Early Diuresis Following Sepsis-Triggered Fluid Resuscitation Is Uncommon

The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) recommends resuscitation with 30 mL/kg intravenous fluids for any patient suspected to have sepsis. Often this intervention needs to be balanced against the risks of volume overload, which can contribute to cardiac, respiratory, and renal failure. Emergency physicians must act with limited information, and may change course during the initial resuscitation as new data becomes available. Our objective was to determine the incidence of early loop diuretic administration following initial fluid resuscitation among emergency department patients with sepsis.

We performed a retrospective observational cohort study at an academic emergency department between 2023–2025. Adult patients who developed sepsis in the emergency department, met organ system dysfunction criteria and had diagnostic codes related to sepsis were included. Patients who did not receive more than 500 mL of IVF were excluded. The primary outcome was the rate of administration of loop diuretics within 12 hours of identification of sepsis stratified by compliance at 3 hours with mandated 30 mL/kg fluid bolus. Comparison between groups was assessed using risk differences. Secondary outcomes included 28-day mortality and rate of invasive mechanical ventilation in the ED.

A total of 1091 patients meeting organ dysfunction and diagnosis criteria for sepsis were identified. 46/1091 (4.2% [95%CI 3.0%, 5.4%] patients received early loop diuretic (ELD). When stratified by compliance with the 30 mL/kg bolus requirement, 11/372 (3.0% [1.2%, 4.7%]) fluid compliant and 35/719 (4.9% [3.3%, 6.4%]) fluid non-compliant received ELD. The risk difference (RD) between these groups was not significant (-1.9% [-4.2%, 0.4%]). Patients receiving ELD were more likely to receive invasive mechanical ventilation in the ED (16/46, 34.8% vs. 180/1045, 17.2%; RD 17.6% [3.6%, 31.5%]) and be deceased at 28-days (13/46, 28.3% vs. 175/1045, 16.8%; RD 11.5% [-1.7%, 24.7%]).

Early diuretic therapy following initial resuscitation in the ED was uncommon. These findings suggest that immediate reversal of empiric sepsis-directed fluid therapy occurs infrequently. Future studies should focus on identifying patient-specific factors that prompt early diuresis and may inform more individualized resuscitation strategies.