Fluid and vasopressor titration during resuscitation in septic shock

Bram Rochwerg, MD, is an intensivist, researcher, and associate professor of medicine at McMaster University. His main focus of research includes resuscitation medicine and intravenous fluid use in sepsis. He works with many international organizations supporting their guideline development projects, including the Canadian Critical Care Society and the Society of Critical Care Medicine.

How do you titrate fluids and vasopressors during resuscitation of patients with septic shock?

Bram Rochwerg, MD: It’s a great question. The way we balance fluids and vasopressors has evolved a lot over the last 10 or 15 years, I’d say. When Rivers and the early goal-directed therapy trials came out in the early 2000s, I feel like everyone moved towards giving such aggressive fluids up front. I think over the coming years we started to appreciate the harms that too much fluid can have as well. And some of these patients are just very vasodilated, and you can give liter after liter of fluid and you don’t see the improvements in hemodynamics that you want. It all comes down to where patients are on the Frank-Starling curve. I think there’s been increasing data and belief that we need to be more judicious with the fluid that we use, really making sure that we’re only giving fluids if they’re leading to physiologic benefits and instead thinking about earlier initiation of vasopressors as a substitute.

I think, in general, that’s sort of the direction that folks have gone. We’re just starting to see some of the trials that have come out in the last little while to support this. CLASSIC was one of them, the PETAL Network did another. They looked at, again, maybe the earlier initiation of vasopressors. A more judicious use of fluids seemed to be probably beneficial. I think the challenge in studying this is, it’s very patient specific, right?

The way that I operationalize this is that I am more judicious in general with how much fluid I use. I make sure that any fluid I’m giving has physiologic benefit. And if I’m not seeing physiologic benefit, then I’ll back off on giving more fluid and I’ll be more liberal with earlier-on vasopressor use for sure.