The study was actually stopped early when the intervention group that received the IV fluid bolus showed an increased mortality of 45 percent. While it is important to recognize the limitations of this study (most of the children presented with malaria, which may predispose the patients to harm from a fluid bolus, and the study was conducted in hospitals without ICU-level capabilities) the results are nonetheless both thought-provoking and unsettling.

Water, Water, Everywhere…

Despite their limitations, IV fluids are here to stay, but the next time you consider another bolus to determine whether or not your patient is “fluid-responsive,” perhaps you should take a step back and ask yourself if they actually instead need blood, vasopressors, or another intervention in the next step of their care. When it comes to fluid “resuscitation,” it turns out that less is indeed more. 

Dr. Cunningham is a third-year emergency medicine resident at Maricopa Medical Center and soon-to-be critical care fellow at Stanford Medical Center in Standford, Calif.

References

1. Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584.
2. Finfer S, Micallef S, Hammond N, et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022;386(9):815-826. doi:10.1056/NEJMoa2114464.
3. Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial [published online ahead of print, 2021 Aug 10]. JAMA. 2021;326(9):1-12. doi:10.1001/jama.2021.11684.
4. Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369(13):1243-1251. doi:10.1056/NEJMra1208627.
5. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109. doi:10.1056/NEJM199410273311701.
6. Lier H, Fries D. Emergency Blood Transfusion for Trauma and Perioperative Resuscitation: Standard of Care. Transfus Med Hemother. 2021;48(6):366-376. Published 2021 Oct 29. doi:10.1159/000519696.
7. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. doi:10.1056/NEJMoa010307.
8. Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506. 10.1056/NEJMoa1404380.
9. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015;372:1301-11. 10.1056/NEJMoa1500896.
10. ProCESS Investigators , Yealy DM, Kellum JA, et al. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med 2014;370:1683-93. 10.1056/NEJMoa1401602.
11. Sadaka F, Juarez M, Naydenov S, O‘Brien J. Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality. J Intensive Care Med. 2014;29(4):213-217. doi:10.1177/0885066613478899.
12. 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(2):259-265. doi:10.1097/CCM.0b013e3181feeb15.
13. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y.
14. Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019;199(9):1097-1105. doi:10.1164/rccm.201806-1034OC.
15. Bai X, Yu W, Ji W, et al. Early versus delayed administration of norepinephrine in patients with septic shock. Crit Care. 2014;18(5):532. Published 2014 Oct 3. doi:10.1186/s13054-014-0532-y.
16. Ford SR, Visram A. Mortality after fluid bolus in African children with sepsis. N Engl J Med. 2011;365(14):1348-1353. doi:10.1056/NEJMc1108712.