What fluids are recommended for resuscitation in sepsis?

Fluid Resuscitation in Sepsis

Crystalloids are the fluid of choice for sepsis resuscitation, with at least 30 mL/kg administered within the first 3 hours, preferably using balanced crystalloids (lactated Ringer's or Plasma-Lyte) over normal saline. 1

Initial Fluid Selection and Volume

Primary Fluid Choice

• Crystalloids are strongly recommended as the initial and subsequent resuscitation fluid (strong recommendation, moderate quality evidence). 1
• Balanced crystalloids (lactated Ringer's or Plasma-Lyte) should be preferred over normal saline when available to reduce the risk of hyperchloremic metabolic acidosis. 2
• Either balanced crystalloids or saline may be used, though the evidence weakly favors balanced solutions. 1

Initial Volume Requirements

• Administer at least 30 mL/kg of IV crystalloid within the first 3 hours of recognizing sepsis-induced hypoperfusion or elevated lactate (strong recommendation, low quality evidence). 1
• More rapid administration and greater volumes may be needed in some patients based on clinical response. 1, 3
• This represents a minimum threshold—not a maximum target—and should be adjusted based on hemodynamic response. 3

Fluid Challenge Technique

Administration Strategy

• Continue fluid administration as long as hemodynamic parameters continue to improve using a fluid challenge technique (best practice statement). 1
• Administer fluid boluses of 250-1000 mL rapidly and reassess after each bolus. 3
• Monitor for positive response including ≥10% increase in systolic/mean arterial pressure, ≥10% reduction in heart rate, improved mental status, peripheral perfusion, and urine output. 4

When to Stop Fluid Administration

• Stop fluid administration immediately when:
  • No improvement in tissue perfusion occurs despite volume loading 4
  • Signs of fluid overload develop (crepitations, respiratory distress) 4
  • Hemodynamic parameters stabilize without further improvement 2

Assessment of Fluid Responsiveness

Preferred Monitoring Approaches

• Dynamic variables should be used over static variables to predict fluid responsiveness when available (weak recommendation, low quality evidence). 1
• Dynamic measures include pulse pressure variation, stroke volume variation, and passive leg raise testing. 2, 3
• Static measures like central venous pressure (CVP) have poor predictive ability and should not be relied upon alone. 2, 3

Clinical Reassessment Parameters

• Perform frequent reassessment including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output, skin perfusion, and mental status. 1, 3
• Continuous observation is essential—never leave the septic patient unattended during initial resuscitation. 4

Albumin Considerations

• Albumin may be added to crystalloids when patients require substantial amounts of crystalloids (weak recommendation, low quality evidence). 1
• This is not a first-line recommendation but rather a consideration for patients with large ongoing crystalloid requirements. 1

Fluids to Avoid

Strong Contraindications

• Hydroxyethyl starches are strongly contraindicated for intravascular volume replacement in sepsis or septic shock (strong recommendation, high quality of evidence). 1
• Hydroxyethyl starches increase mortality and worsen acute kidney injury, particularly in patients with pre-existing renal dysfunction. 2

Weak Recommendations Against

• Crystalloids are preferred over gelatins when resuscitating patients with sepsis or septic shock (weak recommendation, low quality evidence). 1

Integration with Vasopressor Therapy

• If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine as the first-choice vasopressor targeting mean arterial pressure ≥65 mmHg (strong recommendation, moderate quality evidence). 1, 2
• Consider earlier vasopressor initiation if hypotension persists after initial fluid boluses, particularly in patients with compromised respiratory reserve or signs of fluid intolerance. 4
• This approach maintains perfusion while limiting excessive fluid administration in vulnerable patients. 4

Critical Pitfalls to Avoid

Common Errors

• Do not delay resuscitation due to concerns about fluid overload—delayed resuscitation increases mortality and immediate fluid resuscitation is required. 2, 3
• Do not rely solely on CVP or other static measures to guide fluid therapy, as they have poor predictive ability for fluid responsiveness. 2, 3
• Do not neglect continuous reassessment after the initial bolus—ongoing clinical evaluation is essential to determine the need for additional fluids. 3

Special Populations

• In patients with large pleural effusions or respiratory compromise, administer smaller boluses (250-500 mL) and reassess after each bolus rather than giving the full 30 mL/kg rapidly. 4
• Stop fluid administration immediately if crepitations develop or respiratory status worsens in these patients. 4
• In patients with pre-existing acute kidney injury, balanced crystalloids are safer than normal saline to avoid worsening hyperchloremic acidosis and AKI progression. 2

Evolving Evidence and Controversy

While the Surviving Sepsis Campaign guidelines provide strong recommendations for the 30 mL/kg initial bolus, emerging evidence suggests this approach may not be universally beneficial. 5, 6 Some observational data and trials in resource-limited settings have shown potential harm with aggressive fluid resuscitation. 5, 6 However, the current guideline recommendations remain the standard of care based on the best available evidence from high-income healthcare settings. 1 The key is not to view 30 mL/kg as a rigid target but rather as an initial intervention that must be continuously reassessed and adjusted based on individual patient response. 3, 4