Introduction
The four Ds of fluid management
Description | Antibiotics | Fluids | |
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Drug | Inappropriate therapy | More organ failure, longer ICU/hospital length of stay, longer duration mechanical ventilation (MV) | Hyperchloremic metabolic acidosis, more acute kidney injury, more need for renal replacement therapy, increased mortality |
Appropriate therapy | Key factor in empiric AB choice is consideration of patient risk factors (prior AB use, duration of mechanical ventilation, corticosteroids, recent hospitalization, residence in nursing home, etc.) | Key factor in empiric fluid therapy is consideration of patient risk factors (fluid balance, fluid overload, capillary leak, source control, kidney function, organ function). Do not use glucose as a resuscitation fluid | |
Combination therapy | Possible benefits: broader spectrum, synergy, avoidance of emergency of resistance, less toxicity | Possible benefits: specific fluids for different indications (replacement vs maintenance vs resuscitation), less toxicity | |
Appropriate timing | Survival decreases with 7% per hour delay. Needs discipline and practical organization | In refractory shock early goal-directed therapy (EGDT) has proven beneficial. The longer the delay, the more microcirculatory hypoperfusion | |
Dosing | Pharmacokinetics | Depends on distribution volume, clearance (kidney and liver function), albumin level, tissue penetration | Depends on type of fluid: glucose remains 10% intravascular, crystalloids 25%, vs colloids 100% after 1 h, and other factors (distribution volume, osmolality, oncoticity, kidney function) |
Pharmacodynamics | Reflected by the minimal inhibitory concentration. Reflected by “kill” characteristics, time (T > MIC) vs concentration (Cmax/MIC) dependent | Depends on type of fluid and where you want them to go: intravascular (resuscitation), interstitial vs intracellular (cellular dehydration) | |
Toxicity | Some ABs are toxic for kidneys, advice on dose adjustment needed. However, not getting infection under control is not helping the kidneys either | Some fluids (HES—starches) are toxic for the kidneys. However, not getting shock under control is not helping the kidneys either | |
Duration | Appropriate duration | No strong evidence but trend toward shorter duration. Do not use ABs to treat fever, CRP, infiltrates, but use ABs to treat infections | No strong evidence but trend toward shorter duration. Do not use fluids to treat low central venous or mean arterial pressure, urine output, but use fluids to treat hypovolemia |
Treat to response | Stop ABs when signs and symptoms of active infection resolve. Future role for biomarkers (PCT) | Fluids can be stopped when shock is resolved (normal lactate). Future role for biomarkers (NGAL, cystatin C, citrullin, L-FABP) | |
De-escalation | Monitoring | Take cultures first and have the guts to change a winning team | After stabilization with early adequate fluid management (normal PPV, normal cardiac output, normal lactate), stop ongoing resuscitation and move to conservative late fluid management and late goal-directed fluid removal (= deresuscitation) |
Drug
Dosing
Duration
De-escalation
Balanced solutions
The basics
Crystalloids | Gelatins | