Call grows to individualize fluid therapy in septic shock

Septic shock is one of the most common and deadly emergencies in hospitals worldwide. Low circulating blood volume (known as hypovolemia) drives organ hypoperfusion and organ failure. For decades, clinicians have tried to correct this by giving large amounts of intravenous fluids as quickly as possible. This strategy, codified by the Surviving Sepsis Campaign as at least 30 mL/kg of crystalloids within three hours, has become entrenched as standard practice.

But an editorial published online in the Journal of Intensive Medicine on September 04, 2025, argues that this rigid threshold is no longer appropriate. Written by Professor Jean-Louis Teboul of the University of Paris-Saclay, Dr. Jiao Liu of Shanghai Jiao Tong University Medical School Affiliated Ruijin Hospital, and Prof. Olfa Hamzaoui of University Hospitals of Reims Champagne-Ardenne, the piece reviews how both practice and evidence have evolved.

“Initial fluid resuscitation remains a cornerstone in the management of septic shock,” states Prof. Teboul and colleagues. “However, the uniform liberal approach of giving large volumes to every patient is now considered outdated, particularly in the absence of objective volume assessment.”

The editorial traces the origins of the 30 mL/kg recommendation back to the 1980s and 1990s, when high tidal volume ventilation, higher blood pressure targets, and delayed vasopressor use were common. These practices encouraged liberal fluid loading. Today, ventilation strategies, blood pressure targets, and timing of vasopressors have all changed, undermining the original rationale.

According to the authors, recent studies show that a substantial proportion of patients with septic shock become “fluid-unresponsive” shortly after resuscitation begins, suggesting their initial requirements were limited. They also note that in patients with underlying cardiovascular comorbidities, administering 30 mL/kg within three hours may pose additional risks and that excessive fluid administration can exacerbate endothelial injury and glycocalyx disruption.

At the same time, Prof. Teboul and colleagues caution that, “Overly restrictive strategies may also be harmful, especially in patients with profound hypovolemia due to substantial fluid losses or abdominal sepsis.” Instead, they call for a balanced, individualized approach.

Guidelines are beginning to diverge. The Surviving Sepsis Campaign still recommends a minimum of 30 mL/kg within three hours, but classifies this as a weak recommendation based on low-quality evidence. The European Society of Intensive Care Medicine, by contrast, suggests administering up to 30 mL/kg depending on the clinical context, a conditional recommendation based on very low certainty of evidence. Its commentary underscores the importance of tailoring fluid administration to the individual and assessing fluid responsiveness before further administration.

“These opposing recommendations highlight the central role of individualized initial fluid management,” says Prof. Teboul and colleagues. “Estimating fluid requirements based solely on body weight is insufficient, especially given the heterogeneity of sepsis and the wide variability in the degree of hypovolemia across patients.”

The editorial sets out practical ways to achieve this, even without advanced hemodynamic monitoring. Bedside tests such as passive leg raising combined with changes in pulse pressure or velocity-time integral measured by echocardiography can help identify when a patient has become fluid-unresponsive and prevent excessive accumulation. Clinicians are urged to consider comorbidities, infection source, and estimated fluid losses, and to guide management by frequent reassessment rather than waiting the full three hours.

Fluid management, the authors emphasize, should be guided by frequent hemodynamic reassessment rather than an automatic volume target. They note that some patients may require more than 30 mL/kg, while others may need significantly less. The editorial provides a timely summary for clinicians facing this critical decision in the first hours of septic shock by collating the evidence and contrasting international guidelines. Its message is that the first fluid bolus is too important to be dictated by a one-size-fits-all rule.

***

Reference
DOI: 10.1016/j.jointm.2025.08.001