The following is a summary of “Fluid Therapy for Critically Ill Adults With Sepsis,” published in the June 2023 issue of Critical Care by Zampieri et al.
For a study, researchers aimed to analyze the fluid treatment in septic critically ill adults. About 20% to 30% of patients were admitted to an ICU with sepsis.
In sepsis patients, investigators observed intravenous fluid administration enhanced cardiac output and blood pressure, preserved or enhanced intravascular fluid volume, and facilitated medication delivery. Fluid therapy for critically ill patients is divided into 4 stages: resuscitation, optimization, stabilization, and evacuation. The goal of each stage is to optimize tissue perfusion and organ function while minimizing the risks of fluid overload.
Three RCTs involving 3,723 patients with sepsis who received 1 to 2 L of fluid found that goal-directed therapy (fluid boluses, vasopressors, and red blood cell transfusions or inotropes to attain specific hemodynamic targets) did not decrease mortality compared with unstructured clinical care (24.9% vs. 25.4% P = .68). In another RCT involving 1,563 patients with sepsis and hypotension who received 1 L of fluid, further fluid administration did not show improvement compared to vasopressor therapy (14.0% vs. 14.9% P = .61). A third RCT involving 1,554 ICU patients with septic shock found that restricting fluid administration without severe hypoperfusion did not reduce mortality compared to more liberal fluid administration (42.3% vs. 42.1% P= .96).
Another 1,000 patients with acute respiratory impairment during the evacuation phase found that restricted fluid administration and diuretics led to a significantly longer duration without mechanical ventilation (14.6 days vs. 12.1 days P< .001). Hydroxyethyl starch significantly increased the risk of kidney replacement therapy compared to saline (7.0% vs. 5.8% P= .04).
The study indicated that hydroxyethyl starch significantly increased the occurrence of kidney replacement therapy compared to saline (7.0% vs. 5.8%; P= .04), ringer lactate, or acetate.
They concluded fluid administration is essential for critically ill patients with sepsis, but hydroxyethyl starch should be avoided. Patients recovering from acute respiratory distress syndrome should have fluids actively removed.