الفهرس 
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Abstract
Sepsis is an inflammatory response to severe infection characterized by hypovolemia and vasodilation and treated with early antibiotics and fluid resuscitation. In-hospital mortality rates have decreased from 80% in the early years of intensive care to 20-30% in the modern era through improved surveillance, early treatment of underlying infection, and advances in support for failing organs. Despite the central role intravenous (IV) fluid administration has played in sepsis management for the last 15 years, fundamental questions regarding “which fluid” and “in what amount” remain unanswered.
Sepsis is still a major cause of mortality over the world. Distinct phases of hemodynamic resuscitation have been described with different risks, goals, and challenges: resuscitation, optimization, stabilization, and de-escalation phases. Fluid therapy represents one of the cornerstones of resuscitation treatments in order to increase oxygen delivery during circulatory failure. During the salvation phase of septic shock, the current guidelines suggest that an aggressive fluid resuscitation is the best initial therapy.
During the optimization phase, the goal is to maintain adequate tissue perfusion and avoid the effects of fluid overload. During this phase, “liberal” or uncontrolled fluid therapy can induce an increased positive fluid balance with tissue fluid overload leading to potential harmful effects. A restrictive fluid therapy strategy could be used to decrease fluid overload (FO) during the optimization phase in septic shock patients. It is worth mentioning that inappropriate use of fluid therapy can induce its own side effects.
Patients with early sepsis are frequently hypovolemic from decreased intake and increased insensible losses. In addition, inflammation alters vascular resistance, venous capacitance, and vascular leak generating a “relative hypovolemia”. Resultant decreases in stroke volume and cardiac output imbalance oxygen delivery and demand, precipitating tissue hypoxia, anaerobic metabolism, and lactic acidosis.
The classic physiologic rationale for fluid resuscitation in sepsis is to restore intravascular volume, cardiac output, and oxygen delivery. Volume and choice of resuscitation fluids have largely been predicated on this model. Resuscitation endpoints like central venous pressure (CVP), inferior vena cava filling, mixed venous oxygen saturation, and lactate are used to restore preload independence and match oxygen demand and supply. selection of colloids over crystalloids is intended to optimize volume expansion through colloid retention in the intravascular space.
Septic shock patients manifest decreased vasomotor tone and intravascular volume depletion from loss of fluid into the extravascular space via capillary endothelial dysfunction, both which contribute to hypotension.
IVF administration replenishes intravascular fluid lost to the extravascular space and increases volume within dilated vessels, potentially increasing cardiac pre-load, stroke volume, and cardiac output, leading to increased tissue perfusion and oxygen delivery.
The aim of this study was to compare between the outcomes of fluid administration strategies in the form of restricted or usual fluid administration in patient with severe sepsis and septic shock, and to detect the optimal strategy of fluid administration which decreases morbidity and mortality.
This was a Prospective controlled; randomized, comparative study was conducted in the intensive care units at Ain-Shams University Hospitals and Gamal Abdelnaser Hospital. This study was conducted on 80 adult patients divided into two groups: group A: 40 adult patients taking the Usual Care, and group B: 40 adult patients taking the Restrictive Care.
The main findings of the study revealed that:
• There was no statistically significant difference between the two groups regarding age, sex , weight and BMI. Furthermore, there was no statistically significant difference between the two groups regarding height.
• Participants in both groups showed statistically significant difference regarding SOFA score. On the other hand, there were no statistically significant difference between the two groups regarding long term care facility resident, APATCHE II score.
• In the current study, we found that participants in both groups showed statistical significant difference regarding mean arterial blood pressure with marked improvement in the restrictive group, urine output, on central venous pressure much lower in the restrictive group.and lactate level was lower in the restrictive group.
• Chronic medical conditions in participants were statistically similar for the two groups, except for a greater proportion of chronic kidney disease in the usual care group.
• As regard site of infection; there was no statistically significant difference between usual care and restrictive fluid groups regarding site of infection.
• The restrictive fluid group received significantly less resuscitative IV fluid than the usual care group prior to randomization, over 24 hours, over 48 hours, over 72 hours and total, Moreover; the restrictive fluid group also received a lower fraction of non-resuscitative IV fluid than the usual care group. In addition, the restrictive fluid group also received less amount of total forms IV fluid than the usual care group.
• There were no statistically significant differences between the two groups in adjunct resuscitative measures administered including albumin, blood transfusion, or stress dose steroids.
• By day 30, 9 participants (22.5%) in the restrictive fluid group and 7 participants (17.5%) in the usual care had died with no statistical significant difference between the both groups (p= 0.29).
Based on our findings, we recommend for further studies on larger sample size and on large geographical scale to emphasize our conclusion.