Written by Shannon Markus
Spoon Feed
Early fluid resuscitation in sepsis shows a U-shaped relationship between fluid amount and mortality; 30 mL/kg within 3 hours improves survival, supporting current Surviving Sepsis Campaign guidance.
The Goldilocks approach: not too much, not to little
This systematic review and meta-analysis assessed the impact of early (≤8 hr) crystalloid fluid resuscitation on mortality in adult sepsis. A database search yielded 30 studies from 2000-2024 (3 RCTs, 27 observational; total n=119,583). Three RCTs comparing restrictive versus liberal strategies (34–58 mL/kg) showed no mortality difference. Observational studies suggested that giving too little fluid (under 20 mL/kg) was linked to higher death rates (p<0.001), and giving too much fluid (over 45 mL/kg) could also be harmful. Four studies identified improvements in survival when 30 mL/kg was completed within 3 hours. However, almost all conclusions are based on low-certainty or very low-certainty evidence, which is a big limitation. Overall, evidence supports current Surviving Sepsis Campaign recommendations (30 mL/kg within 3 hr) as reasonable while we wait on trials defining individualized, hemodynamically-guided resuscitation strategies.
How does this change my practice?
The authors acknowledge the results of this review are a bit all over the place, and most of the resultant recommendations are based on ‘very low’ quality evidence. This largely reflects that many questions around fluid resuscitation in sepsis remain unresolved and require further research. The only recommendation supported by evidence above ‘very low’ quality is the Surviving Sepsis guideline of administering 30 mL/kg of fluids within 3 hours, which is likely beneficial.
Source
The Effect of Early Fluid Resuscitation on Mortality in Sepsis: A Systematic Review and Meta-Analysis. Crit Care Med. 2025 Sep 1;53(9):e1790-e1802. doi: 10.1097/CCM.0000000000006769. Epub 2025 Jul 10. PMID: 40637496.
