UMEM Educational Pearls

Title: IVF Resuscitation in Obese Septic Patients: Not one-weight-fits-all?

Keywords: sepsis, resuscitation, obesity, IV fluids, bolus (PubMed Search)

Posted: 12/5/2017 by Kami Windsor, MD
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Background:

We are all familiar with the Surviving Sepsis Campaign recommendation (& CMS core measure) for an initial 30ml/kg bolus of IV crystalloid within the first 3 hours for our patients with septic shock. There is minimal data, however, on how much IVF we should be giving our patients with BMIs ≥30.

A recent study in obese patients with septic shock retrospectively stratified the total fluids administered at 3 hours into 3 different weight categories, to categorize patients as having received 30mL per kg of ___ body weight, whether actual (ABW), adjusted (AjdBW), or ideal (IBW**).

AdjBW = (ABW – IBW) *40% + IBW

They found:

Most patients received fluids based on actual body weight, BUT
Patients at highest BMIs received ABW fluids less often
30ml/kg dosing according to adjusted body weight was associated with improved mortality compared to IVF per actual or ideal body weight.

Bottom Line:

If the 30ml/kg IVF bolus seems clinically appropriate for your obese patient, consider administering according to Adjusted Body Weight first.
As always, reevaluate your septic shock patients frequently to determine if additional fluids are necessary, and go to vasopressors early if they are not fluid responsive.

**IBW calculated using Devine’s formula for men and women:

Males: IBW = 50 + 2.3*(# inches over 5 feet)
Females: IBW = 45.5 + 2.3*(# inches over 5 feet)

References

Taylor SP, Karvetski CH, Templin MA, et al. Initial fluid resuscitation following adjusted body weight dosing is associated with improved mortality in obese patients with suspected septic shock. J Crit Care. 2017;43: 7-12.
Rhodes A, Evans LE, Alhazzani, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and shock: 2016. Crit Care Med. 2017;45(3): 486-552.