ARISE FLUIDS: restricted fluids with early vasopressors matched a fluid-first approach

Design

Multicentre randomised trial (ARISE FLUIDS)

Population

1,000 adults presenting to EDs in Australia and New Zealand with septic shock

Primary outcome

Days alive and out of hospital at day 90

Effect

Median 76 vs 76 days; difference 0.0 (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. One group received restricted fluid volumes with early vasopressors; the other larger fluid volumes with vasopressors later, for at least six and up to 24 hours. 963 were analysed.

The restricted group received a median 1.1 litres less fluid in 24 hours, and 18.9 percentage points more received vasopressors. Days alive and out of hospital at 90 days were identical: median 76 in both (difference 0.0, 95% CI −2.7 to 2.7). Adverse events were similar except pulmonary oedema, which was 0.6% with restriction against 5.0% with the fluid-first approach.

This joins earlier trials in finding no outcome difference between the two philosophies. The practical change is permission: clinicians can move earlier to vasopressors and limit fluid without disadvantaging the patient, with less pulmonary oedema. It does not support withholding initial fluid, and the separation between groups was modest — about a litre.

• Consider moving to vasopressors earlier rather than giving repeated large fluid volumes.
• Expect similar survival either way; the difference was in pulmonary oedema.
• Favour restriction in patients at risk of overload, such as those with heart failure or kidney disease.
• Still give initial fluid resuscitation; this trial compared volumes, not fluid versus none.
• Reassess after each bolus and record the reason for any further fluid.

Why it matters

It removes the argument that holding back fluid risks worse outcomes, while showing a concrete harm of giving more.

Don't overread it

Survival was equal, so this does not show restriction is better — only that it was no worse and caused less oedema.

The statistics, in plain English

The confidence interval of −2.7 to 2.7 days means any true difference in days alive and home is likely under three days either way. Pulmonary oedema fell from about 5 in 100 to under 1 in 100.

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