ARISE FLUIDS: less fluid and earlier vasopressors gave the same outcome with less pulmonary oedema

Design

Multicentre randomised trial

Population

1,000 adults with septic shock in emergency departments in Australia and New Zealand

Primary outcome

Days alive and out of hospital to day 90

Effect

Median 76 vs 76; difference 0.0 days (95% CI −2.7 to 2.7); pulmonary oedema 0.6% vs 5.0%

ARISE FLUIDS, published in NEJM on 11 June 2026, randomised 1,000 adults presenting to emergency departments in Australia and New Zealand with septic shock to restricted fluid with early vasopressors, or larger fluid volumes with later vasopressors, for six to 24 hours.

The restrictive group received about 1.1 litres less fluid in the first day and more of them received vasopressors. Days alive and out of hospital at 90 days were the same, median 76 in both groups, with a tight confidence interval. Pulmonary oedema occurred in 0.6% of the restrictive group against 5.0% of the liberal group; other adverse events were similar.

This follows CLOVERS, which also found no difference in mortality between the two strategies. Taken together, clinicians can choose an early-vasopressor approach without fear of worse outcomes, and it spares patients from fluid overload. For emergency departments where ICU beds are scarce, as in many Indian hospitals, a strategy that avoids pulmonary oedema while waiting has practical value.

• Consider starting noradrenaline early in septic shock rather than giving large fixed fluid volumes first.
• Limit initial fluid to what produces a measurable improvement in perfusion.
• Watch for pulmonary oedema, which was eight times as common with the liberal fluid approach.
• Do not delay antibiotics and source control while deciding on fluid strategy.

Why it matters

Two large trials now show no penalty for restricting fluid, and this one shows a safety gain.

Don't overread it

The restrictive strategy did not improve survival or time out of hospital; its advantage is fewer complications.

The statistics, in plain English

A difference of 0.0 days with an interval of −2.7 to 2.7 rules out any meaningful benefit or harm on the primary outcome. The pulmonary oedema difference (0.6% vs 5.0%) is a secondary safety finding but a large one.

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