Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Current Anesthesiology Reports
Published in: Current Anesthesiology Reports 2/2019

01-06-2019 | Septicemia | Critical Care Anesthesia (BS Rasmussen, Section Editor)

Fluid Management in Septic Shock: a Review of Physiology, Goal-Directed Therapy, Fluid Dose, and Selection

Authors: Michael W. Best, Craig S. Jabaley

Published in: Current Anesthesiology Reports | Issue 2/2019

Login to get access

Abstract

Purpose of Review

To review our current understanding of the intravascular space, therapeutic goals of fluid resuscitation, suitable endpoints of resuscitation, and appropriate choice of fluids.

Recent Findings

An evolving understanding of the endothelium and glycocalyx has improved our understanding of the intravascular space. More aggressive fluid resuscitation after adoption of the Surviving Sepsis Campaign guidelines has led to an initial reduction in mortality associated with sepsis; however, the untoward effects of volume overload are increasingly evident. Fluid responsiveness is likely the best endpoint for resuscitation. Albumin has not been shown to be superior to crystalloids in the resuscitation of septic patients. As 0.9% saline has been associated with acute kidney injury, balanced buffered salt solutions are considered the preferred resuscitation fluid of choice.

Summary

Fluid resuscitation with buffered crystalloid solutions is preferred and should likely continue if the patient remains fluid responsive. This strategy risks volume overload.
Literature
1.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for Sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–10.CrossRef
2.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.CrossRef
3.
•• Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486–552 The most recent guidelines from the Surviving Sepsis Campaign, often considered to set the standard of care for the management of patients with sepsis. CrossRef
4.
•• Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Crit Care Med. 2018;46(6):997–1000 A new 1-h sepsis bundle is defined and recommended.CrossRef
5.
Woodcock TE, Woodcock TM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth. 2012;108(3):384–94.CrossRef
6.
Nieuwdorp M, van Haeften TW, Gouverneur MCLG, Mooij HL, van Lieshout MHP, Levi M, et al. Loss of endothelial glycocalyx during acute hyperglycemia coincides with endothelial dysfunction and coagulation activation in vivo. Diabetes. 2006;55(2):480–6.CrossRef
7.
PE M. The physiology of volume resuscitation. Curr Anesthesiol Rep. 2014;4(4):353–9.CrossRef
8.
Becker BF, Jacob M, Leipert S, Salmon AHJ, Chappell D. Degradation of the endothelial glycocalyx in clinical settings: searching for the sheddases. Br J Clin Pharmacol. 2015;80(3):389–402.CrossRef
9.
Marik P, Bellomo R. A rational approach to fluid therapy in sepsis. Br J Anaesth. 2016;116(3):339–49.CrossRef
10.
• Johansson PI, Stensballe J, Ostrowski SR. Shock induced endotheliopathy (SHINE) in acute critical illness - a unifying pathophysiologic mechanism. Crit Care. 2017;21(1):25 A review of how endothelial changes during critical illness affect the disease process and observed pathophysiology. CrossRef
11.
• Bentzer P, Griesdale DE, Boyd J, MacLean K, Sirounis D, Ayas NT. Will this hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316(12):1298–309 A review of various physiologic markers used to define fluid responsiveness with an evaluation of their sensitivities and specifities. CrossRef
12.
Lesur O, Delile E, Asfar P, Radermacher P. Hemodynamic support in the early phase of septic shock: a review of challenges and unanswered questions. Ann Intensive Care. 2018;8(1):102.CrossRef
13.
Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA, et al. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010;303(8):739–46.CrossRef
14.
Egal M, Erler NS, de Geus HRH, van Bommel J, Groeneveld ABJ. Targeting oliguria reversal in goal-directed hemodynamic management does not reduce renal dysfunction in perioperative and critically ill patients: a systematic review and meta-analysis. Anesth Analg. 2016;122(1):173–85.CrossRef
15.
MacDonald N, Pearse RM. Are we close to the ideal intravenous fluid? Br J Anaesth. 2017;119(suppl_1):i63–71.CrossRef
16.
Investigators A, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–506.CrossRef
17.
Pro CI, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683–93.CrossRef
18.
Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301–11.CrossRef
19.
