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Table 4 Specific fluid therapy recommended in pre-described clinical case scenarios. All guidelines adopt a universal initial approach to fluids (do not take into consideration presenting comorbidities)

From: Recommendations for fluid management of adults with sepsis in sub-Saharan Africa: a systematic review of guidelines

GuidelineScenario AScenario BScenario C
Shock and altered mental statusNon-response to initial management, high lactateHigh lactate and likely congestive cardiac failure
Cecconi [19]Guideline on haemodynamic monitoring in circulatory shock, not specific to sepsis. Recommendations are given in general terms and are not directly applicable to the clinical scenarios.
Dunser [22]> 4 L crystalloid in first 24 h.No additional specific guidance.Warning given regarding fluid overload. No fluid if not clinically hypo-perfused.
Hollenberg [20]250-500 ml boluses over 15 min titrated to clinical endpoints and cardiac measures of fluid responsiveness. No ceiling given (liberal).No additional specific guidance.No additional specific guidance.
Misango [15]30 ml/kg crystalloid over 3 h, continue if fluid responsive.Peripheral perfusion guided therapy.Peripheral perfusion guided therapy. Clinical examination to detect overload.
Moller [17]Guideline on choice of first-line vasopressor, no specific recommendations relevant to the clinical scenarios.
NICE [16]No definitive guide without lactate.500 ml crystalloid over < 15 min. Seek senior help at 2 L.500 ml bolus in response to high lactate, as in scenario B. No specific guidance regarding fluid overload.
Perner [18]Guideline on choice of resuscitation fluid, general recommendation for use of crystalloid over other fluid types; no other specific recommendations relevant to the clinical scenarios.
Reinhart [23]500-1000 ml crystalloid over 30 minRepeat bolus according to response, central monitoring. Target lactate.Continue and monitor central pressures
Rhodes [9]30 ml/kg crystalloid over 3 hRepeat bolus according to response, including invasive and non-invasive monitoring. Target lactate. No volume ceiling given.Clinical reassessment to detect pulmonary oedema
WHO [25]1000 mL crystalloid immediately, continued at 20 ml/kg/h (max 60 ml/kg in first 2 h).Between 2 and 6 h, fluid at 5-10 ml/kg/h if SBP < 90 and signs of poor perfusion continue.Alert for signs of fluid overload (increased JVP, increasing crackles/rales): reduce rate if present.