Fluid Restriction for Patients with Septic Shock?

A key principle of the early treatment of patients with septic shock is adequate volume resuscitation. Guidelines (based on limited evidence) recommend 30 mL/kg of crystalloid as an initial bolus (NEJM JW Gen Med Dec 15 2021 and Crit Care Med 2021; 49:1974). Under-resuscitation risks ongoing tissue hypoxia, but excessive fluids could also cause harm.

European investigators randomized 1500 patients with septic shock to either a restrictive or standard fluid protocol. All patients had received ≥1 L of intravenous fluid and were receiving vasopressors. In the restrictive arm, additional fluids (250–500 mL isotonic fluid) could be given for marked hypoperfusion (i.e., lactate >4 mmol/L, mean arterial pressure <50 mm Hg, mottling above the knee, …