Kuan WS, Ibrahim I, Leong BSH, Jain S, Lu Q, Cheung YB, et al. Emergency department management of sepsis patients: a randomized, goal-oriented, noninvasive sepsis trial. Ann Emerg Med. 2016;67(3):367–378 e3.CrossRef
20.
Andrews B, Semler MW, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, et al. Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial. JAMA. 2017;318(13):1233–40.CrossRef
21.
Investigators P, et al. Early, goal-directed therapy for septic shock - a patient-level meta-analysis. N Engl J Med. 2017;376(23):2223–34.CrossRef
22.
Rochwerg B, Alhazzani W, Sindi A, Heels-Ansdell D, Thabane L, Fox-Robichaud A, et al. Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Ann Intern Med. 2014;161(5):347–55.CrossRef
23.
• Hernandez G, Teboul JL. Is the macrocirculation really dissociated from the microcirculation in septic shock? Intensive Care Med. 2016;42(10):1621–4 A review discussing when measures of the macrocirculation (e.g., blood pressure, stroke volume) is indicative or not indicative of microcirculation and the physiologic implications of these relationships. CrossRef
24.
Ince C, Mik EG. Microcirculatory and mitochondrial hypoxia in sepsis, shock, and resuscitation. J Appl Physiol (1985). 2016;120(2):226–35.CrossRef
25.
Hahn RG, Lyons G. The half-life of infusion fluids: an educational review. Eur J Anaesthesiol. 2016;33(7):475–82.CrossRef
26.
Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370(15):1412–21.CrossRef
27.
Finfer S, Bellomo R, Boyce N, French J, Myburgh J, Norton R, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350(22):2247–56.CrossRef
28.
Annane D, Siami S, Jaber S, Martin C, Elatrous S, Declère AD, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013;310(17):1809–17.CrossRef
29.
Patel A, Laffan MA, Waheed U, Brett SJ. Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality. BMJ. 2014;349:g4561.CrossRef
30.
Investigators SS, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007;357(9):874–84.CrossRef
31.
Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125–39.CrossRef
32.
Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367(20):1901–11.CrossRef
33.
Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367(2):124–34.CrossRef
34.
Hebert PC, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409–17.CrossRef
35.
Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014;371(15):1381–91.CrossRef
36.
Magee CA, Bastin MLT, Laine ME, Bissell BD, Howington GT, Moran PR, et al. Insidious harm of medication diluents as a contributor to cumulative volume and hyperchloremia: a prospective, open-label, sequential period pilot study. Crit Care Med. 2018;46(8):1217–23.CrossRef
37.
• Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819–28 A landmark study that demonstrated increased acute kidney injury associated with the use of 0.9% saline compared to balanced, buffered salt solutions in non-critically ill patients. CrossRef
38.
•• Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829–39 A landmark study that demonstrated increased adverse kidney events associated with the use of 0.9% saline compared to balanced, buffered salt solutions in criticially ill patients. CrossRef
39.
40.
Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C, et al. Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial. JAMA. 2015;314(16):1701–10.CrossRef
Metadata
Title
Fluid Management in Septic Shock: a Review of Physiology, Goal-Directed Therapy, Fluid Dose, and Selection
Authors
Michael W. Best
Craig S. Jabaley
Publication date
01-06-2019
Publisher
Springer US
Published in
Current Anesthesiology Reports / Issue 2/2019
Electronic ISSN: 2167-6275
DOI
https://doi.org/10.1007/s40140-019-00330-3

Other articles of this Issue 2/2019

Current Anesthesiology Reports 2/2019 Go to the issue

Critical Care Anesthesia (BS Rasmussen, Section Editor)

How Does Frailty Affect ICU Outcome?

Pediatric Anesthesia (J Lerman, Section Editor)

Current Concepts in the Management of the Difficult Pediatric Airway

Pediatric Anesthesia (J Lerman, Section Editor)

Stage 1 Palliation of Hypoplastic Left Heart Syndrome: What the Pediatric Anesthesiologist Needs to Know

Pediatric Anesthesia (J Lerman, Section Editor)

Pharmacologic Treatment of Insomnia in Children and Adolescents with Chronic Pain Conditions

Pediatric Anesthesia (J Lerman, Section Editor)

Pediatric Obstructive Sleep Apnea: Neurocognitive Consequences

Critical Care Anesthesia (BS Rasmussen, Section Editor)

Transfusion Requirements in Anesthesia and Intensive Care