Rate in Septic Shock
- The optimal maintenance fluid rate for patients in septic shock is not explicitly stated in the provided studies, as they primarily focus on the initial fluid resuscitation rates and volumes.
- However, the studies suggest that the initial fluid resuscitation rate and volume can impact patient outcomes, such as mortality and shock reversal time 2, 3, 4, 5.
- A study published in 2020 found that an initial fluid resuscitation rate of 0.25-0.50 ml/kg/min may be associated with early shock reversal and lower 28-day mortality 3.
- Another study published in 2021 found that an initial fluid resuscitation dose of 20-30 ml/kg within the first hour may be associated with reduced 28-day mortality 5.
- It is essential to note that the maintenance fluid rate may vary depending on individual patient factors, such as fluid responsiveness, hemodynamic stability, and organ function.
- Further research is needed to determine the optimal maintenance fluid rate for patients in septic shock, as the current evidence is limited and primarily focused on initial fluid resuscitation.
- The provided studies do not offer a clear recommendation for maintenance fluid rates, but rather emphasize the importance of individualized fluid management and careful monitoring of patient responses to fluid resuscitation 6, 4.