Clinical question: In patients presenting to the intensive care unit (ICU) for sepsis, which intravenous (IV) fluid resuscitation strategy (restrictive, liberal, or moderate) is optimal for lower mortality?
Background: IV fluids are used to restore effective circulating volume and tissue perfusion for patients with sepsis. Early goal-directed therapy, directed by the Rivers trial in 2001, has led to the swift adoption of high-volume IV fluid resuscitation. However, subsequent studies have shown varying benefits between restrictive and liberal IV fluid resuscitation strategies. Clinical uncertainty regarding either IV fluid resuscitation strategy for septic patients has led to large practice variation among physicians.
Study design: Retrospective analysis of the Premier Healthcare Database
Setting: 612 U.S. hospitals from January 1, 2016, to December 31, 2019
Synopsis: Inclusion criteria were patients with ICD-10-CM codes for sepsis, septic shock, or infection with acute organ dysfunction on admission, aged 18 years or older, admitted from the emergency department (ED) to the ICU on hospital day one, and who received IV antibiotics and IV fluids on hospital day one. Exclusion criteria were hospitals with less than 20 cases and poor IV fluid reporting, patients given less than 1 L of fluids, identified as do not resuscitate (DNR), who underwent surgery, or who transferred from another hospital. The primary outcome was hospital mortality. The study analyzed 190,682 patients with sepsis and septic shock among 24,445 attending physicians who were separated into five fluid groups: very low, low, moderate, high, and very high. Patients in the moderate fluid group were administered a median of 4.0 L of IV fluids on hospital day one and experienced a 2.5% reduction of risk-adjusted mortality compared with very low group (1.6 L) or very high group (6.1 L), P <0.01. A large variance of IV fluid resuscitation was observed (95% range, 1.7 to 7.4 L) despite similar patient characteristics. Limitations of the study are that the observational study design cannot establish causality between IV fluid resuscitation and sepsis mortality, the absence of data on timing of antibiotics administration and patient height and weight, and use of ICD-10 coding to identify patients.
Bottom line: A moderate IV fluid resuscitation approach (3.6 to 4.5 L) is associated with lower mortality in ICU patients presenting with sepsis, compared to restrictive and liberal fluid strategies. Further randomized controlled trials and guidelines are needed to determine optimal use of IV fluid resuscitation and to reduce physician variability.
Citation: Corl KA, et al. Moderate IV fluid resuscitation is associated with decreased sepsis mortality. Crit Care Med. 2024;52(11):e557-e567. doi: 10.1097/CCM.0000000000006394.
Dr. Whang is a hospitalist in the division of hospital medicine at the University of California Davis Medical Center in Sacramento, Calif.