Indiscriminate Fluid Boluses in the Setting of Septic Shock (June 2011)

The perils of giving critically-ill patients arbitrary amounts of fluid without advanced monitoring (see section on modern fluid management below) was recently hilighted by the FEAST Trial, which included 3141 febrile pediatric patients with impaired perfusion (defined as capillary refill > 3 seconds, a lower-limb temperature gradient, “weak” radial-pulse volume, or severe tachycardia [defined based on age]) and randomized them to 20-40 mL/kg of normal saline, albumin, or no bolus on hospital admission. The primary outcome, death at 48 hours mortality was 10.6%, 10.5%, and 7.3% in the albumin-bolus, saline-bolus, and control groups, respectively. Mortality at 4 weeks was 12.2%, 12.0%, and 8.7%, respectively [Maitland K. NEJM 364: 2483, 2011; FREE Full-text at NEJM]. Criticisms of this study include a protocol change (which increased the amount of the fluid boluses) midway through the study, lack of control or documentation of fluid management after the first hour, unavailability of monitoring data, and lack of advanced hemodynamic monitoring. However, the 20-40 mL/kg bolus was thought to be relatively conservative in the presence of what appeared to be septic shock and by any account these results are surprising. For comparison, in adults, the Surviving Sepsis Guidelines (2008 version) recommend “Give fluid challenges of 1000 mL of crystalloids or 300–500 mL of colloids over 30 mins. More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion” (Level of Evidence 1D) [Dellinger R. CCM 36: 296, 2008]

For more information see Fluid Management section

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