Rethinking IV Fluid Resuscitation in Sepsis

  • Fluid resuscitation is a key component in the management of sepsis and shock to improve fluid volume.
  • The risks of fluid overload may contribute to poorer outcomes.
  • Despite widespread support for fluid resuscitation, data supporting large volumes is limited.
  • The Surviving Sepsis Campaign recommends patients receive 30 mL/kg crystalloid fluids within 3 hours of sepsis identification.
  • This recommendation is also part of the CMS SEP-1 compliance guidelines.
  • The determination of 30 mL/kg is based on average fluid volumes administered in previous large sepsis trials.
  • The topic remains controversial, with questionable mortality benefit.
  • Additional studies demonstrate deleterious effects of large fluid volumes in critically ill patients.
  • Patients with end-stage renal disease, heart failure or with advanced age often receive less fluids or have delays in administration with varying degrees of mortality impact.
  • There is a paucity of high-quality data to guide clinical practice.
  • Table 1 indicates several recent studies demonstrating a benefit to early IV fluid resuscitation.
  • Table 2 indicates several recent studies demonstrating limited value or even potential harm with IV fluid resuscitation.
  • The significant heterogeneity of sepsis makes the generalization of a recommendation difficult.
  • Key study weakness in both camps include:
    • Small underpowered data groups
    • Often single center studies
    • High risk of methodologic bias
    • Wide variances in therapeutic approaches to fluid administration
    • Inconsistent outcome reporting
    • Missing data
    • Missing outcomes other than mortality and length of stay
  • Well designed, large multicenter clinical trials are needed
  • Plausible current approach:
    • In patients with evidence of tissue hypoperfusion, fluid administration is most likely beneficial.
    • If tissue perfusion appears satisfactory, fluid administration may not have a rational role
    • When fluid administration has failed to improve hypoperfusion, earlier initiation of vasopressor therapy is associated with hemodynamic resuscitation and reduced mortality
  • Fluid resuscitation is not without potential harm and may be of questionable value.
  • Clinicians should recognize the substantial heterogeneity of sepsis and focus on tailoring fluid resuscitation to the individual needs of the patient based on assessment of clinical responsiveness.
  • Earlier use of vasopressors to fluid administration should be considered in unresponsive patients.

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Erkan Hassan is the Co-Founder & Chief Clinical Officer of Sepsis Program Optimization where he designs & oversees the implementation of solutions to optimize sepsis programs.

To discuss your organization’s Barriers of Effective Sepsis Care, contact Erkan by phone (844) 4SEPSIS (844-473-7747), email (, or video chat.