In this episode, I’ll discuss a study about a restrictive fluid strategy for patients with sepsis presenting to the emergency department.
For over 2 decades aggressive fluid resuscitation has been a mainstay of treatment recommendations for patients with sepsis. And while there is little debate that strict fluid restriction in a septic patient can lead to hypoperfusion and impaired circulation, some experts feel the pendulum has swung too far in the direction of liberal fluid administration and that this causes its own set of problems, namely fluid overload, edema, and kidney damage.
Specifically, it is felt that the recommendation to give 30 mL/kg of crystalloid IV fluid to all septic patients is of low quality. Furthermore, some recent studies looking at fluid volumes in adult patients with primarily septic shock in the ICU have shown either no difference or indicated a benefit with fluid restriction.
Since there is now clinical equipoise on the study of how much fluid for a septic patient is the right amount, a group of authors recently published a feasibility study in Academic Emergency Medicine that looked at standard of care vs a fluid restricted protocol in septic patients who presented to an ED but were not in shock.
In the restrictive group, IV crystalloids were not given unless one of the following 4 criteria were met:
- Lactate concentration ≥ 4 mmol/l
- Hypotension (systolic blood pressure < 90 mmHg)
- Mottling beyond edge of kneecap (i.e., Mottling score >2)33
- Severe oliguria, i.e., diuresis < 0.1 ml/kg/h, during the first 4 hours of admission
If one or more of these criteria were met, a fluid bolus of 250 ml isotonic crystalloid IV fluid could be administered per protocol.
123 patients were split between groups.
At 24-hours, the mean IV crystalloid fluid volumes were just under 600 mL in the restrictive group and just under 1400 mL in the standard care group.
One-third of the patients in the restrictive group did have a protocol violation where they received an IV bolus despite not meeting criteria. Almost two-thirds of patients in the restrictive group did not receive crystalloid fluids unless as carrier for medication, to correct electrolytes or to replace fluid loss.
The authors concluded it was feasible to restrict IV fluids in septic ED patients that were not in shock, and this justifies larger studies to examine the issue at a scale big enough to draw more firm conclusions on outcomes between these two strategies.
Keep an eye out for more studies drilling down on how much fluid should be given to septic patients.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.