🩺 THIS WEEK IN EM
CLOVERS Didn’t Prove Fluids Are Bad. It Proved Dogma Is.
The CLOVERS trial randomized 1,563 patients with sepsis-induced hypotension to a restrictive strategy versus a liberal fluid strategy early in care. The restrictive group got vasopressors sooner and less fluid overall; the liberal group got more upfront crystalloid.
Ninety-day mortality was essentially the same: 14.0% in the restrictive group versus 14.9% in the liberal group. In the first 24 hours, the restrictive group received meaningfully less fluid while reaching vasopressors earlier. The important point is not that pressors “won.” It’s that the old ritual of pouring in liters before allowing yourself to touch norepinephrine looks a lot less defensible.
This trial did not prove that fluids are useless. It proved that septic shock is not one hemodynamic species and should not be managed as if it is. Some patients need fluid. Some need pressors. Most need reassessment instead of ideology.
Bottom line: After initial resuscitation, early sepsis care should be individualized. Liberal fluids did not beat a more restrictive, earlier-pressor strategy.
National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023.
Balanced Fluids Are Still Reasonable. They’re Just Not Magic.
The PLUS trial compared Plasma-Lyte 148 with saline in more than 5,000 critically ill adults and found no significant difference in mortality. That disappointed people hoping for a knockout win for balanced fluids.
But it also did not rescue saline as some kind of misunderstood hero. The cleaner read is that balanced crystalloids are a reasonable default, especially when you’re worried about hyperchloremia, acidosis, or large-volume resuscitation, but the benefit is not so dramatic that one ICU trial settles the argument forever.
PLUS is best understood as a tempering trial, not a reversal trial. It tells you to stop talking like balanced fluids are a miracle while also not giving you permission to act like chloride load never matters.
Bottom line: Balanced crystalloids remain a sensible default for many ED patients, but the superiority signal over saline is not universal or overwhelming.
Finfer S, Micallef S, Hammond N, et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022;386(9):815-826.
Vitamin C for Sepsis Is Dead. Please Stop Resuscitating It.
The LOVIT trial randomized 872 adults with sepsis on vasopressors to high-dose IV vitamin C or placebo. Vitamin C did not help. Worse, the composite outcome of death or persistent organ dysfunction at day 28 was more common in the vitamin C group: 44.5% versus 38.5% (RR 1.21, p=0.01).
That matters because vitamin C keeps reappearing every few years with the same energy as a bad reboot nobody asked for. LOVIT was large, randomized, blinded, and much harder to hand-wave away than the earlier enthusiasm cycle.
Could someone someday carve out a narrow subgroup that benefits? Maybe. But that is not the same thing as having evidence for routine use now, and right now the best evidence argues against it.
Bottom line: Routine high-dose IV vitamin C for sepsis should stop. It does not improve outcomes and may cause harm.
Lamontagne F, Masse MH, Menard J, et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022;386(25):2387-2398.
📚 STILL CHANGING PRACTICE
If you haven’t internalized this yet, now’s the time.
EGDT Is Dead. And That’s Fine.
ProCESS, ARISE, and ProMISe collectively buried the rigid Early Goal-Directed Therapy model. No mortality benefit. More procedures. More protocol worship. Not better outcomes.
That does not mean Rivers taught nothing useful. Early antibiotics still matter. Lactate still matters. Vasopressors still matter. Reassessment still matters. What died was the idea that every septic patient needs the same central-line-driven checklist to survive.
The lesson is broader than sepsis: once “usual care” gets better, yesterday’s heroic bundle often becomes today’s unnecessary ritual.
Bottom line: EGDT as a rigid protocol is obsolete. Good sepsis care is still early, aggressive, and thoughtful — just less formulaic.
ProCESS Investigators, Yealy DM, Kellum JA, et al. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014;370(18):1683-1693.
Next Week 🔭
• Targeted temperature management post-arrest: The TTM2 trial rewrote the post-arrest protocol — what do you do now?
• Cardiogenic shock and ECMO: When to call the ECMO team
• Immediate coronary angiography post-OHCA: Still a thing? Two trials say probably not
The Hallway Consult is built for EM clinicians who want the useful version of the literature. Forward it to a colleague if it helped.