Evaluation and Predictors of Fluid Resuscitation in Patients With Severe Sepsis and Septic Shock

Crit Care Med. 2019 Nov;47(11):1582-1590. doi: 10.1097/CCM.0000000000003960.


Objectives: Rapid fluid resuscitation has become standard in sepsis care, despite "low-quality" evidence and absence of guidelines for populations "at risk" for volume overload. Our objectives include as follows: 1) identify predictors of reaching a 30 mL/kg crystalloid bolus within 3 hours of sepsis onset (30by3); 2) assess the impact of 30by3 and fluid dosing on clinical outcomes; 3) examine differences in perceived "at-risk" volume-sensitive populations, including end-stage renal disease, heart failure, obesity, advanced age, or with documentation of volume "overload" by bedside examination.

Design: Retrospective cohort study. All outcome analyses controlled for sex, end-stage renal disease, heart failure, sepsis severity (severe sepsis vs septic shock), obesity, Mortality in Emergency Department Sepsis score, and time to antibiotics.

Setting: Urban, tertiary care center between January 1, 2014, and May 31, 2017.

Patients: Emergency Department treated adults (age ≥18 yr; n = 1,032) with severe sepsis or septic shock.

Interventions: Administration of IV fluids by bolus.

Measurements and main results: In total, 509 patients received 30by3 (49.3%). Overall mortality was 17.1% (n = 176), with 20.4% mortality in the shock group. Patients who were elderly (odds ratio, 0.62; 95% CI, 0.46-0.83), male (odds ratio, 0.66; CI, 0.49-0.87), obese (odds ratio, 0.18; CI, 0.13-0.25), or with end-stage renal disease (odds ratio, 0.23; CI, 0.13-0.40), heart failure (odds ratio, 0.42; CI, 0.29-0.60), or documented volume "overload" (odds ratio, 0.30; CI, 0.20-0.45) were less likely to achieve 30by3. Failure to meet 30by3 had increased odds of mortality (odds ratio, 1.52; CI, 1.03-2.24), delayed hypotension (odds ratio, 1.42; CI, 1.02-1.99), and increased ICU stay (~2 d) (β = 2.0; CI, 0.5-3.6), without differential effects for "at-risk" groups. Higher fluid volumes administered by 3 hours correlated with decreased mortality, with a plateau effect between 35 and 45 mL/kg (p < 0.05).

Conclusions: Failure to reach 30by3 was associated with increased odds of in-hospital mortality, irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival. These findings are retrospective and require future validation.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Age Factors
  • Cohort Studies
  • Comorbidity
  • Emergency Service, Hospital
  • Female
  • Fluid Therapy*
  • Hospital Mortality*
  • Humans
  • Intensive Care Units
  • Kidney Failure, Chronic
  • Male
  • Middle Aged
  • Patient Admission
  • Resuscitation*
  • Retrospective Studies
  • Sepsis / mortality
  • Sepsis / therapy*
  • Sex Factors
  • Shock, Septic / mortality
  • Shock, Septic / therapy*