What are the recommendations for fluid resuscitation in shock?

Fluid Resuscitation Recommendations in Shock

Initial fluid resuscitation in shock should be performed with balanced/buffered crystalloids, administering at least 30 mL/kg within the first 3 hours, with continued fluid challenges as long as hemodynamic improvement occurs. 1

Initial Fluid Choice and Administration

• First-line fluid: Isotonic crystalloids, preferably balanced/buffered solutions 1, 2

  • Balanced crystalloids may be associated with lower mortality compared to normal saline 3, 2
  • Normal saline (0.9% NaCl) has been linked to higher incidence of acid-base disorders, electrolyte abnormalities, and potentially acute kidney injury 2

• Initial volume and rate:

  • Administer at least 30 mL/kg crystalloid within first 3 hours 1
  • In pediatric patients: 10-20 mL/kg per bolus, up to 40-60 mL/kg in first hour 1
  • Rate should be titrated to clinical markers of cardiac output 1

Monitoring Response and Ongoing Management

• Continue fluid challenges as long as hemodynamic improvement occurs 1

• Reassess every 30-60 minutes based on patient risk level 1

• Monitor for signs of fluid overresuscitation:

  • Reduce fluid rate when filling pressures rise without improvement in tissue perfusion 1
  • After initial resuscitation, be cautious with additional fluids as the hemodynamic effects of crystalloids are short-lived (approximately 60-90 minutes) 4

• Measure serum lactate (elevated ≥2 mmol/L indicates tissue hypoperfusion) 1

  • Repeat lactate measurement within 6 hours if initially elevated

Vasopressor Support

• If fluid resuscitation fails to restore adequate tissue perfusion, initiate vasopressors 1
  • Norepinephrine is the first-choice vasopressor
  • Target mean arterial pressure (MAP) ≥65 mmHg
  • Consider epinephrine as second agent when needed

Special Considerations

Colloid Solutions

• Albumin: May be considered in specific clinical settings 5, but should not be used as first-line therapy

  • FDA labeling indicates albumin can be used for hypovolemic shock, but administration rate should not exceed 2 mL/minute to avoid circulatory embarrassment and pulmonary edema 6

• Synthetic colloids (HES): Should be avoided in septic shock as they may decrease survival 5, 7

Pediatric Considerations

• In neonates and children with hypovolemia, isotonic saline is recommended as the first-choice fluid for resuscitation 8
• Initial fluid volume should be 10-20 mL/kg, with repeated doses based on individual clinical response 8
• Pediatric advanced life-support guidelines recommend up to 60 mL/kg fluid resuscitation during treatment of hypovolemic and septic shock 8

Common Pitfalls to Avoid

1. Delayed resuscitation: Early goal-directed therapy is crucial; delays in fluid administration can lead to tissue hypoxia, multiple organ failure, and death 8

2. Overresuscitation: Monitor for signs of fluid overload, especially after the initial resuscitation phase 1, 4

3. Inappropriate colloid use: Using hydroxyethyl starches in septic shock can increase mortality 7, 5

4. Exclusive use of normal saline: Consider balanced crystalloids to reduce the risk of hyperchloremic metabolic acidosis and kidney injury 3, 2

5. Failure to reassess: Continuous monitoring and reassessment are essential to guide ongoing fluid management 1