Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension
NEJM, 2023 · Multicenter randomized trial
Clinical question
After initial fluids, does an early restrictive fluid/vasopressor-prioritized strategy improve outcomes compared with liberal fluids?
What the trial found
A vasopressor-prioritized restrictive approach was not superior to a liberal fluid approach for mortality.
Current guideline position
Supports individualized rather than fixed-volume post-initial resuscitation.
Clinical interpretation
Avoid dogmatic fluid strategies; individualize additional fluid using perfusion, responsiveness, tolerance, and shock phenotype.
The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.
Life-threatening organ dysfunction caused by a dysregulated host response to infection — recognized by an acute rise in SOFA score, not by infection plus fever alone.
Cellular dysoxia, DO2/VO2 physiology, the 4 shock phenotypes, dynamic fluid responsiveness (PLR/PPV) vs fluid tolerance (VExUS), and vasoactive pharmacology.