Intravenous fluids in septic shock: should we be content with the blanket approach?
Recently, the findings of CLASSIC trial were published in the NEJM, which demonstrated that among adult patients with septic shock in the ICU, intravenous fluid (IVF) restriction did not result in fewer deaths at 90 days compared to standard IVF therapy. However, these findings should not be regarded as a license for indiscriminate administration of IVF in patients with septic shock. As rightly pointed out in the accompanying editorial, other way to look at it is that the restrictive fluid-management strategy is safe (notably, the standard-care group received substantially less fluid compared to prior studies reporting fluid overload-related adverse effects). Moreover, IVF use is so ubiquitous that some clinicians overlook the fact that they are drugs; as with any other drug, we need to first define the patient’s problem (i.e., determine an indication), specify a therapeutic objective (i.e., establish a stop-point), and choose the dose/type of fluid accordingly.
Therefore, it does not seem prudent to prescribe IVF empirically (and liberally) in everybody with a diagnosis of septic shock irrespective of demonstrable harm. Do we administer ourselves Normal saline in the physicians’ lounge because there is no clinical trial suggesting harm?
Bedside tools such as point-of-care ultrasonography facilitate “individualization” of therapy throughout the course of critical-illness by providing real-time insights into hemodynamics. Future studies should consider documenting this non-invasively obtained data both at the initiation and termination of a therapeutic intervention and assess if and how it relates to the outcome; ultimately, integration of physiology and evidence strengthens the applicability of a trial. Below figure summarizes our proposed decision-making process when contemplating fluid therapy. If POCUS reveals findings listed on the right, physician should question themselves whether the patient would really benefit from intravenous fluid therapy.