Restricted fluid resuscitation in suspected sepsis associated hypotension (REFRESH): a pilot randomised controlled trial

Macdonald, Stephen; Keijzers, Gerben; Taylor, David; Kinnear, Frances; Arendts, Glenn; Fatovich, Daniel M; Bellomo, Rinaldo; McCutcheon, David; Fraser, John F.; Ascencio-Lane, Juan-Carlos; Burrows, Sally; Litton, Edward; Harley, Amanda; Anstey, Matthew; Mukherjee, Ashes

doi:10.1007/s00134-018-5433-0

Cited by 99 publications

(137 citation statements)

References 31 publications

Supporting

Mentioning

124

Contrasting

Order By: Relevance

“…17 Our study found that the restricted fluid and early vasopressor regimen resulted in a significantly lower volume of fluid administered over the first 24 h of care, with no signal of harm. 17 Our study found that the restricted fluid and early vasopressor regimen resulted in a significantly lower volume of fluid administered over the first 24 h of care, with no signal of harm.…”

Section: Introductionmentioning

confidence: 53%

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan

Keijzers

Macdonald

Udy

et al. 2019

Emerg Medicine Australasia

Self Cite

View full text Add to dashboard Cite

Objective There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). Methods ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in‐hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. Discussion This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.

show abstract

Section: Introductionmentioning

confidence: 53%

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan

Keijzers

Macdonald

Udy

et al. 2019

Emerg Medicine Australasia

Self Cite

View full text Add to dashboard Cite

show abstract

“…Although one of the studies that emphasized earlier restrictions of volume reported an earlier time to the use of vasopressors in the restrictive group, no difference was observed in overall vasopressor use in this study or across any of the other studies (Table ). No significant increase in vasopressor‐associated limb ischemia was observed across the four studies that reported this outcome .…”

Section: Dosing Of Fluids In Sepsis During the Initial Resuscitation mentioning

confidence: 80%

“…Beyond the studies conducted in resource-limited settings, five additional studies [37][38][39][40][41] in 497patients examined either a restrictive or a conservative (usual care) fluid approach in septic patients for a total of 706 patients across the six studies ( Table 2). Three of these studies 37,40,41 (293 subjects) examined a restrictive approach after 25-30 ml/kg of fluids had already been administered during EGDT.…”

Section: Restrictive Resuscitation Meta-analysis Resultsmentioning

confidence: 99%

“…All six studies were powered for an absolute difference in fluid volume, vasopressor‐free days, or were designed as pilot studies with a mortality outcome that did not have a predefined power analysis. Overall risk of bias ranged from low in the adult resource‐limited study, moderate in three studies, and high in two studies . The mean volume spared after the EGDT period (ranging from 24 hrs–5 days) was 1201 ml across the five studies conducted in settings that were not resource limited.…”

Section: Dosing Of Fluids In Sepsis During the Initial Resuscitation mentioning

confidence: 91%

“…The secondary outcome was adverse kidney events (acute kidney injury [AKI], kidney failure, or need for renal replacement therapy). The literature search yielded 806 results, of which six studies met the inclusion criteria (File ).…”

Section: Dosing Of Fluids In Sepsis During the Initial Resuscitation mentioning

confidence: 99%

See 2 more Smart Citations

Establishing the Therapeutic Index of Fluid Resuscitation in the Septic Patient: A Narrative Review and Meta‐Analysis

2020

View full text Add to dashboard Cite

This comprehensive review comparatively evaluates the safety and benefits of parenteral fluids used in resuscitation with a focus on sepsis. It also provides a random‐effects meta‐analysis of studies comparing restrictive resuscitation and usual care in sepsis with the primary outcome of mortality. In the septic patient, fluid therapy remains a complex interplay between fluid compartments in the body, the integrity of the endothelial barrier, and the inflammatory tone of the patient. Recent data have emerged describing the pharmacokinetics of fluid resuscitation that can be affected by the factors just listed, as well as mean arterial pressure, rate of infusion, volume of fluid infusate, nature of the fluid, and drug interactions. Fluid overload in sepsis has been associated with vasodilation, kidney injury, and increased mortality. Restrictive resuscitation after the initial septic insult is an emerging practice. Our search strategy of Medline databases revealed six randomized studies with 706 patients that examined restrictive resuscitation in sepsis. Results of this meta‐analysis demonstrated no differences in mortality with restrictive resuscitation compared with usual care (30.6% vs 37.8%; risk ratio 0.83, 95% confidence interval 0.66–1.05, respectively) but was limited by the small number of studies and larger quantities of pre‐randomization fluids. Another approach to address fluid overload is active (diuresis) de‐resuscitation strategies that may shorten the need for mechanical ventilation and intensive care unit length of stay. Data suggest that colloids may confer mortality benefit over saline in the most severely ill septic patients. Compared with isotonic saline, balanced resuscitation fluids are associated with a lower incidence of acute kidney injury and mortality. The benefits of balanced resuscitation fluids are most evident when higher volumes of fluids are used for sepsis. Clinicians should consider these pharmacotherapeutic factors when selecting a fluid, its quantity, and rate of infusion.

show abstract

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J‐SSCG 2020)

Egi

Ogura

Yatabe

et al. 2021

Acute Medicine & Surgery

View full text Add to dashboard Cite

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J‐SSCG 2020), a Japanese‐specific set of clinical practice guidelines for sepsis and septic shock created as revised from J‐SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English‐language version of these guidelines was created based on the contents of the original Japanese‐language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high‐quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J‐SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU‐acquired weakness [ICU‐AW], post‐intensive care syndrome [PICS], and body temperature management). The J‐SSCG 2020 covered a total of 22 areas with four additional new areas (patient‐ and family‐centered care, sepsis treatment system, neuro‐intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large‐scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE‐based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J‐SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

show abstract

Restricted fluid resuscitation in suspected sepsis associated hypotension (REFRESH): a pilot randomised controlled trial

Cited by 99 publications

References 31 publications

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan

Establishing the Therapeutic Index of Fluid Resuscitation in the Septic Patient: A Narrative Review and Meta‐Analysis

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J‐SSCG 2020)

Contact Info

Product

Resources

About