Fixed minimum volume resuscitation: Pro
The hemodynamic hallmarks of sepsis are arterial vasodilatation and increased capillary permeability. The fluid shift from the intravascular space together with the decrease in systemic vascular resistance and altered ventricular performance may lead to a relative hypovolemia and hypotension contributing to tissue hypoperfusion. As a consequence, fluid resuscitation is a key step to treat sepsis when signs of hypoperfusion are present. It is widely acknowledged that a lack of adequate fluid resuscitation during the first initial and crucial hours of hypoperfusion can have hazardous consequences in terms of organ dysfunction. Insufficient fluid resuscitation leads to delayed or absent shock reversal, and over-reliance on vasopressors, which is equally or even more harmful. For instance, the use of vasopressors in the presence of hypovolemia can lead to acute kidney injury (AKI) . Sepsis is a leading cause of AKI among critically ill patients and both are associated with high mortality rates. Although the physiopathology of AKI is multifactorial , the restoration of normovolemia is a necessary step to prevent or reverse the pre-renal component of AKI.
The Surviving Sepsis Campaign (SSC) guidelines indicate fluid resuscitation with 30 mL/kg within 3 h for all patients with hypotension or hyperlactatemia. The recommended approach is the use of a fixed initial volume followed by titration according to response, either based on dynamic (e.g., change in pulse pressure, stroke volume variation) or static (e.g., arterial pressure, heart rate) variables and careful administration of more fluids as needed. This initial fluid volume, around 2.0 L, should be sufficient to correct hypovolemia and is very unlikely to cause significant harm in virtually any patient. This approach aims to ensure an early and minimal correction of hypovolemia. The administration of 30 mL/kg is not meant to be the total amount of resuscitation. Some patients may need considerably more fluid than this, and this must be assessed on an individual patient basis by clinicians at the bedside titrating additional fluid against clinical endpoints.
There is no randomized control trial (RCT) comparing these two different strategies, i.e., a fixed initial volume followed by titration or a more restrictive strategy in which titration is used from the start of resuscitation. RCTs assessing restrictive fluid strategies in the early phases of shock are also lacking. The results of the single RCT performed to date, the FEAST trial, are not generalizable and certainly not adaptable to the adult population . FEAST was conducted in African children, with a mean age of 24 months, most of whom (57 %) had malaria and 32 % had hemoglobin levels lower than 5 mg/dL. There was no (or minimal) access to positive pressure ventilation. Fluid resuscitation might result in different outcomes in the presence of malaria and severe anemia. Severe dilutional anemia is potentially detrimental and could have contributed to the increased mortality in the fluids arms as patients randomized to the control group received blood transfusions while in these groups patients were receiving fluid bolus. It is also notable that there were no reports on the length of time needed to reach the study hospitals but a delay is certainly expected in Africa. It is well known that delays in resuscitation are associated with worse outcomes. Another RCT, the FACTT trial, compared liberal and restrictive strategies in fluid resuscitation in patients with acute respiratory distress syndrome (ARDS) . The focus was not the first hours of resuscitation and patients with shock were taken out of the protocol for the restrictive fluid arm until shock resolved. This prospective change in the treatment strategy precludes any generalizability of the restrictive strategy in FACTT to resuscitation in sepsis.
