The Surviving Sepsis Campaign (SSC) has come up with sepsis treatment bundles, a series of steps which should be followed within a certain time limit after sepsis diagnosis. The three hour bundle, which is to be completed within three hours of diagnosis, includes measuring lactate levels, obtaining blood cultures before administering antibiotics, administering antibiotics, and administering fluids.
One of the first things that physicians do out of those four is initiating fluid resuscitation. If not, tissue hypoxia can worsen and it can lead to increased risk of mortality. Since the inflammatory response in sepsis causes vasodilation, membrane permeability is increased, leading to an intravascular fluid deficit.
The ideal fluid given in sepsis would increase blood pressure without accumulating in tissues, have a similar chemical structure to plasma, be cost effective, and reduce mortality. There are two types of common fluids - crystalloids, which are commonly used, and colloids (albumin), which is tempting to use because colloids are more effective in increasing plasma volume.
Several studies have been done to test whether one solution is better than the other.
- In the SAFE study, 700 patients in the ICU either got saline or albumin. There were no differences in 28 day mortality, mechanical ventilation days, renal replacement therapy, or ICU length of stay.
- In CRISTAL, a 2013 study, almost 3000 patients were assigned to colloids or crystalloids. There was no difference in 28 day mortality, but colloids led to a decrease in 90 day mortality. The latter result was considered exploratory and not conclusive.
- ALBIOS was a study done in Italy across 100 ICUs where over 1,800 patients were randomly assigned to receive both crystalloids and albumin vs. just crystalloids. There was no difference in 28 day mortality.
For sepsis specifically, it is recommended to use crystalloids instead of colloids. Even though it’s better at increasing plasma volume, there are some safety issues with hydroxyethyl starch colloids (HES). HES has a higher molecular weight which can lead to increased risks of renal failure requiring dialysis around three weeks after HES administration. It may be better to use crystalloids because they are cost effective and have less serious side effects.