Fluid resuscitation in sepsis is controversial. The only large randomised controlled trial (RCT) of different volume fluid bolus resuscitation in severe infection is the Fluid Expansion as Supportive Therapy (FEAST) study. FEAST was conducted in Africa, in a low resource setting, without access to intensive care; it demonstrated a lower mortality rate in children receiving restrictive fluid therapy (no bolus) compared to those given more liberal fluid therapy (20 ml/kg in the first hour). Despite these findings, the current ACCM guidance continues to recommend a liberal fluid strategy, with up to 60 ml/kg bolus fluid in the first hour of treatment.
Review of current evidence relating to fluid resuscitation strategies in sepsis.
Literature review.
Numerous observational studies support the current ACCM guidance. However, these are all before/after studies in which liberal fluid bolus therapy has formed part of a bundle of care. There have been no large scale RCTs. There have been three small RCTs of different volume resuscitation strategies in settings in which intensive care is available. These studies between them included 316 children and showed no difference in mortality between the restrictive and liberal fluid resuscitation groups. There is also emerging evidence from observational studies that fluid overload in a PICU setting is associated with poor outcomes, both in relation to length of organ support and mortality.
Possible strategies to limit fluid bolus resuscitation will be discussed. Non invasive haemodynamic markers of volume status and evidence based resuscitation targets should be developed to help guide treatment.