Episode 55: Fluids in Sepsis, Post-intubation Analgesia and Sedation

In this second part of the Weingart-Himmel Sessions on critical care pearls for the community ED on the EM Cases podcast, Dr. Scott Weingart and Dr. Walter Himmel discuss the many controversies and recent changes in fluid management in severe sepsis and septic shock. With the recently published ARISE trial, and some deviations from Early Goal Directed Therapy, we are changing the way we think about fluids in sepsis: the type of fluid, the volume of fluid, the rate of fluid administration, the timing of introducing vasopressors and the goals of fluid resuscitation. In the next section of the podcast we discuss the PAD mnemonic for post-intubation analgesia and sedation, the prevention of delirium, and medication choices to minimize time on the ventilator, and improve prognosis.



Written Summary & blog post prepared by Dr. Anton Helman, December 2014

Cite this podcast as: Helman, A, Weingart, S, Himmel, W. Fluids in Sepsis, Post-intubation Analgesia and Sedation. Emergency Medicine Cases. December, 2014. https://emergencymedicinecases.com/episode-55-weingart-himmel-sessions-2-fluids-in-sepsis-post-intubation-analgesia-sedation/. Accessed [date].

Go to part 1 of this 2-part podcast on critical care

Fluid of Choice in Severe Sepsis & Septic Shock

Choices for initial fluid management in the ED for severe sepsis and septic shock are Normal Saline, Ringer’s Lactate or Plasmalite. Practically speaking, Normal Saline is what North American EDs are most familiar with and is recommended for the first 3-4L of fluid resuscitation despite concerns of hyperchloremic acidosis with larger volumes. If more than 3-4L of fluid is required, some experts suggest switching to Ringer’s Lactate or Plasmalite to minimize the risk of acidosis.

How do colloids such as albumin compare to crystalloids for fluid resuscitation in hypovolemic shock?

The CRISTAL trial comparing albumin and crystalloids showed no difference in 28 day mortality.

Update 2021: Retrospective, cohort review of 109 patients admitted for operative management of newly diagnosed ectopic pregnancy. Use of point-of-care ultrasound (POCUS) showed shorter length of stay in ER and faster time to OR for ruptured ectopic when compared to radiology-based ultrasound alone. Abstract

How Much Fluid, How Fast for Severe Sepsis & Septic Shock

Based on the recent PROCESS and ARISE trials our experts recommend 3-4L over the first 6 hours of resuscitation.

Our experts recommend 2L in the first 30 mins with a minimum of 2 large bore peripheral IVs under pressure bags pumped up to 300mmHg.

Update 2019: A pilot prospective RCT involving 109 patients showed a restrictive IV fluid resuscitation strategy (