From the Guidelines
The Surviving Sepsis Campaign guidelines recommend administering an initial fluid bolus of 30 mL/kg of crystalloid fluid within the first 3 hours for patients with sepsis-induced hypoperfusion or septic shock. This recommendation is based on the guidelines published in Critical Care Medicine in 2017 1. The guidelines suggest that crystalloids should be the initial fluid of choice for resuscitation, and that the fluid challenge technique should be applied, where fluid administration is continued as long as hemodynamic factors continue to improve 1.
The guidelines also recommend against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock 1. Additionally, the guidelines suggest using either balanced crystalloids or saline for fluid resuscitation of patients with sepsis or septic shock, and using 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 1.
It is essential to monitor patients closely during fluid administration for signs of volume overload, including increasing respiratory rate, oxygen requirements, or development of pulmonary crackles 1. The use of dynamic variables such as passive leg raise, fluid responsiveness tests, or bedside ultrasound can help guide additional fluid administration after the initial bolus 1.
In patients who remain hypotensive after initial fluid resuscitation, vasopressors should be started, with norepinephrine as the first-line agent 1. The rationale behind aggressive early fluid resuscitation is to restore intravascular volume, improve tissue perfusion, and reverse the shock state. However, it's crucial to avoid fluid overload, which can lead to pulmonary edema and other complications.
Key points to consider when administering fluid bolus in sepsis include:
- Administering an initial fluid bolus of 30 mL/kg of crystalloid fluid within the first 3 hours
- Using crystalloids as the initial fluid of choice for resuscitation
- Applying the fluid challenge technique to guide additional fluid administration
- Monitoring patients closely for signs of volume overload
- Using dynamic variables to guide additional fluid administration
- Starting vasopressors with norepinephrine as the first-line agent in patients who remain hypotensive after initial fluid resuscitation.
From the Research
Surviving Sepsis Campaign Guidelines for Fluid Bolus Administration
The Surviving Sepsis Campaign (SSC) guidelines recommend the administration of 30 mL/kg of crystalloid fluid for patients with septic shock who are hypotensive or have a lactate level ≥4 mmol/L 2. However, the optimal volume and timing of fluid administration are still debated.
Key Findings
- A study published in 2021 found that an initial fluid resuscitation dose of 20-30 mL/kg within the first hour was associated with reduced 28-day mortality in patients with septic shock 2.
- Another study published in 2022 suggested that minimizing additional fluid administration after initial resuscitation may be beneficial, but no single measure has been established as the best method to guide ongoing fluid management in sepsis 3.
- A 2019 study found that failure to reach a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset was associated with increased odds of in-hospital mortality, irrespective of comorbidities 4.
- A 2023 study noted that the current recommendation of the SSC guidelines to administer 30 mL/kg fluid cannot be applied to all patients, and that complications of fluid over-resuscitation can further delay organ recovery and increase mortality 5.
Considerations for Fluid Administration
- The use of balanced crystalloids, rather than saline, is supported by current data 3.
- The role of albumin administration in sepsis remains uncertain 3.
- Dynamic measures of "fluid responsiveness" can predict which patients will experience an increase in cardiac output from a fluid bolus, but the applicability of these measures to patient populations and their effect on clinical outcomes is still uncertain 3.