Should a full 30cc/kg fluid bolus be administered to a patient with end-stage liver disease (ESLD) and sepsis, or should early vasopressors be considered instead?

From the Guidelines

For septic patients with end-stage liver disease, a modified fluid resuscitation approach is recommended rather than the standard 30 cc/kg bolus, starting with a smaller initial fluid bolus of 10-15 cc/kg while closely monitoring for signs of volume overload, and initiating vasopressors early if the patient remains hypotensive after this initial fluid challenge, as suggested by the most recent guidelines 1. The rationale behind this approach is that end-stage liver disease patients have baseline splanchnic vasodilation, reduced effective circulating volume, and are at higher risk for pulmonary edema and hepatorenal syndrome with excessive fluid administration, as noted in the guidelines 1. Key considerations in the management of these patients include:

• Using balanced crystalloids like lactated Ringer's to minimize hyperchloremic acidosis, as recommended by the Surviving Sepsis Campaign Guidelines 1
• Initiating vasopressors early, with norepinephrine as the first-line agent at an initial dose of 0.05-0.1 mcg/kg/min, titrated to maintain a mean arterial pressure of at least 65 mmHg, as suggested by the guidelines 1
• Closely monitoring for signs of volume overload, including increasing oxygen requirements, worsening ascites, or peripheral edema, and adjusting the fluid and vasopressor strategy accordingly, as recommended by the guidelines 1
• Considering the use of invasive hemodynamic monitoring to guide fluid and vasopressor management, as suggested by the guidelines 1 Overall, the goal is to provide individualized care that balances the need for adequate fluid resuscitation with the risk of volume overload and other complications, while prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

Vasopressin injection is indicated to increase blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines. The recommended starting dose is: Septic Shock: 0. 01 units/minute Titrate up by 0.005 units/minute at 10-to 15-minute intervals until the target blood pressure is reached.

The FDA drug label does not answer the question about whether a full 30cc/kg fluid bolus should be administered to a patient with end-stage liver disease (ESLD) and sepsis, or if early vasopressors should be considered instead 2, 2.

From the Research

Fluid Resuscitation in ESLD Patients with Sepsis

• The administration of a full 30cc/kg fluid bolus to patients with end-stage liver disease (ESLD) and sepsis is a topic of debate 3, 4, 5, 6, 7.
• A study published in The American journal of emergency medicine found that ESLD patients with septic shock had higher mortality rates compared to non-ESLD patients, and that maximum lactate and presence of pneumonia were independently associated with death 3.
• Another study published in Chest found that there was no difference in intubation incidence between ESLD patients with sepsis who received a restricted fluid bolus (< 30mL/kg) and those who received a standard fluid bolus (≥ 30mL/kg) 4.
• A review of fluid management in liver failure patients suggested that fluid therapy should use crystalloids, and balanced salt solutions may limit the risk of hyperchloremic acidosis and subsequent adverse kidney events 5.
• The use of early vasopressors in ESLD patients with sepsis who are not fluid-responsive is recommended, with norepinephrine as the first-line vasopressor 6.
• A study published in Critical care medicine found that failure to reach a 30mL/kg crystalloid bolus within 3 hours of sepsis onset was associated with increased odds of in-hospital mortality, irrespective of comorbidities 7.

Considerations for Fluid Resuscitation

• The decision to administer a full 30cc/kg fluid bolus to an ESLD patient with sepsis should be made on a case-by-case basis, taking into account the patient's individual characteristics and comorbidities 3, 4, 5, 6, 7.
• The use of balanced crystalloids and normal saline as resuscitation fluids is recommended, with the goal of achieving a mean arterial pressure ≥ 65mmHg 6.
• Early vasopressors should be considered in patients who are not fluid-responsive, with the goal of achieving adequate blood pressure and perfusion of vital organs 6.
• The patient's lactate level and presence of pneumonia should be taken into account when making decisions about fluid resuscitation and vasopressor use 3.