TY - JOUR
T1 - Liberal Versus Restrictive Intravenous Fluid Therapy for Early Septic Shock
T2 - Rationale for a Randomized Trial
AU - CLOVERS Protocol Committee and NHLBI Prevention and Early Treatment of Acute Lung Injury (PETAL) Network Investigators
AU - Self, Wesley H.
AU - Semler, Matthew W.
AU - Bellomo, Rinaldo
AU - Brown, Samuel M.
AU - deBoisblanc, Bennett P.
AU - Exline, Matthew C.
AU - Ginde, Adit A.
AU - Grissom, Colin K.
AU - Janz, David R.
AU - Jones, Alan E.
AU - Liu, Kathleen D.
AU - Macdonald, Stephen P.J.
AU - Miller, Chadwick D.
AU - Park, Pauline K.
AU - Reineck, Lora A.
AU - Rice, Todd W.
AU - Steingrub, Jay S.
AU - Talmor, Daniel
AU - Yealy, Donald M.
AU - Douglas, Ivor S.
AU - Shapiro, Nathan I.
PY - 2018/10/1
Y1 - 2018/10/1
N2 - Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume of initial fluid (50 to 75 mL/kg [4 to 6 L in an 80-kg adult] during the first 6 hours) and later use of vasopressors, versus a restrictive fluids approach, consisting of a smaller volume of initial fluid (≤30 mL/kg [≤2 to 3 L]), with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies, the Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis trial. The purpose of this article is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial.
AB - Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume of initial fluid (50 to 75 mL/kg [4 to 6 L in an 80-kg adult] during the first 6 hours) and later use of vasopressors, versus a restrictive fluids approach, consisting of a smaller volume of initial fluid (≤30 mL/kg [≤2 to 3 L]), with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies, the Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis trial. The purpose of this article is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial.
UR - http://www.scopus.com/inward/record.url?scp=85046641764&partnerID=8YFLogxK
U2 - 10.1016/j.annemergmed.2018.03.039
DO - 10.1016/j.annemergmed.2018.03.039
M3 - Article
C2 - 29753517
AN - SCOPUS:85046641764
SN - 0196-0644
VL - 72
SP - 457
EP - 466
JO - Annals of Emergency Medicine
JF - Annals of Emergency Medicine
IS - 4
ER -