What is the initial fluid management in sepsis?

From the Guidelines

In sepsis initial management, administer 30 mL/kg of crystalloid fluid intravenously within the first 3 hours of recognition, as recommended by the Surviving Sepsis Campaign guidelines 1. This initial bolus should be given rapidly, with reassessment after each 500 mL. For a 70 kg adult, this equals approximately 2-2.5 liters of fluid. After the initial bolus, additional fluid should be guided by frequent reassessment of hemodynamic status, including:

• Blood pressure
• Heart rate
• Capillary refill
• Urine output
• When available, more advanced hemodynamic parameters Fluid administration aims to restore intravascular volume, improve tissue perfusion, and maintain adequate organ function in sepsis, where vasodilation and increased vascular permeability lead to relative hypovolemia. Be cautious with fluid administration in patients with heart failure or renal failure, as excessive fluid may worsen respiratory status. If hypotension persists despite adequate fluid resuscitation, vasopressors (starting with norepinephrine) should be initiated to maintain a mean arterial pressure of at least 65 mmHg, as suggested by the guidelines 1. The use of crystalloids as the initial fluid of choice is supported by the guidelines, with a strong recommendation and moderate quality of evidence 1. Additionally, the guidelines suggest using either balanced crystalloids or saline for fluid resuscitation, with a weak recommendation and low quality of evidence 1. It is essential to note that the guidelines recommend against using hydroxyethyl starches for intravascular volume replacement in patients with sepsis or septic shock, with a strong recommendation and high quality of evidence 1.

From the FDA Drug Label

Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. The degree of dilution depends on clinical fluid volume requirements. If large volumes of fluid (dextrose) are needed at a flow rate that would involve an excessive dose of the pressor agent per unit of time, a solution more dilute than 4 mcg per mL should be used

• The amount of fluid indicated in sepsis initial management is not explicitly stated, but blood volume depletion should be corrected as fully as possible before administering any vasopressor.
• The choice of fluid and the rate of administration depend on clinical fluid volume requirements 2

From the Research

Initial Fluid Resuscitation in Sepsis

• The amount of fluid indicated in sepsis initial management is a topic of ongoing debate and research.
• According to international consensus guidelines, the administration of at least 30mL/kg of isotonic crystalloid fluid is recommended for initial resuscitation of septic shock 3.
• However, some studies suggest that a more conservative fluid strategy may be beneficial, with a medium initial fluid volume dose of 20-30 mL/kg associated with reduced 28-day mortality 4.
• The Surviving Sepsis Campaign guidelines recommend rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥4 mmol/L in patients with septic shock, but there is limited evidence to support this recommendation 5.
• The type of fluid used for initial resuscitation is also important, with crystalloids being the preferred solution, and balanced crystalloids potentially improving patient-centered outcomes 6.
• A recent study found that initial fluid resuscitation with lactated Ringer's solution compared to 0.9% saline may be associated with improved survival in patients with sepsis-induced hypotension 7.

Key Findings

• Initial fluid resuscitation with 30 mL/kg of crystalloid fluid is recommended, but the evidence to support this is limited 3, 5.
• A medium initial fluid volume dose of 20-30 mL/kg may be associated with reduced 28-day mortality 4.
• Crystalloids are the preferred fluid for initial resuscitation, with balanced crystalloids potentially improving outcomes 6.
• The type of fluid used for initial resuscitation may impact patient outcomes, with lactated Ringer's solution potentially being associated with improved survival compared to 0.9% saline 7.