Fluid Selection for Sepsis Resuscitation
Use lactated Ringer's (LR) as your primary resuscitation fluid for sepsis rather than rotating with normal saline (NS), as LR is associated with reduced mortality and better clinical outcomes while avoiding hyperchloremic acidosis. 1, 2
Primary Recommendation
- Balanced crystalloids like LR are preferred over normal saline for initial resuscitation in sepsis and septic shock to reduce the risk of hyperchloremic metabolic acidosis 1
- The most recent high-quality evidence from 2025 shows that initial fluid resuscitation with LR compared to NS was associated with a 29% reduction in mortality (adjusted HR 0.71,95% CI 0.51-0.99, p=0.043) in patients with sepsis-induced hypotension 2
- Patients receiving LR had 1.6 more hospital-free days at 28 days compared to those receiving NS 2
Why Not Rotate Between Fluids
- There is no evidence supporting a "rotation" strategy between LR and NS 1, 3, 2
- The concern about LR raising serum lactate levels is clinically insignificant—while LR can increase lactate by approximately 0.93 mmol/L, this modest rise does not interfere with lactate-guided resuscitation or clinical decision-making 4
- NS causes hyperchloremic metabolic acidosis with higher chloride levels and decreased bicarbonate levels, which is particularly problematic in patients with chronic kidney disease 1, 2
Initial Resuscitation Protocol
- Administer at least 30 mL/kg of LR within the first 3 hours of resuscitation 1
- Use a fluid challenge technique where administration continues as long as hemodynamic parameters improve 1
- After the initial bolus, give smaller fluid boluses of 250-500 mL and reassess after each bolus 1
Monitoring During Resuscitation
- Draw initial serum lactate within the first 3 hours and repeat within 6 hours if elevated (≥2 mmol/L) 5
- Monitor dynamic measures of fluid responsiveness, blood pressure, heart rate, mental status, peripheral perfusion, and urine output 1
- Target mean arterial pressure of 65 mmHg 6
- Guide resuscitation to normalize lactate levels as a marker of tissue hypoperfusion 6, 5
Special Considerations
- In patients with chronic kidney disease, LR remains preferred but requires careful monitoring for fluid overload since renal excretion is impaired 1
- Consider earlier initiation of vasopressors (norepinephrine first-line) if hypotension persists despite initial fluid resuscitation to maintain perfusion while limiting excessive fluid 1
- Albumin may be considered when substantial crystalloid volumes are required 1
Critical Pitfall to Avoid
- Do not attribute persistent lactate elevation to the lactate content in LR—this delays recognition of serious underlying pathology such as ongoing sepsis, mesenteric ischemia, or inadequate resuscitation 6
- The lactate in LR (28 mmol/L) is metabolized by the liver and does not cause clinically significant elevations that would mask tissue hypoperfusion 4
When to Stop Fluid Administration
- Stop when no improvement in tissue perfusion occurs, signs of fluid overload develop, or hemodynamic parameters stabilize 1
- Assess fluid responsiveness dynamically using passive leg raising with cardiac output monitoring or respiratory variation in vena cava diameter before giving additional boluses 6