Clinical question: Are there safety or mortality benefits to the use of a more restrictive versus liberal IV fluid strategy for ongoing IV fluid resuscitation in critically ill patients with septic shock?
Background: IV fluids are administered to improve circulation in patients with septic shock. The use of higher volumes of IV fluids has been associated with harm in observational studies and randomized trials involving patients with sepsis and septic shock.
Study design: Stratified, parallel-group, open-label, randomized, clinical trial
Setting: Intensive care units (ICUs) in Denmark, Norway, Sweden, Switzerland, Italy, the Czech Republic, the United Kingdom, and Belgium
Synopsis: Primary outcome data was available on 1,545 intensive care unit patients. Each group shared similar characteristics at baseline. Half of these patients were in the restrictive-fluid group. After initial IV fluid resuscitation, patients in the restrictive arm could only receive fluid based on four conditions: in severe hypoperfusion; to replace documented fluid losses; to correct dehydration or electrolyte deficiency because the enteral route was contraindicated; or to ensure a total daily fluid intake of one liter. Median IV fluid received in this group was 1,798 mL. The other half was assigned to the standard-fluid group. There was no upper limit set for the amount of IVF that a patient in the second group could receive and the median was 3,811 mL.
Three main limitations were noted: protocol violations existed in the restrictive group; the patients had already received a median of about three liters of fluid resuscitation in the hours between presentation and randomization; and the group already requiring respiratory support seemed to do a bit better with fluid restriction.
Bottom line: After initial IV fluid resuscitation, the use of a restrictive strategy for ongoing resuscitation in septic ICU patients appears safe, though not necessarily superior to a more liberal fluid resuscitation.
Citation: Meyhoff TS, Hjortrup PB, et al. Restriction of intravenous fluid in ICU Patients with septic shock. N Engl J Med. 2022;386(26):2459-70.
Ms. Conlon
Ms. Conlon is a physician assistant in the department of abdominal transplant surgery at Stanford Health Care in Palo Alto, Calif.