Discovering the Best Fluid Strategies for Sepsis

This guide provides you with a review of the most effective strategies for treating sepsis, based on the appropriate usage and dosage of intravenous (IV) fluid therapy at each stage of treatment.

This evidence-based approach covers four aspects of fluid use, determining whether IV fluid administration is necessary, setting goals for fluid therapy, and deciding on the timing and type of fluids, among other clinical parameters. The advice given here is drawn from an extensive literature survey that includes 28 randomized clinical trials (RCTs), seven secondary analyses of RCTs, 20 observational studies, five systematic reviews or meta-analyses, one scoping review, one practice guideline, and 14 references from a reference review.

Dr. Fernando Zampieri’s Views

According to Fernando G. Zampieri, MD, Ph.D., assistant adjunct professor of critical care medicine at the University of Alberta and Alberta Health Services in Edmonton, Alberta, Canada, crystalloids should be the standard care for most critically ill patients, particularly during early resuscitation. He warns against using starches in critically ill patients and suggests balanced solutions could be a better choice for most patients, except those with traumatic brain injury, where 0.9% saline is recommended.

Understanding the Four Therapeutic Phases

Around 20%-30% of patients admitted to an intensive care unit have sepsis, and fluid therapy plays a crucial role in their treatment. Fluid therapy can be broken down into four overlapping phases, starting from the onset of the illness to the resolution of sepsis. These phases are resuscitation, optimization, stabilization, and evacuation.

The review outlines the key recommendations for managing these phases, based on the studies conducted. Some of the key findings include:

  • Among 3723 patients with sepsis who received 1-2 L of fluid, goal-directed therapy did not decrease mortality compared to unstructured clinical care.
  • In another study of 1563 patients with sepsis and hypotension who received 1 L of fluid, favoring vasopressor treatment did not improve mortality compared to further fluid administration.
  • A separate study showed that restricting fluid administration in the absence of severe hypoperfusion did not reduce mortality compared to more liberal fluid administration.
  • Limiting fluid administration and administering diuretics improved the number of days alive without mechanical ventilation compared to fluid treatment to attain higher intracardiac pressure.

Concerns About Fluid Therapy

The authors express concerns about fluid therapy. They suggest initiating fluid therapy for patients showing signs of sepsis-induced hypoperfusion who are likely to have increased cardiac output with fluid administration. Fluid administration should be halted when evidence of hypoperfusion resolves, the patient no longer responds to fluid, or the patient shows signs of fluid overload.

Balanced solutions should be chosen over 0.9% saline for fluid therapy, and hydroxyethyl starches should be avoided. Consideration should also be given to fluid removal after the resuscitation and optimization phases and when a patient has stabilized. Diuretics are the first-line therapy to facilitate fluid elimination.

Zampieri highlights that the use of ultrasonography as a bedside tool to guide fluid resuscitation is promising but lacks validation in robust randomized controlled trials.

Fluids as Drugs

Dr. Hernando Gomez, an associate professor of critical care medicine at the University of Pittsburgh, comments on the review, emphasizing that while fluids can be harmful when used incorrectly or excessively, fluid resuscitation is vital for patients with sepsis showing signs of hypoperfusion.

He reminds us that every strategy to assess fluid responsiveness has limitations. Based on the evidence, he urges clinicians to treat fluids like a drug and carefully evaluate the risks and benefits before deciding to administer fluids to their patients. It is also important to differentiate between the need for fluids and fluid responsiveness.

In conclusion, this guide serves as a general direction for fluid therapy in sepsis, but it must be applied with caution to accommodate different clinical scenarios.

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