This may sound crazy, but there are several lines of evidence that support a restrictive fluid approach, including a randomized controlled trial of children with severe malaria, a severity-adjusted analysis of 23,513 septic adults that found each liter beyond five associated with a mortality increase, and a recent randomized controlled trial of adults with septic shock showing significantly improved survival among those getting 2 versus 3.5 L in the first six hours.8-10 A randomized trial of a liberal versus restrictive fluid approach for septic ED patients is currently being planned by the Prevention and Early Treatment of Acute Lung Injury network.
Explore This IssueACEP Now: Vol 37 – No 03 – March 2018
I asked Peter DeBlieux, MD, an emergency medicine and critical care specialist at Louisiana State University in New Orleans, for his perspective. He said, “Despite some missteps, the best aspect of SSC is promoting recognition; early recognition of sepsis means sooner antibiotics, source control, and care coordination with consultants. Continued recognition of the need for research to improve outcomes for this major killer is critically important.”
One of my mentors once told me it’s best to be neither the first nor the last to embrace an innovation. Unfortunately, in many ways, we’re back to where we started with sepsis.
- Dellinger RP1, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2004;30(4):536-555.
- Eichacker PQ, Natanson C, Danner RL. Surviving sepsis—practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med. 2006;355(16):1640-1642)
- Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008;34(1):17-60.
- 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.
- Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant activate proten C for severe sepsis. N Engl J Med. 2001;344(10):699-709.
- Lindenauer PK, Lagu T, Shieh MS, et al. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009. 2012;307(13):1405-1413.
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552.
- Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364(26):2483-2495.
- Marik PE, Linde-Zwirble WT, Bittner EA, et al. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database. Intensive Care Med 2017;43(5):625-632.
- Andrews B, Semler MW, Muchemwa L, 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):1233-1240.