What is the recommended fluid therapy approach for patients with varying clinical scenarios, including severe dehydration, burns, major surgery, sepsis, and trauma, considering factors such as age, weight, medical history, and underlying conditions?

Fluid Therapy in Different Clinical Scenarios

Initial Resuscitation Approach

Administer at least 30 mL/kg of crystalloid solution within the first 3 hours using a fluid challenge technique with frequent reassessment, stopping immediately if tissue perfusion fails to improve or signs of fluid overload develop. 1

Crystalloid Selection and Administration

• Crystalloids are the fluid of choice for initial resuscitation across all clinical scenarios 1
• Balanced crystalloids are preferred over isotonic saline in critically ill patients, sepsis, and kidney injury (low certainty evidence) 2
• Isotonic saline may be preferred in traumatic brain injury patients (very low certainty evidence) 2
• Administer fluid boluses of 250-1000 mL rapidly and repeatedly, continuing as long as hemodynamic parameters improve 1

Critical Reassessment After Each Bolus

Stop fluid administration when any of the following occur:

• No improvement in tissue perfusion despite volume loading 3, 1
• Development of pulmonary crackles, increased jugular venous pressure, or worsening respiratory function 1, 4
• Hemodynamic parameters stabilize 1

This is a critical pitfall—delayed reassessment leads to either under-resuscitation or dangerous fluid overload 1

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Sepsis-Specific Management

Early Resuscitation Phase (First 6 Hours)

• Initiate treatment within 1 hour of recognizing sepsis 3
• Administer 30 mL/kg crystalloid over 3 hours 1
• Some patients may require several liters during the first 24-48 hours 3
• Children with septic shock may require up to 110 mL/kg during early resuscitation 3

Monitoring and Targets

• Assess response by: 10% increase in systolic/mean arterial pressure, 10% reduction in heart rate, improvement in mental state, peripheral perfusion, and/or urine output 3
• Target serum lactate reduction of at least 20% if elevated 1
• Monitor respiratory rate, work of breathing, skin perfusion, and capillary refill 1

Special Sepsis Considerations

• In children with profound anemia and severe sepsis (particularly malaria), administer fluid boluses cautiously and consider blood transfusion instead 3
• Balance adequate pulmonary gas exchange against optimum intravascular filling when mechanical ventilation is unavailable 3
• Initiate norepinephrine if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure of 65 mmHg 3, 1

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Trauma and Major Surgery

Perioperative Fluid Strategy

• Implement goal-directed fluid therapy intraoperatively to reduce postoperative complications and hospital length of stay 5
• Patients can have clear fluids and carbohydrate-rich drinks up to 2 hours before surgery 5
• Transition to oral fluids as soon as possible postoperatively 5

Hemorrhagic Shock Management

• Higher doses exceeding 20 mL/kg have been reported in postoperative and trauma patients with severe blood loss 6
• Do NOT use hydroxyethyl starch solutions due to increased risk of acute kidney injury, mortality, and bleeding complications 1, 6
• Albumin may be considered when patients require substantial amounts of crystalloids 1

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Burns

• Effective fluid resuscitation is a cornerstone of modern burn treatment given severe fluid loss 7
• Apply the same crystalloid-based resuscitation principles with aggressive early fluid administration 7
• Expect high fluid requirements proportional to burn surface area 7

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Patients with Cardiac Dysfunction or Pulmonary Edema

Modified Approach

• Administer smaller boluses of 250-500 mL over 15-30 minutes with frequent reassessment in patients with pre-existing cardiac dysfunction 1
• Pre-existing B-lines on lung ultrasound are a contraindication to aggressive fluid resuscitation 4
• Use dynamic assessment of fluid responsiveness before administering large volumes 4

When Fluid Overload Develops

• Immediately initiate de-resuscitation in patients with fluid overload and pulmonary edema 4
• Administer diuretics (furosemide) for fluid overload 4
• Initiate vasopressor support (norepinephrine) if hypotension persists despite fluid overload 4
• Provide respiratory support including supplemental oxygen and non-invasive ventilation as needed 4

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Dynamic Assessment of Fluid Responsiveness

Passive Leg Raise (PLR) Testing

If PLR is POSITIVE (cardiac output increases): administer 500 mL crystalloid bolus 8

If PLR is NEGATIVE (no cardiac output increase): do NOT give additional fluid—initiate vasopressor therapy instead 8

• PLR has 92% specificity and 88% sensitivity for predicting fluid responsiveness 8
• Only ~50% of hypotensive postoperative patients actually respond to fluid boluses, making PLR critical to avoid inappropriate fluid administration 8
• Monitor cardiac output changes using echocardiography, pulse pressure variation, or clinical response 8

Static Measures Are Unreliable

• Do NOT rely solely on central venous pressure (CVP) to guide fluid therapy—it poorly predicts preload responsiveness 1, 8
• Heart rate, blood pressure, and urine output may not detect early hypovolemia 9
• Edema is a late sign of fluid overload 9

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Vasopressor Initiation

• Norepinephrine is the first-choice vasopressor when hypotension persists despite adequate fluid resuscitation 3, 1
• Target mean arterial pressure of 65 mmHg, with higher targets in patients with chronic hypertension 3, 1
• Consider vasopressors after 60 mL/kg within the first 2 hours in sepsis 3
• Administer via central venous line using syringe or infusion pump when available 3

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Special Populations

Cirrhosis

• Use albumin rather than crystalloids in patients with cirrhosis (very low certainty evidence) 2

Traumatic Brain Injury

• Use isotonic saline rather than albumin or balanced crystalloids (very low certainty evidence) 2

Patients with Comorbidities

• Be especially vigilant for fluid overload in patients with heart failure or renal disease 8
• Consider earlier vasopressor initiation in these populations 8

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Common Pitfalls to Avoid

• Delayed resuscitation increases mortality—immediate fluid resuscitation is required 1
• Neglecting reassessment after initial bolus leads to under-resuscitation or fluid overload 1
• Excessive fluid administration without consideration of patient response causes complications including acute kidney injury, gastrointestinal dysfunction, and cardiac/pulmonary complications 5
• Relying on urine output alone as an indicator of hydration status in postoperative patients is unreliable 5
• Using hydroxyethyl starch solutions in any critically ill patient is contraindicated 1, 6