A critique of fluid bolus resuscitation in severe sepsis

Abstract

Resuscitation of septic patients by means of one or more fluid boluses is recommended by guidelines from multiple relevant organizations and as a component of surviving sepsis campaigns. The technique is considered a key and life-saving intervention during the initial treatment of severe sepsis in children and adults. Such recommendations, however, are only based on expert opinion and lack adequate experimental or controlled human evidence. Despite these limitations, fluid bolus therapy (20 to 40 ml/kg) is widely practiced and is currently considered a cornerstone of the management of sepsis. In this pointof-view critique, we will argue that such therapy has weak physiological support, has limited experimental support, and is at odds with emerging observational data in several subgroups of critically ill patients or those having major abdominal surgery. Finally, we will argue that this paradigm is now challenged by the findings of a large randomized controlled trial in septic children. In the present article, we contend that the concept of large fluid bolus resuscitation in sepsis needs to be investigated further.

Post-ICU Admission Fluid Balance and Pediatric Septic Shock Outcomes

“…Optimal fluid balance in septic shock is currently an area of much debate (9, 21). There are two inter-related, but distinct issues central to this debate.…”

“…While seemingly a fundamental tenet of septic shock management, aggressive fluid resuscitation for septic shock was recently criticized as being only weakly supported by evidence (9). Further, recent cohort studies have reported an association between positive fluid balance and increased mortality in adult and pediatric patients with sepsis, as well as other critical illnesses (10-19).…”

QUESTION 2: Are intravenous fluid boluses beneficial in late preterm or term infants with suspected haemodynamic compromise?

“…The FEAST study found increased 48-hourly mortality in critically ill children randomised to receive fluid bolus therapy 7. With increasing disquiet over the use of fluid bolus therapy in both paediatric and adult critical care settings,8 it is timely to examine this practice in the neonatal critical care setting. Multicentre randomised trials are needed to answer the question of whether fluid bolus therapy provides any objective clinical benefit in late preterm and term infants with suspected haemodynamic compromise with a variety of underlying clinical conditions.…”

Pediatric Sepsis

“…While seemingly one of the most fundamental principles in the field of critical care medicine, aggressive fluid resuscitation in septic shock has been recently questioned and critiqued as being weakly supported [28]. Indeed, cohort studies have reported an association between positive fluid balance and mortality [29–32].…”