Fluids and sepsis: changing the paradigm of fluid therapy: a case report

Abstract

BackgroundOver the past 16 years, sepsis management has been guided by large-volume fluid administration to achieve certain hemodynamic optimization as advocated in the Rivers protocol. However, the safety of such practice has been questioned because large-volume fluid administration is associated with fluid overload and carries the worst outcome in patients with sepsis. Researchers in multiple studies have declared that using less fluid leads to increased survival, but they did not describe how to administer fluids in a timely and appropriate manner.Case presentationAn 86-year-old previously healthy Sundanese man was admitted to the intensive care unit at our institution with septic shock, acute kidney injury, and respiratory distress. Standard care was implemented during his initial care in the high-care unit; nevertheless, his condition worsened, and he was transferred to the intensive care unit. We describe the timing of fluid administration and elaborate on the amount of fluids needed using a conservative fluid regimen in a continuum of resuscitated sepsis.ConclusionsBecause fluid depletion in septic shock is caused by capillary leak and pathologic vasoplegia, continuation of fluid administration will drive intravascular fluid into the interstitial space, thereby producing marked tissue edema and disrupting vital oxygenation. Thus, fluids have the power to heal or kill. Therefore, management of patients with sepsis should entail early vasopressors with adequate fluid resuscitation followed by a conservative fluid regimen.

Patient-Specific Monitoring and Trend Analysis of Model-Based Markers of Fluid Responsiveness in Sepsis: A Proof-of-Concept Animal Study

“…As septic shock is induced fluid is lost from the circulation due to increased vascular permeability [24], [14]. The loss in total volume would result in a drop in blood pressure and SBV T , which are both characteristic of septic shock [21], [14], [18], [31] and evident in this experiment.…”

Increasing the Knowledge of Critical Care Nursing Staff Related to Sepsis: A Program Development Project

“…After the patient is stabilized in the initial resuscitation phase, these fluids should be tapered to prevent fluid overload which will worsen oxygen transport. The authors further discuss how complex sepsis treatment is and how practitioners need to be more aware of the possible poor outcomes that intravenous fluid therapy can have on the patient (Hariyanto, Yahya, Widiastuti, Wibowo, & Tampubolon, 2017).…”

“…The patient discussed in the study received four liters of crystalloid infusions, nevertheless the patient's MAP remained below 65 and vasopressor therapy was initiated. The patient's urine output was less than 1ml/kg/hr and the patient's creatine levels were rising daily(Hariyanto, Yahya, Widiastuti, Wibowo, & Tampubolon, 2017).The authors point out that the nursing staff and practitioners need to be cautious of continuing intravenous fluids. Further fluid therapy could increase edema.…”

“…Fluid administration continues throughout the treatment of the septic patient if the patient's hemodynamic status is improving and patient is tolerating the fluid Hariyanto, Yahya, Widiastuti, Wibowo, & Tampubolon, (2017). explored both the benefits and disadvantages that fluid challenges cause during sepsis care in a case report on an 86year-old man with no prior comorbidities.…”

“…The authors conclude that starting vasopressors at an earlier time can have a beneficial outcome for the patient. Acquiring an adequate MAP can cause adequate organ perfusion and decrease the formation of edema(Hariyanto, Yahya, Widiastuti, Wibowo, & Tampubolon, 2017).Current evidence on fluid therapy and sepsis care should urge practitioners to reconsider the regimen of fluid management. Aggressive fluid management after the resuscitation phase in sepsis care has well-documented poor outcomes for the patient.…”