Evaluation of the Recommended 30 cc/kg Fluid Dose for Patients With Septic Shock and Hypoperfusion With Lactate Greater Than 4 mmol/L

Abstract

OBJECTIVES: The Surviving Sepsis Campaign Guidelines recommend fluid administration of 30 cc/kg ideal body weight (IBW) for patients with sepsis and lactate greater than 4 mmol/L within 3 hours of identification. In this study, we explore the impact of fluid dose on lactate normalization, treatment cost, length of stay, and mortality in patients with lactate greater than 4. DESIGN: Multicenter retrospective observational study. SETTING: Eight-hospital urban healthcare system in Northeastern United States. PATIENTS: Patients with sepsis, initial lactate value greater than 4 mmol/L, and received appropriate antibiotics within 3 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We stratified patients into five groups based on the dose of fluid administered within 3 hours after sepsis identification. The groupings were less than 15 cc/kg IBW, 15.1–25 cc/kg IBW, 25.1–35 cc/kg IBW, 35.1–50 cc/kg IBW, and greater than 50 cc/kg IBW. We used the group that received a fluid dose of 25.1–35 cc/kg IBW, as a reference group. The mean age was 66 years, and 56% were male. Three hundred seventy-one (25%) received less than 15 cc/kg of IBW of crystalloid fluid, 278 (17%) received 15–25 cc/kg of IBW, 316 (21%) received 25.1–35 cc/kg of IBW, 319 (21%) received 35.1–50 cc/kg of IBW, and 207 (14%) received greater than 50 cc/kg of IBW. After multilinear regression, there was no significant difference in lactate normalization between the reference group and any of the other fluid groups. We also found no statistically significant difference in the observed/expected cost, or observed/expected length of stay, between the reference group and any of the other fluid groups. Mortality was higher among patients who received greater than 50 cc/kg IBW when compared to the recommended dose. CONCLUSIONS: In patients with sepsis and lactate value greater than 4 mmol/L, high or low fluid doses were not associated with better lactate clearance or patient outcomes. Greater than 50 cc/kg IBW dose of fluids within 3 hours is associated with higher mortality.