COMMENTARY

Choosing Fluids Wisely for Septic Shock

Greg Martin, MD

Disclosures

June 24, 2016

Association Between Initial Fluid Choice and Subsequent In-hospital Mortality During the Resuscitation of Adults With Septic Shock

Raghunathan K, Bonavia A, Nathanson BH, et al
Anesthesiology. 2015;123:1385-1393

Summary

Sepsis is a common condition in the intensive care unit (ICU), and the Surviving Sepsis Campaign (SSC) recommends specific doses of fluids to be administered.[1] Also within the recent version of the SSC guidelines, there are recommendations for fluid type (to use crystalloid, consider albumin, and avoid starch products), but the evidence to differentiate crystalloid formulations is poor.[2] The authors sought to determine the association between fluid type and mortality among patients with septic shock. They queried the Premier database and identified 60,734 adult severe sepsis patients who received at least 2 L of intravenous fluids before day 2 and were admitted to an ICU in the United States between January 2006 and December 2010. In-hospital mortality was 20.2% in patients who received exclusively saline, lower at 17.7% in patients who received a combination of saline and balanced crystalloid solutions (P < .001), and higher in the patients who received saline with a colloid (24.2%). In propensity score-matched comparisons, the administration of balanced crystalloids by hospital day 2 was associated with lower mortality irrespective of whether colloids were also used. Colloid use was associated with greater hospital length of stay (LOS) and costs per day. The authors concluded that coadministration of balanced crystalloids with saline is associated with lower mortality and no difference in LOS or costs, whereas coadministration of colloids is associated with greater LOS and costs.

Viewpoint

This large retrospective cohort study of patients with severe sepsis and septic shock requiring IV fluid resuscitation found that balanced crystalloid solutions are associated with superior outcomes when compared with exclusive saline resuscitation. An increasing body of literature suggests that saline use has adverse consequences that are believed to be due to its high chloride load.[3] This is particularly true when administered in large volumes, as would be expected in severe sepsis and septic shock. For example, removing saline from fluid use in Australian ICUs resulted in lower rates of acute kidney injury.[4] Because colloids are often mixed in saline, it is difficult to know if outcomes associated with the use of colloids are "contaminated" by the effect of saline. For sepsis patients in particular, but perhaps all ICU patients requiring larger volumes of fluid administration, until additional and higher-quality evidence is available, it seems prudent to avoid purely saline-based fluid resuscitation.

Abstract

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