Initial Fluid Management for Sepsis
Administer at least 30 mL/kg of crystalloid solution within the first 3 hours of resuscitation in patients with sepsis-induced hypoperfusion or septic shock. 1
Fluid Type Selection
Crystalloids are the fluid of choice for initial resuscitation and subsequent intravascular volume replacement (strong recommendation, moderate quality evidence). 1
Either balanced crystalloids or normal saline can be used for fluid resuscitation (weak recommendation, low quality of evidence). 1 However, balanced crystalloids may be preferred to avoid hyperchloremic metabolic acidosis, particularly in patients with chronic kidney disease. 2
Hydroxyethyl starches must NOT be used for intravascular volume replacement due to increased risk of acute kidney injury and mortality (strong recommendation, high quality of evidence). 1
Albumin may be added to crystalloids when patients require substantial amounts of crystalloids (weak recommendation, low quality of evidence). 1
Crystalloids are preferred over gelatins (weak recommendation, low quality of evidence). 1
Administration Technique
Use a fluid challenge technique where fluid administration is continued as long as hemodynamic factors continue to improve. 1
Administer fluid boluses of 250-1000 mL rapidly and repeatedly, assessing response after each bolus. 3
More rapid administration and greater amounts of fluid may be needed in some patients beyond the initial 30 mL/kg. 1
Hemodynamic improvement can be assessed using dynamic measures (e.g., change in pulse pressure, stroke volume variation) or static variables (e.g., arterial pressure, heart rate). 1
Reassessment and Ongoing Management
Following initial fluid resuscitation, additional fluids must be guided by frequent reassessment of hemodynamic status. 1
Reassessment should include thorough clinical examination and evaluation of heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, mental status, and peripheral perfusion. 1, 4
Dynamic measures of fluid responsiveness are preferred over static measures like central venous pressure where available (weak recommendation, low quality of evidence). 1
Target normalization of lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion (weak recommendation, low quality of evidence). 1
When to Stop Fluid Administration
Stop fluid administration when:
No improvement in tissue perfusion occurs in response to volume loading. 3
Signs of fluid overload develop, including pulmonary crackles, increased jugular venous pressure, or worsening respiratory function. 4, 3
Hemodynamic parameters stabilize. 3
Vasopressor Initiation
If the patient remains hypotensive despite adequate fluid resuscitation, initiate vasopressor therapy targeting a mean arterial pressure of 65 mmHg. 1, 4
- Norepinephrine is the first-choice vasopressor (strong recommendation, moderate quality evidence). 1, 4
Special Considerations for Chronic Kidney Disease
Patients with chronic kidney disease require careful monitoring for fluid overload due to impaired renal excretion. 2
Consider smaller fluid boluses of 250-500 mL with reassessment after each bolus. 2
Earlier initiation of vasopressors may be appropriate to maintain perfusion while limiting excessive fluid administration. 2
Common Pitfalls
Delayed resuscitation increases mortality - immediate fluid resuscitation is required as sepsis and septic shock are medical emergencies. 1, 3
Relying solely on static measures like central venous pressure to guide fluid therapy is not recommended due to poor predictive ability for fluid responsiveness. 3, 2
Neglecting reassessment after initial bolus can lead to under-resuscitation or fluid overload. 3
Note on the 30 mL/kg recommendation: While the Surviving Sepsis Campaign strongly recommends at least 30 mL/kg within 3 hours 1, some observational data suggests that medium volumes (20-30 mL/kg) may be associated with lower mortality than higher volumes. 5 However, the guideline recommendation remains the standard of care, with emphasis on individualized reassessment and stopping fluids when hemodynamic improvement plateaus or signs of overload develop.