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Fluid resuscitation in septic shock: too much, too little or just right?
Critical Care volume 16, Article number: 436 (2012)
In their interesting observational study Smith and Perner  describe fluid resuscitation (FR) in 164 patients with septic shock, concluding that survival was better in patients receiving higher volumes over the first 72 h. I think we should be cautious, however, to conclude from this that more is better.
Median FR was 4.0 L over 24 h, and 7.5 L by 72 h - relatively small volumes for patients with ongoing shock. FR volumes reported from trials performed in septic shock are substantially larger despite comparable illness severity; mean FR over 72 h was approximately 19 L in the Vasopressin in Septic Shock Trial (VASST) study , 13 L in the study by Rivers and colleagues  and 16 L in another recent study . Indeed, median FR in the high-volume group (10.9 L at 72 h) was comparable to the lowest quartile, associated with the best prognosis, in the VASST study (16 L at 96 h) . Thus, I do not believe that the benefit of higher-volume FR described is in conflict with the harm associated with larger volumes reported previously . Similarly, median FR in the lower-volume group was only 4.3 L in 72 h. As FR was physician-directed, lower-volume FR might have been indicated by factors like chronic cardiac failure or fluid unresponsiveness associated with poorer outcomes irrespective of FR; no evidence is provided to conclude that increasing FR in this group would have improved survival.
Overall, this report records excellent outcomes using moderate FR by recent standards. Further trials are needed to characterize the dose and indications for FR in septic shock.
Anders Perner and Søren H Smith
Thanks to Dr Prowle for his interest in our study. We agree that observations in cohort studies should be interpreted with caution, in particular in complex clinical settings such as fluid resuscitation of patients with sepsis in the ICU. The interpretation of studies in this area is further complicated by differences in the reporting of fluid therapy. The types of, and indications for, fluids are most often not reported, so when previous trials [2–4] report that more than 10 L of fluid was given by day 3, we do not know if this fluid was given for resuscitation. In trials of fluid resuscitation  (unpublished observations from the 6S trial ), 2.5 L of other fluids were given for each liter of resuscitation fluid. The indications for giving other fluids may include nutrition, maintenance, fluids with medications and electrolytes or even to keep a drip open, but we do not know the details. Taken together, we support the notion that the controversy of fluid volume in septic shock may only be resolved in randomized trials of higher versus lower fluid volumes in these patients. Such trials should be top priority for the ICU research community.
Vasopressin in Septic Shock Trial.
Smith SH, Perner A: Higher vs. lower fluid volume for septic shock: clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort. Crit Care 2012, 16: R76. 10.1186/cc11333
Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA: Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011, 39: 259-265. 10.1097/CCM.0b013e3181feeb15
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345: 1368-1377. 10.1056/NEJMoa010307
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA, Emergency Medicine Shock Research Network I: Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA 2010, 303: 739-746. 10.1001/jama.2010.158
Finfer S, McEvoy S, Bellomo R, McArthur C, Myburgh J, Norton R: Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med 2011, 37: 86-96.
Perner A, Haase N, Wetterslev J, Aneman A, Tenhunen J, Guttormsen AB, Klemenzson G, Pott F, Bodker KD, Badstolokken PM, Bendtsen A, Soe-Jensen P, Tousi H, Bestle M, Pawlowicz M, Winding R, Bulow HH, Kancir C, Steensen M, Nielsen J, Fogh B, Madsen KR, Larsen NH, Carlsson M, Wiis J, Petersen JA, Iversen S, Schoidt O, Leivdal S, Berezowicz P, et al.: Comparing the effect of hydroxyethyl starch 130/0.4 with balanced crystalloid solution on mortality and kidney failure in patients with severe sepsis (6S - Scandinavian Starch for Severe Sepsis/Septic Shock trial): study protocol, design and rationale for a double-blinded, randomised clinical trial. Trials 2011, 12: 24. 10.1186/1745-6215-12-24
The author declares that they have no competing interests.
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Prowle, J.R. Fluid resuscitation in septic shock: too much, too little or just right?. Crit Care 16, 436 (2012). https://doi.org/10.1186/cc11362
- Septic Shock
- Fluid Volume
- Fluid Resuscitation
- Fluid Therapy