Amount of fluids received by patients in the control arm in the EGDT trials
Prior to randomization (mL)
2083 ± 1405
2591 ± 1331
1790 (1000, 2500)a
Prior to randomization (mL/kg)
28 ± 21
34.7 ± 20.1
Between 0 and 6 h after randomization (mL)
3499 ± 2438
2279 ± 1881
1713 ± 1401
2022 ± 1271
Between 0 and 6 h after randomization (mL/kg)
23.2 ± 21.2
Additionally, none of these studies showed that the fixed amount of fluids strategy is associated with harm. Although several researchers have suggested an increase in morbidity and mortality associated with positive fluid balances , the vast majority of these papers have analyzed fluid balance during the whole ICU stay or during the first ICU days and not in the first hours of shock. Some clinicians are reticent to give 30 mL/kg in patients with heart failure or chronic kidney failure because of the theoretical risk of volume overload. However, a recent before–after study in patients with intermediate levels of lactate (2–4 mmol/dL) showed that fluid resuscitation with 30 mL/kg was associated with a reduction in the risk of death, primarily in patients with heart failure or chronic kidney disease . The impact in mortality remained significant over 1 year after the inclusion with no increase in adverse events. This finding reinforces the importance of early fluid resuscitation in all patients with sepsis and any degree of lactic acidosis, even in patients with renal or cardiac failure. There is also no evidence that aggressive fluid resuscitation in the first 6 h worsens respiratory dysfunction and leads to mechanical ventilation (MV). Although patients in the EGDT arm receive more fluids in the first 6 h, only 2.6 % of those not under MV needed to be ventilated within the 7–72 h as compared to 16.8 % in the control arm . The EGDT arm and the protocol-based arm, in ARISE and PROCESS, received more fluids but there was no difference in the percentage of patients needing MV as compared to the other arms [11, 12].
Unfortunately, the clinical reality is that physicians are far more prone to under-resuscitate than otherwise. The change in behavior during the past few years is striking. Patients in the control arm of the Rivers trial received more than 13,000 mL in the first 72 h while those in the usual care arm of the new EDGT trials received around 6000 mL [10, 11, 12, 13]. In this context, a necessary step to ensure minimal treatment is to set goals of care, a well-established strategy in quality improvement initiatives. This is even more relevant in resource-limited settings where access to knowledge is limited and key treatment steps need to be given in simple messages. The ability to assess fluid responsiveness is not a reality in the vast majority of these settings. It is certainly possible that a fixed minimum amount of 30 mL/kg is excessive for a small fraction of patients. For instance, chronic ICU patients might not need this fixed amount of fluids and might benefit from a proper assessment of fluid responsiveness in settings where these techniques are available. But published data strongly suggest that the large majority of patients benefit from beginning resuscitation with this minimum amount. A fixed amount does not mean the physician should abandon the need to assess fluid responsiveness and titrate fluid administration accordingly. We need to frequently reevaluate the patients and limit resuscitation efforts to what is required by our individual patients. We believe it is the administration of an initial fixed minimum of 30 mL/kg of fluids combined with frequent reassessment of fluid responsiveness that will optimize our ability to adequately resuscitate patients with severe sepsis and septic shock.
Compliance with ethical standards
Conflicts of interest
The authors state that there is no conflict of interest.
- 3.Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M, Babiker AG, Gibb DM, FEAST Trial Group (2011) Mortality after fluid bolus in African children with severe infection. N Engl J Med 364:2483–2495CrossRefPubMedGoogle Scholar
- 4.National Heart, Lung, and Blood Institute Acute Respiratory Distress (ARDS) Syndrome Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL (2006) Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 354:2564–2575CrossRefGoogle Scholar
- 5.Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S, Angus DC (2010) The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 36:222–231CrossRefPubMedPubMedCentralGoogle Scholar
- 7.Rhodes A, Phillips G, Beale R, Cecconi M, Chiche JD, De Backer D, Divatia J, Du B, Evans L, Ferrer R, Girardis M, Koulenti D, Machado F, Simpson SQ, Tan CC, Wittebole X, Levy M (2015) The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med 41:1620–1628CrossRefPubMedGoogle Scholar
- 8.Noritomi DT, Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Leibel F, Machado FR (2014) Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 40:182–191CrossRefPubMedGoogle Scholar
- 9.Scheer CS, Fuchs C, Kuhn SO, Vollmer M, Rehberg S, Friesecke S, Abel P, Balau V, Bandt C, Meissner K, Hahnenkamp K, Grundling M (2016) Quality improvement initiative for severe sepsis and septic shock reduces 90-day mortality: a 7.5-year observational study. Crit Care Med (in press)Google Scholar
- 14.Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N (2014) Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 46:361–380CrossRefPubMedGoogle Scholar