Liberal Versus Restrictive Fluid Therapy in the Early Management of Sepsis and Septic Shock: A Systematic Review

Sepsis and septic shock remain life-threatening conditions with high morbidity and mortality. Optimal fluid management during early resuscitation remains controversial, particularly regarding liberal versus restrictive strategies. This systematic review aimed to evaluate clinical outcomes associated with different intravenous (IV) fluid approaches in adult patients with sepsis and septic shock. A literature search was conducted in May 2024 using major medical databases. Observational cohort studies and randomized clinical trials assessing mortality and clinically relevant outcomes were included. Five studies met the inclusion criteria, comprising four retrospective cohort analyses and one multicenter randomized clinical trial. Observational data consistently demonstrated that higher cumulative fluid balance was independently associated with increased mortality and adverse outcomes, particularly after the initial resuscitation phase. However, randomized evidence did not demonstrate a significant difference in 90-day mortality between restrictive and liberal fluid strategies during early resuscitation. Overall, current evidence does not conclusively establish the superiority of one fixed fluid approach over another. These findings suggest that fluid management should be individualized and guided by patient physiology and dynamic clinical assessment rather than rigid volume thresholds. Further high-quality randomized studies are needed to clarify the optimal strategy.