Fluid Therapy in Febrile Patients
For febrile patients with septic shock, administer at least 30 mL/kg of crystalloid fluid within the first 3 hours, using balanced crystalloids (lactated Ringer's or Plasma-Lyte) as first-line therapy, while avoiding routine fluid boluses in febrile patients without signs of shock. 1, 2, 3
Initial Assessment: Distinguish Shock from Severe Febrile Illness
The critical first step is determining whether the febrile patient has true shock versus severe febrile illness without shock. This distinction fundamentally changes fluid management:
Signs of shock requiring aggressive fluid resuscitation include: 1
- Capillary refill time ≥3 seconds
- Lower-limb temperature gradient
- Weak radial pulse volume
- Hypotension (late sign in children)
- Altered mental status
- Oliguria
Severe febrile illness WITHOUT shock includes: 1
- Impaired consciousness (prostration)
- Respiratory distress
- Impaired perfusion with only 1-2 signs above
- Fever with tachycardia but maintained blood pressure
For Febrile Patients WITH Septic Shock
Immediate Resuscitation Protocol
Administer 30 mL/kg of crystalloid within the first 3 hours as the initial fluid challenge. 1, 2, 3 This represents a strong recommendation based on moderate-quality evidence from the Surviving Sepsis Campaign guidelines.
Use balanced crystalloids (lactated Ringer's or Plasma-Lyte) preferentially over normal saline to reduce the risk of hyperchloremic metabolic acidosis and potential acute kidney injury. 3, 4, 5 Normal saline causes hyperchloremic acidosis and is associated with worse renal outcomes in septic patients. 3, 5
Continue fluid administration using a challenge technique: Give additional fluid boluses as long as hemodynamic parameters improve, monitoring dynamic measures (pulse pressure variation, stroke volume variation) when available, or static variables (arterial pressure, heart rate, mental status, urine output). 1, 2, 3
When to Add Albumin
Consider adding albumin when patients require substantial amounts of crystalloids (typically >30-40 mL/kg), as albumin may provide additional benefit in septic patients beyond volume expansion alone. 1, 2 This is a weak recommendation based on low-quality evidence, but albumin remains in the intravascular space longer than crystalloids, potentially reducing edema formation. 6, 4
Fluids to Avoid
Never use hydroxyethyl starches in septic patients - they increase mortality, acute kidney injury, and need for renal replacement therapy. 1, 2, 3, 4, 5 This is a strong recommendation based on high-quality evidence.
Avoid gelatins when crystalloids are available. 1
Vasopressor Initiation
Start norepinephrine as the first-choice vasopressor if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure ≥65 mmHg. 1, 2, 3 Do not delay vasopressor therapy while continuing to administer excessive fluid volumes, as this increases mortality. 2
For Febrile Patients WITHOUT Shock (Severe Febrile Illness)
Avoid routine bolus intravenous fluids in febrile patients who are not in shock. 1, 7 This is a weak recommendation based on low-quality evidence from the FEAST trial, which showed no benefit and potential harm from routine fluid boluses in children with severe febrile illness without overt shock.
Instead, provide oral rehydration when possible and frequent clinical reassessment to detect early deterioration. 1, 7 The emphasis should be on monitoring rather than aggressive fluid administration.
Special Considerations for Pediatric Patients
Children with Septic Shock
Administer an initial fluid bolus of 20 mL/kg over 5-10 minutes for infants and children with septic shock, with immediate reassessment after each bolus. 1, 7, 2 This differs from the adult recommendation of 30 mL/kg.
Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists, then switch to inotropic support rather than continuing fluid administration if no improvement occurs. 7, 2 Aggressive crystalloid resuscitation achieves near 100% survival when properly administered in pediatric dengue shock syndrome. 7
Children with Severe Febrile Illness Without Shock
Do not give routine bolus IV fluids to children with severe febrile illness who are not in shock, as this increases fluid overload and respiratory complications without improving outcomes. 1, 7 The FEAST trial demonstrated potential harm from this approach in resource-limited settings.
Disease-Specific Modifications
Dengue Shock Syndrome
Administer 20 mL/kg crystalloid bolus with careful reassessment for dengue shock syndrome. 1, 7 Dengue behaves differently than bacterial septic shock, with moderate-quality evidence showing colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids). 7
Monitor hematocrit closely - rising hematocrit indicates ongoing plasma leakage requiring continued resuscitation, while falling hematocrit suggests successful plasma expansion. 7
Severe Malaria
Use 20 mL/kg fluid bolus for severe malaria with shock, but avoid routine boluses in severe malaria without shock, as restrictive fluids showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005). 1, 7
Critical Monitoring Parameters
Assess for signs of adequate tissue perfusion: 2
- Normal capillary refill time
- Absence of skin mottling
- Warm and dry extremities
- Well-felt peripheral pulses
- Return to baseline mental status
- Adequate urine output (>0.5 mL/kg/hr)
Stop fluid administration when: 2, 3
- No improvement in tissue perfusion occurs
- Signs of fluid overload develop (hepatomegaly, pulmonary rales, respiratory distress)
- Hemodynamic parameters stabilize
Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion. 2, 3
Common Pitfalls to Avoid
Do not delay initial fluid resuscitation in established septic shock - delays significantly increase mortality, and once hypotension occurs, cardiovascular collapse may rapidly follow. 7, 2 Blood pressure alone is not a reliable endpoint, especially in children. 7
Do not rely solely on static measures like central venous pressure to guide fluid therapy - they have poor predictive ability for fluid responsiveness. 2, 3 Dynamic measures are preferred when available.
Do not continue aggressive fluid resuscitation once signs of fluid overload appear - switch to inotropic support instead. 7, 2 Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3%. 7
Do not use restrictive fluid strategies in established shock - three RCTs demonstrated near 100% survival with aggressive fluid management in dengue shock syndrome. 7 The FEAST trial findings apply to severe febrile illness without overt shock, not to established septic shock. 1
Do not administer excessive fluid boluses in patients without shock - this leads to fluid overload and respiratory complications without improving outcomes. 1, 7
Four Phases of Fluid Therapy
Following the SOSD (Salvage, Optimization, Stabilization, De-escalation) framework: 8
Salvage phase: Generous fluid administration to restore perfusion (30 mL/kg in adults, 20 mL/kg boluses in children) 1, 2, 3
Optimization phase: Continued fluid challenges guided by hemodynamic response and fluid responsiveness assessment 2, 3, 8
Stabilization phase: Maintenance fluids only, avoiding further boluses unless new indication develops 8
De-escalation phase: Active fluid removal when fluid overload >10% develops, potentially using diuretics or continuous renal replacement therapy 7, 8