Can the Treatment Approach of Sepsis With Balanced Crystalloid Fluids Translate Into Therapy for Acute Respiratory Distress Syndrome if Considered as “Lung-Limited Sepsis”?*

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Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection resulting in significant morbidity and mortality among both adult and children worldwide. Recently, an increase in published sepsis treatment updates has modified and replaced earlier recommendations in the light of new studies, as is physiologic in the life cycle of practice variables and guidelines (1).
Clinical attention must focus on the entire spectrum of management, from initial resuscitation to stabilization procedures, organ failure resolution, and even include functional outcomes as analyzed during follow-up assessment (2, 3). Current standard guidelines do not make specific recommendations for either balanced or unbalanced fluid replacement in the initial treatment of severe sepsis. Isotonic crystalloid solutions are preferred because of having a strong ion difference (SID) closer to plasma SID and causing minimal acid base disturbances. Administration of colloids or hemoderivatives presents several contrasting suggestions. Colloids, even if suggested in the first phase of shock resuscitation, are not suggested or are suggested with caution in the subsequent phases (4, 5).
Early goal-directed therapy (EGDT) is considered a standard of care in the management of patients with severe sepsis and septic shock but involves an aggressive fluid resuscitation strategy to achieve a central venous pressure above 8 mm Hg. However, a recent meta-analysis of EGDT and the Protocolized Care for Early Septic Shock, Australasian Resuscitation in Sepsis Evaluation, and Protocolized Management in Sepsis multicenter clinical trials have demonstrated that using EGDT as a standard of care does not improve outcomes for patients with severe sepsis and septic shock (6).
In this issue of Critical Care Medicine, Emrath et al (7) compare balanced and unbalanced fluids in pediatric sepsis and provide some interesting points for reflection while clearly acknowledging the limitations of their study. The retrospective design of the analysis of the available data yields biases that can be addressed but not completely removed from consideration.
However, what remains clearly evident from a paucity of literature on the topic is the necessity of an adequate control of infused fluids for children with severe respiratory failure, with a strong preference in favor of crystalloid balanced fluid management compared with unbalanced fluid management to improve patient outcomes.
This study is not the first and follows recent studies on the same topic. Differences in choice of resuscitation fluids (colloid vs crystalloids) have been assessed by systematic review that concluded that there was insufficient evidence to make a definitive choice of fluids, given the weak evidence base (8, 9).
Even though it is well established that fluid resuscitation is a central component of sepsis management, to date there is no consensus as to the ideal composition of fluid to be used for resuscitation. The use of balanced fluids, such as Ringer’s lactate, seems very promising but further research is needed to confirm their role (10).
The positive effect of crystalloid composition on outcomes in children with severe sepsis demonstrated by the retrospective study by Emrath et al (7) requires further prospective studies to confirm the validity of the results.
In the past 20 years, numerous animal and adult patient studies demonstrated that less extensive lung injury occurred if intrapulmonary hydrostatic pressure was reduced, either through reducing fluid infusion or diuretic therapy. A few human observational studies have documented an improvement in terms of survival with reduced infused fluid volumes and lower filling pressure maintenance.

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