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)
Guideline | Scenario A | Scenario B | Scenario C |
|---|---|---|---|
Shock and altered mental status | Non-response to initial management, high lactate | High 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 min | Repeat bolus according to response, central monitoring. Target lactate. | Continue and monitor central pressures |
Rhodes [9] | 30 ml/kg crystalloid over 3 h | Repeat 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. |