NEJM Journal Watch
Patricia Kritek, MD
In two trials, restrictive fluid resuscitation was adequate and even preferable to more-aggressive resuscitation.
Resuscitation is a central part of the care of many critically ill patients, including those with septic shock and severe pancreatitis. For years, emphasis was placed on rapid administration of large volumes of fluid to ensure tissue perfusion in these patients. More recently, we have become more nuanced about how much fluid is “enough,” as complications of aggressive resuscitation (e.g., pulmonary edema, anasarca) have been noted. In 2022, two new studies added to that knowledge.
Spanish investigators randomized 249 patients with acute pancreatitis to either aggressive or moderate fluid resuscitation with lactated Ringer’s solution. They excluded patients who presented with “moderately severe or severe” pancreatitis — for example, those with shock or organ failure. The aggressive and moderate fluid protocols translated to median volumes of 7.8 L versus 5.5 L in the first 48 hours. The trial was stopped early, because 20% of the aggressively resuscitated patients developed fluid overload (compared with 6% of the moderate group). The two groups developed severe pancreatitis with similar frequency (≈20%; NEJM JW Gen Med Oct 15 2022 and N Engl J Med 2022; 387:989).
With the same concern for harm from too much fluid, European investigators randomized 1500 patients with septic shock to either restrictive or standard fluid resuscitation. Median fluid administered in the intensive care unit (ICU; after at least 1 L of intravenous fluid prior to randomization) was 1.8 L versus 3.8 L, and no difference was noted in 90-day mortality or adverse events (NEJM JW Gen Med Aug 15 2022 and N Engl J Med 2022; 386:2459). At first glance, this result suggests no advantage to restricting fluid. However, the 2-L difference during an ICU stay isn’t very much, suggesting that “usual care” here also was relatively restrictive.
Early fluid resuscitation still is an essential part of the care of patients with sepsis and pancreatitis. That being said, we have a growing body of literature that shows harm when we administer massive amounts of fluid, compared with more cautious volume repletion. Fluid resuscitation should be tailored to the specific patient, and defaulting to a more conservative approach after an initial bolus makes sense.