Fluid Administration in Septic Shock

Abstract

The management of septic shock in the critically ill patient is based on appropriate treatment of the infective source, by removal or drainage of septic foci and adequate antibiotic therapy, and on supportive intensive care. The main stay of cardiovascular support is the correct administration of resuscitative fluid therapy in order to permit adequate tissue perfusion. Only when this has failed should additional support such as vasopressors and inotropes be contemplated. Fluid therapy in sepsis should have the same guiding principles as fluid therapy in other contexts: rational choice of fluid type, based on knowledge of individual fluid properties, and a logical approach to titration of fluid volume. However septic shock presents some additional unique challenges that may both influence the choice of fluid type and necessitate use of more advanced techniques to titrate fluid volume. In particular the problems of vascular leak and widespread inflammatory activation need to be addressed. There is evidence that choice of fluid may modulate inflammatory mechanisms. Appropriate choice of fluid can probably also minimise loss of volume from the intra-vascular space and subsequent development of tissue oedema. Loss of circulating volume due to increased vascular permeability is one of the reasons why high volumes of fluid are commonly required during resuscitation of the septic patient. High volume resuscitation brings with it the necessity of careful titration of fluid therapy with appropriate monitoring and an increased risk of fluid associated adverse effects becoming clinically relevant.