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Unraveling the Complexities of Fluid Therapy in Sepsis: Examining the Evidence

Introduction:

Fluid therapy is fundamental in sepsis care, yet existing guidelines lack robust evidence for a standardized approach. This blog explores the nuances of fluid resuscitation in sepsis, emphasizing the need for thoughtful consideration due to the associated risks of fluid overload and its impact on mortality.


I. The Impact of Fluid Overload:

Fluid overload is linked to higher mortality risk. The adverse effects, categorized into hemodynamic consequences and tissue edema, manifest subtly but are critical.

Pulmonary and systemic congestion, affecting organs like kidneys and intestines, emphasize the need for a personalized approach to prevent complications.


II. What are some Clinical Triggers for Fluid Therapy?

Clinical triggers for fluid therapy include hypovolemia, hypotension, tachycardia, lactic acidosis, severe infections, shock, decreased urine output (oliguria), surgical procedures, burns or trauma, and perioperative care. These triggers prompt healthcare professionals to administer fluids based on the patient's clinical condition, aiming to optimize organ perfusion and maintain hemodynamic stability.


III. The Controversy of Fluid Therapy:

  • The 30 ml/kg Recommendation:

The fourth edition of the SSC guidelines, released in 2016, introduced a robust recommendation: septic patients with hypotension or elevated blood lactate should receive at least 30 mL/kg of intravenous crystalloid within 3 hours. However, the supporting evidence for this directive is lacking.


Furthermore, the guidelines leave a crucial question unanswered: should clinicians base this calculation on actual body weight, predicted body weight, or ideal body weight? This choice significantly impacts prescribed fluid amounts, particularly in cases of extreme weight, adding complexity to an already debated recommendation.

  • Rationale for Fluid Therapy:

The essence of fluid therapy hinges on key assumptions like hypovolemia and the Frank-Starling curve. A thorough examination becomes imperative for a nuanced grasp in varied clinical contexts. This critical assessment lays the groundwork for fluid resuscitation practices tailored to the distinctive needs of each patient.


Recent revelations from the Mayo Clinic shed light on the prevalence of fluid overload in sepsis, introducing intricacies to resuscitation choices. The implications of this study reshape considerations in fluid management. The focus intensifies on challenges associated with weight-based recommendations, unveiling associated caveats. Moreover, it prompts a critical inquiry into the conventional "one-size-fits-all" paradigm advocated by the Surviving Sepsis Campaign. The presentation of evidence supports a shift towards a more personalized and adaptable fluid resuscitation strategy.


IV. Evidence from Studies:


1. Feast (Fluid Expansion As Supportive Therapy) Trial:

This study aimed to assess the impact of fluid resuscitation on critically ill children with severe infections in Africa at resource-limited areas. 3141 Children were administered to various fluids or received no bolus in addition to standard care. Surprising findings from the feast trial, challenging conventional thoughts, are presented.

Kaplan–Meier curves show the rate of death in the three study groups over the course of 48 hours from randomization (Panel A) and over the course of 4 weeks from randomization (Panel B).
Figure 1. Kaplan–Meier Curves for Mortality.

The 48-hour mortality rates were 10.6% (111 out of 1,050 children) in the albumin-bolus group, 10.5% (110 out of 1,047 children) in the saline-bolus group, and 7.3% (76 out of 1,044 children) in the control group. Surprisingly, the study found that giving boluses increased 48-hour mortality compared to no bolus.



The 4-week mortality rates were 12.2%, 12.0%, and 8.7% in the respective groups. Both albumin and saline boluses resulted in higher mortality rates, challenging the belief that fluid resuscitation is universally beneficial in such cases. This suggests caution in fluid administration for critically ill children in similar settings.





2. Clinical Trial on Sepsis and Hypotension:

In this study, more than 200 patients underwent randomization into two groups: one receiving the sepsis protocol, involving early resuscitation in hospitals, and the other receiving usual care, Fluid restricted and Resuscitation was determined by primary doctors based on individual patient cases, conditions, and severity.

Figure 2. Kaplan–Meier Curves for Survival

It's important to note that the study excluded patients presenting with O2 saturation less than 90%, respiratory rate exceeding 40 breaths per minute, congestive heart failure (CHF), and end-stage renal disease (ESRD).


As a result of this study, Mortality outcomes favoring fluid restriction over aggressive fluid administration are highlighted. The mortality rate for patients with sepsis protocol was 48% while the Mortality rate for patients with usual care was 33% and therefore Higher survival rate for usual Care (Restricted fluid therapy).



3. Classic Trial on Fluid Therapy Approach:

The conservative versus liberal approach to fluid therapy in septic shock is discussed.

Conservative vs liberal approach to fluid therapy in septic shock
Figure 3. Classical Trial (Int Care Med'16)

The research involved more than 150 patients experiencing septic shock. In the ICU, the patients were randomly assigned to two groups. One group with Standard Care was on pressors for < 12 hours, received 30 ml/kg of resuscitation fluid, while the other group underwent fluid restriction, only getting resuscitation fluid (crystalloid fluid boluses of 250-500mL) if they showed signs of severe hypoperfusion, lactate levels exceeding 4 mmol/L, MAP below 50 mm Hg, or oliguria within the first 2 hours.


Once Again, the results of this study concluded Favorable outcomes with fluid restriction signal a shift toward considering less fluid as potentially better.




Conclusion:

Fluid management in sepsis requires a cautious approach to mitigate the risks of fluid overload. Recent trials underscore the short-lived nature of fluid responsiveness, advocating for individualized strategies. Understanding the limitations of perfusion markers and acknowledging the changing landscape of fluid therapy in sepsis is imperative for optimal patient care.


References and Related links:




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