FOAMcast - An Emergency Medicine Podcast · FOAMcast

CLOVERS Trial: Restricted vs Liberal Fluids in Sepsis-Induced Hypotension

·21 min·1 clip

Lauren Westifer ties sepsis fluids to SEP-1 billing and hospital scoring.

1. FOAMcast covers the CLOVERS trial on restrictive versus liberal fluids in sepsis-induced hypotension. 2. Lauren Westifer hosts Jeremy Faust, who says he has "opinions on sepsis" and has enrolled patients in the study. 3. The episode asks whether clinicians should keep giving fluids or move earlier to vasopressors when septic patients become hypotensive. 4. Westifer connects the issue to SEP-1 and says hospitals can be dinged on billing if they do not give the exact fluid amount. 5. Faust traces that pressure to the Rivers trial, early goal-directed therapy, and the Surviving Sepsis Campaign's 30 cc per kg approach. 6. Westifer notes that the 2021 Surviving Sepsis Campaign downgraded its recommendation from strong to weak. 7. Faust adds that AseP's position paper says there is no ideal fluid bolus and no single known number. 8. The CLOVERS trial is described as an open-label, multicenter, randomized superiority trial published in the New England Journal. 9. Eligibility required suspected infection plus sepsis-induced hypotension, defined as systolic blood pressure under 100 after at least one liter of fluid. 10. The trial excluded patients who were volume overloaded, severely volume depleted from non-sepsis causes, or hypotensive more than four hours earlier. 11. Faust stresses that patients were already fluid-resuscitated before enrollment, which he says is often forgotten in sepsis care. 12. The restrictive arm used vasopressin and norepinephrine titrated to a MAP above 65 or systolic pressure above 90. 13. The liberal arm used two liters of fluid within a couple of hours, then 500 mL boluses for hypotension or lactate response. 14. The randomization split was 782 patients in the restrictive group and 781 in the liberal group. 15. The primary endpoint was death before discharge by 90 days, and the rates were 14.0% versus 14.9%. 16. Secondary outcomes included organ-support days, mechanical ventilation, renal replacement therapy, ICU days, ARDS, SOFA score, and serious adverse events. 17. Faust says the clearest subgroup signal was in dialysis patients, where the restrictive strategy seemed more favorable. 18. He also notes that only 60% of patients in the restrictive arm received vasopressors, and the trial stopped early for futility. 19. The conversation is informal and technical, with Westifer pressing on methods and Faust speaking as a researcher-clinician. 20. Listeners who follow emergency medicine, sepsis trials, and fluid-vs-pressor debates will get the most from this episode.

As heard by us

A clinician-facing fluids debate that stays close to sepsis metrics, enrollment friction, and bedside tradeoffs.

Foamcast follows the fluids in sepsis question without losing sight of the practical mess around it: government metrics, the Clovers trial, and the simple fact that enrollment is never clean.

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You want the CLOVERS sepsis-fluids debate without the hand-waving.

Read the full recommendation in PlayNext →

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