What is the recommended fluid management strategy for a patient in severe septic shock, including the use of crystalloids (e.g. 0.9% saline or lactated Ringer's solution) and colloids (e.g. 20% albumin)?

Fluid Management in Severe Septic Shock

Initial Resuscitation Strategy

Use crystalloids as your first-line resuscitation fluid, specifically balanced crystalloids (lactated Ringer's or Plasma-Lyte) over normal saline, and administer at least 30 mL/kg within the first 3 hours of sepsis recognition. 1, 2

Crystalloid Selection and Administration

• Balanced crystalloids (lactated Ringer's or Plasma-Lyte) should be strongly preferred over normal saline to reduce the risk of hyperchloremic metabolic acidosis and potential acute kidney injury progression 1, 3, 4
• Administer a minimum of 30 mL/kg of crystalloid within the first 3 hours, though patients may require substantially more—often exceeding 4 liters during the first 24 hours in severe cases 1, 2, 5
• Continue fluid administration as long as hemodynamic parameters continue to improve, using dynamic measures (pulse pressure variation, stroke volume variation) or static variables (arterial pressure, heart rate, mental status, urine output) 1, 2

When to Add Colloids (Albumin)

Consider adding albumin to crystalloids when patients require substantial amounts of crystalloids to maintain adequate mean arterial pressure. 5

• Albumin can be used as an adjunct in septic patients with hypoalbuminemia and evidence of organ dysfunction 5
• The role of albumin remains somewhat uncertain in general septic shock, but it may be beneficial when crystalloid requirements are excessive 3, 6
• Never use hydroxyethyl starches (HES)—they increase mortality and worsen acute kidney injury 1, 3, 4
• Gelatin-based colloids show no clear mortality benefit over crystalloids and should not be preferred 7

Hemodynamic Targets and Monitoring

• Target a mean arterial pressure (MAP) ≥65 mmHg 1, 2, 5
• Do not rely solely on central venous pressure (CVP) to guide fluid therapy—it has poor predictive ability for fluid responsiveness 1
• Stop fluid administration when no improvement in tissue perfusion occurs, signs of fluid overload develop, or hemodynamic parameters stabilize 1
• Monitor continuously for signs of fluid overload including pulmonary crackles, increased jugular venous pressure, and worsening respiratory function 2, 5

Vasopressor Support

• Initiate norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation 1, 2, 5
• Consider adding epinephrine when an additional agent is needed to maintain adequate blood pressure 2, 5

Critical Pitfalls to Avoid

• Do not delay resuscitation due to concerns about fluid overload—delayed resuscitation increases mortality 1
• Avoid normal saline when balanced crystalloids are available, as normal saline causes hyperchloremic metabolic acidosis 1, 3, 4
• Never use low-dose dopamine for renal protection—it is ineffective 1
• Absolutely avoid hydroxyethyl starches, which have strong evidence of harm including increased mortality 1, 3, 6, 4

Evidence Nuances

While crystalloids are less efficient than colloids at stabilizing certain resuscitation endpoints (requiring approximately 2 liters more volume compared to albumin), they demonstrate equal or superior mortality outcomes, particularly when compared to synthetic colloids 6. The evidence strongly supports crystalloids as first-line therapy, with albumin reserved for specific situations where crystalloid requirements become excessive 1, 5, 3.