The Further Vindication of "Dr. Hassabolus"

My nickname, one of many I suspect, in the ICU is "Dr. Hassabolus." That is because, more often than not, I will treat acute hypotension with colloid and/or crystalloid boluses. It does not mean that I am averse to vasopressors, far from it. And, boluses are still my go-to treatment for acute hypotension.

And I have been vindicated by the medical literature.

There have been two major trials comparing restrictive to liberal fluid in septic shock:

1. CLOVERS (Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis): This was a multicenter U.S. trial that randomized 1,563 adults with sepsis-induced hypotension (after 1–3 L of initial fluid) to a restrictive fluid strategy (early vasopressors, less fluid) versus a liberal fluid strategy (more fluids before vasopressors) for 24 hours. No significant difference in 90-day mortality was observed between groups.

2. CLASSIC (Conservative vs Liberal Approach to Fluid Therapy of Septic Shock in Intensive Care): This European multicenter trial randomized 1,554 ICU patients with septic shock (after at least 1 L of fluid) to a restrictive fluid protocol versus standard care (liberal fluid). No significant difference in 90-day mortality or serious adverse events was found.

Two systematic reviews and meta-analyses also did not find that restrictive fluid was better than liberal fluids in sepsis. In addition, the European Society of Intensive Care Medicine also recommended in their guidelines to deliver up to 30 ml/kg of fluids for patients with sepsis at the time of their presentation.

And so, again, Dr. Hassabolus has been vindicated.

Now, I am not saying that aggressive fluid resuscitation is better. The literature does not say that. At the same time, the literature does not say that it is worse, either. I asked Dr. Matt Hoffman, the editor of PulmCCM.org about this literature, and here is what he said to me in an email:

Those who consider themselves expert at ultrasound or other methods of measuring fluid responsiveness might be comfortable restricting volume resuscitation in the early phase of sepsis. I suspect most other clinicians continue to follow the "bolus now, diurese later" management strategy for most patients in shock from sepsis.

Couldn't agree more, and the literature says that I am not wrong.

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