Early Liberal Fluid Therapy for Sepsis Patients Is Not Harmful: Hydrophobia Is Unwarranted but Drink Responsibly

Critical Care Medicine www.ccmjournal.org 2263 EARLY INTERVENTIONS IMPROVE OUTCOME Sepsis in the year 2016 remains the most expensive disease treated in hospitals and is the most common cause of in-hospital deaths in the United States (1). However, over the last 15 years, since the introduction of early goal-directed therapy (EGDT) and the Surviving Sepsis Campaign (SSC), there has been a consistent and historic reduction in mortality (2). The reduction from a historic mortality of 46.5% to less than 30% was validated when a trio of multinational trials named Protocolized Care for Early Septic Shock (ProCESS), Australasian Resuscitation in Sepsis Evaluation (ARISE), and Protocolized Management in Sepsis (ProMISe) “compared” various forms of resuscitation strategies (2, 3). This independently obtained historic mortality of 46.5% from an international task force of experts is identical to that of the original EGDT trial (2). Thus, it is absolutely clear that a protocolized approach consisting of early detection (lactate and fluid challenge), antibiotic therapy, source control, prevention of sudden cardiopulmonary events, and early hemodynamic optimization improves outcomes. Even with unprecedented and replicated mortality benefit, many have proposed to dissemble the original EGDT trial and its components (4). ProCESS, ARISE, and ProMISe attempted to replicate and examine the efficacy of EGDT and have shown all time low mortalities, equal mortality reduction in all arms with no harm of EGDT. For some, these trials have made EGDT synonymous with an early liberal fluid strategy and its negative consequences (5–8). In rebuttal to our distinguished colleagues Genga and Russell (9); we advocate that treating early sepsis is not a time to be hydrophobic. Early fluid therapy in the context of a physiologically based protocol such as EGDT improves mortality for severe sepsis and septic shock.