Electrolytes
Isotonic crystalloids are the standard for initial volume resuscitation. Fluids are drugs and should be used that way. When given in quantity, they expand the intravascular and interstitial fluid spaces. Typically, approximately 30% of administered isotonic fluid remains intravascular; therefore, large quantities may be required to maintain an adequate circulating volume.
Normal saline and lactated Ringer solution
Both normal saline (NS) and lactated Ringer solution (LR) are essentially isotonic and have equivalent volume restorative properties. Large volume NS resuscitation causes a hyperchloremic metabolic acidosis and in large population-based clinical trials was associated with worse outcomes than patients treated with balanced salt solutions like LR. However, these mortality differences were small. Fluid resuscitation should not be delayed to use a balanced salt solution if NS is the only fluid available.
The amounts of intravascular fluid required are related to the degree of vascular endothelial injury and impaired vasomotor tone; thus, not only may very large quantities of fluids be required initially, but continual fluid resuscitation also is often required during the initial days of management.
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Stages of sepsis based on American College of Chest Physicians/Society of Critical Care Medicine Consensus Panel guidelines.
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Pathogenesis of sepsis and multiorgan failure.
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Venn diagram showing overlap of infection, bacteremia, sepsis, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction.
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Acute respiratory distress syndrome (ARDS) present in this chest x-ray (CXR) film is a common organ system affected in multiorgan failure of sepsis.
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Acute respiratory distress syndrome (ARDS) shown in this chest x-ray (CXR) film is a common complication of septic shock. Note bilateral airspace infiltration, absence of cardiomegaly, vascular redistribution, and Kerley B lines.
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Organizing phase of diffuse alveolar damage (ARDS) secondary to septic shock shows diffuse alveolar injury and infiltration with inflammatory cells.
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Organizing diffuse alveolar damage in a different location showing disorganization of pulmonary architecture.
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A high-power view of organizing diffuse alveolar damage (ARDS) shows hyperplasia of type II pneumocytes and hyaline membrane deposits.