When considering how to translate the results of the FACTT into clinical practice, several factors should be considered. First, only patients who were not experiencing cardiopulmonary shock were managed by the protocol. If the mean arterial pressure was < 60 mm Hg or the patient required therapy with vasopressors (other than dopamine at a dose of < 5 μg/kg/min), fluid management was left to the judgment of the managing physician. Thus, the finding that a conservative fluid management strategy was associated with better outcomes in this study does not imply that patients who are in shock ought to have fluids restricted. Second, the mean time from ICU admission to protocol implementation was approximately 43 h. Therefore, as pointed out by Rivers in the editorial accompanying the trial,9the results of the FACTT do not conflict with the finding that early goal-directed therapy in patients with sepsis (with its concomitant aggressive resuscitation) improves outcomes.10 In the trial that first established the benefits of early goal-directed therapy,10 patients with early severe sepsis or septic shock were enrolled on average 1.5 h after arrival in the emergency department and were treated for at least 6 h with aggressive crystalloid resuscitation, using central venous pressure monitoring, and optimization of oxygen delivery using vasopressors, RBC transfusions, and inotropes as necessary. This strategy decreased the in-hospital mortality rate in that single-center study from 46.5 to 30.5% (p = 0.009) and is now widely accepted as appropriate initial management of early severe sepsis. Third, the liberal fluid management strategy would be more accurately called a usual fluid management strategy, since the average daily fluid gain of approximately 1 L in this group is quite similar to that observed in prior studies1–2 from the Acute Respiratory Distress Syndrome Network in which fluid management was not protocolized (Fig 2
). In contrast, the conservative fluid management group had a net fluid balance of approximately zero over the first 7 days of the protocol. These data may provide useful benchmarks to guide the fluid management of critically ill patients in the real world, with the important caveats that electrolytes must be closely monitored and the many safety features of the FACTT (like holding back therapy with diuretics until patients had been out of shock for at least 12 h) must be noted. Finally, patients with an established need for dialysis were excluded from the trial, and it remains unclear what volume management strategy should be followed in this population.