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Journal update monthly top five
  1. Benjamin Clarke1,2,
  2. Salma Alawiye1,
  3. Rory Anderson3,
  4. Clare Moceivei1,
  5. Thomas James Cox1,
  6. Joseph Sharpe1,
  7. Matthew J Reed1,2,4,
  8. Anisa Jabeen Nasir Jafar5,6
  1. 1 Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
  2. 2 Emergency Medicine Research Group of Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
  3. 3 Emergency Department, St John's Hospital, Livingston, UK
  4. 4 Acute Care Edinburgh, Usher Institute, University of Edinburgh, Edinburgh, UK
  5. 5 Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
  6. 6 Emergency Department, Salford Royal Foundation Trust, Salford, UK
  1. Correspondence to Dr Benjamin Clarke, Emergency Department, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK; b.clarke{at}

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This month’s update is by the South East Scotland team. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper.

The papers are ranked as:

  • Worth a peek—interesting, but not yet ready for prime time.

  • Head turner—new concepts.

  • Game changer—this paper could/should change practice.

Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension by Shapiro et al

Topic: sepsis

Outcome rating: head turner

Several studies (FEAST, CLASSIC) have challenged the benefit of large volumes of fluid for septic shock. The Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) study is an unblinded, randomised multicentre trial conducted at 60 US EDs aiming to establish whether a restrictive fluid strategy outperformed a liberal fluid strategy in patients presenting with sepsis-induced hypotension.1

A total of 1563 adults with sepsis-induced hypotension (defined as systolic BP <100 mm Hg or mean arterial pressure <65 mm Hg after 1000 mL crystalloid plus suspected/confirmed infection) were enrolled and randomly assigned to either a restrictive (prioritising early vasopressors) or liberal (prioritising fluid boluses) fluid strategy. The primary outcome was death before discharge at 90 days. Exclusion criteria included inability to obtain informed consent, >4 hours since meeting inclusion criteria for sepsis-induced hypotension, >3 L intravenous fluid pre-enrolment or the presence of fluid overload or severe volume depletion.

The trial was halted after a planned interim analysis due to futility. The 90-day in-hospital mortality was 14.0% in the restrictive arm and 14.9% in the liberal arm (difference –0.9% (95% CI −4.4% to 2.6%)). There were no significant differences in secondary outcomes. There was clear separation in intravenous fluid administered over the first 24 hours (median 1267 mL …

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  • Contributors BC—literature search, article selection, editing of paper summaries, drafting of the manuscript and submission of the manuscript. SA, RA, CM, TJC and JS—article selection, critical appraisal and article summaries. MJR and AJNJ—article selection and editing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.