Fluid resuscitation in septic shock: too much, too little or just right?

[1] describe fl uid resuscitation (FR) in 164 patients with septic shock, concluding that survival was better in patients receiving higher volumes over the fi rst 72 h. I think we should be cautious, however, to conclude from this that more is better. Median FR was 4.0 L over 24 h, and 7.5 L by 72 h relatively small volumes for patients with ongoing shock. FR volumes reported from trials performed in septic shock are substantially larger despite comparable illness severity; mean FR over 72 h was approximately 19 L in the Vasopressin in Septic Shock Trial (VASST) study [2], 13 L in the study by Rivers and colleagues [3] and 16 L in another recent study [4]. Indeed, median FR in the highvolume group (10.9 L at 72 h) was comparable to the lowest quartile, associated with the best prognosis, in the VASST study (16 L at 96 h) [2]. Th us, I do not believe that the benefi t of higher-volume FR described is in confl ict with the harm associated with larger volumes reported previously [2]. Similarly, median FR in the lower-volume group was only 4.3 L in 72 h. As FR was physiciandirected, lower-volume FR might have been indicated by factors like chronic cardiac failure or fl uid unresponsiveness associated with poorer outcomes irrespective of FR; no evidence is provided to conclude that increasing FR in this group would have improved survival. Overall, this report records excellent outcomes using moderate FR by recent standards. Further trials are needed to characterize the dose and indications for FR in septic shock.