RIFTS RCT - Restrictive Fluid in Septic Shock

Written by Clay Smith

Spoon Feed
A restrictive fluid approach (<60mL/kg/72h) vs standard care had no impact on 30-day mortality or other adverse secondary outcomes in this pilot study of patients with severe sepsis or septic shock.

Why does this matter?
CENSER was a small RCT that showed early pressors improved shock control. CLOVERS is currently underway to test whether a restrictive fluid/early pressor approach vs a more liberal fluid approach improves mortality. This study looks purely at the impact of restricting fluid. For context, the original EGDT trial gave 168 mL/kg in the first 72 hours. That’s a lot.

Opposite of - “You gotta swell to get well”
This was a small, single system, two-hospital RCT with 109 patients with severe sepsis or septic shock (Sepsis 2) randomized to either restrictive fluid (<60mL/kg in 72h) or standard care. The restrictive group received significantly less fluid (47.1 mL/kg in 72h) than the standard care group (61.1 mL/kg in 72h). An important side note: both groups received about half as much fluid compared to what was administered in ARISE, ProMISe, and ProCESS. In the present study, there was no difference in 30-day mortality, nor was there any difference in organ failure, length of stay, or other adverse secondary outcomes. The restrictive fluid group spent 21 fewer hours on mechanical ventilation compared to usual care (16.8, 95%CI 7.0–26.5 vs 37.8, 95%CI 22.0–126.5; p= 0.02). This was a single center small study, considered a safety pilot for a larger trial. But the pendulum is already swinging toward less fluid. I was always taught during residency to pound patients with fluid. One of my attending physicians said, “You gotta swell to get well.” My…how things change.

Source
The Restrictive IV Fluid Trial in Severe Sepsis and Septic Shock (RIFTS): A Randomized Pilot Study. Crit Care Med. 2019 Apr 12. doi: 10.1097/CCM.0000000000003779. [Epub ahead of print]

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Reviewed by Thomas Davis

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