Fluid Resuscitation in Septic Shock

Algorithm Steps

1. ▶

   Start

   Sepsis/Septic Shock Identified

   Hypoperfusion or lactate ≥2 mmol/L

   1. ●

      Action

      Initial Fluid Resuscitation: 30 mL/kg

      Within first 3 hours (Strong recommendation)

      • 30 mL/kg crystalloid
      • Give within first 3 hours of sepsis recognition
      • Use ideal body weight
      • SSC 2021: Strong recommendation
      1. ●

         Action

         Fluid Type: Balanced Crystalloid

         Suggest balanced over normal saline

         • Lactated Ringer's or Plasmalyte preferred
         • SSC 2021: Weak recommendation
         • Normal saline acceptable if balanced unavailable
         • AVOID hydroxyethyl starch (HES)
         • Albumin: can consider if large volumes needed
         1. ⚠

            Warning

            ⚠️ AVOID Hydroxyethyl Starch

            Strong recommendation AGAINST

            • Associated with AKI and mortality
            • Do NOT use HES for resuscitation
            • Colloids not superior to crystalloids
         2. ◆

            Decision

            Reassess After Initial Resuscitation

            Evaluate hemodynamic status and perfusion

            • Blood pressure/MAP
            • Heart rate
            • Urine output
            • Capillary refill
            • Lactate clearance
            • Mental status
            1. ●

               Action

               Hemodynamically Responsive

               Adequate response to initial fluids

               • MAP ≥65 mmHg
               • Improving lactate
               • Improving perfusion markers
               • Continue monitoring, conservative fluids
               1. ⚠

                  Warning

                  ⚠️ Watch for Fluid Overload

                  Harms of over-resuscitation

                  • Pulmonary edema
                  • Increased ventilator days
                  • Abdominal compartment syndrome
                  • Peripheral edema
                  • Conservative strategy after initial resuscitation
               2. ✓

                  Outcome

                  Adequately Resuscitated

                  MAP ≥65, lactate clearing, perfusion improving

            2. ◆

               Decision

               Persistent Hypoperfusion

               Not responsive to 30 mL/kg

               1. ●

                  Action

                  Assess Fluid Responsiveness

                  Guide additional fluid boluses

                  • Passive leg raise (PLR) + CO monitoring
                  • Pulse pressure variation (if applicable)
                  • Stroke volume variation
                  • Ultrasound (IVC, cardiac)
                  • Avoid static measures (CVP alone)
                  1. ◆

                     Decision

                     Fluid Responsive?

                     Will additional fluids improve CO?

                     1. ●

                        Action

                        Give Additional Fluid Bolus

                        250-500 mL boluses, reassess after each

                        • 250-500 mL crystalloid bolus
                        • Reassess after each bolus
                        • Stop when no longer responsive
                        • Watch for signs of fluid overload
                     2. ●

                        Action

                        Start/Escalate Vasopressors

                        If not fluid responsive

                        • Norepinephrine first-line
                        • Can start during resuscitation if severe
                        • MAP target ≥65 mmHg
                        • See vasopressor algorithm
                        1. ✓

                           Outcome

                           Ongoing Shock

                           Continue vasopressors, reassess daily fluid status