Sepsis fluid therapy

Septic patients have enormous fluid requirements as a result of peripheral vasodilation and capillary leakage. Rapid fluid resuscitation is the best initial therapeutic intervention for the treatment of hypotension in sepsis. The goal of fluid therapy is to maximize cardiac output by increasing the left ventricular preload, which ultimately will restore tissue perfusion. Fluid administration should be titrated to clinical end points such as heart rate, urine output, blood pressure, and mental status. An increased serum lactate level, a byproduct of cellular anaerobic metabolism, should normalize as the tissue perfusion improves. 

An important overall approach for treatment of sepsis is goal-directed therapy. Mortality can be reduced by early placement and use of a central venous catheter, increased fluid volume administration, dobutamine therapy if needed, and red blood cell transfusion, to achieve specific physiologic goals in the first 6 hours. Evidence-based treatment recommendations for sepsis and septic shock from the Surviving Sepsis campaign are presented in Table 45-3. 

Early goal-directed therapy with aggressive fluid resuscitation in the emergency department within the first 6 hours of presentation improves survival in sepsis and septic shock. 

Indications for renal replacement therapy in the acute setting and for other disease processes are different from those for ESRD. A common mode of ESRD therapy in the outpatient setting is intermittent hemodialysis (IHD) where a patient receives intense treatment over the course of a few hours several times a week. Acute renal failure in the inpatient setting is often treated with continuous renal replacement therapy (CRRT), which is applied for the entire duration of the patient s clinical need and relies upon hemofiltration to a higher degree than IHD (Meyer, 2000). Other nonrenal indications for CRRT are based on the theoretical removal of inflammatory mediators or toxins and elimination of excess fluid (Schetz, 1999). These illnesses include sepsis and systemic inflammatory response syndrome, acute respiratory distress syndrome, congestive heart failure with volume overload, tumor lysis syndrome, crush injury, and genetic metabolic disturbances (Schetz, 1999). 

Comparative studies In a multicenter, blinded, randomly assigned trial, 804 patients with severe sepsis needing fluid resuscitation were randomised to receive either hydroxyethyl starch (HES) 130/0.42 or Ringer s acetate and followed for 90 days [45 ]. HES 130/0.42 was associated with an increased risk of death (RR 1.17,95% Cl=1.01-1.36), increased treatment with renal replacement therapy (RR 1.35,95% Cl=1.01-1.80) and increased risk of severe bleeding (RR 1.52,95% Cl = 0.94-2.48). 

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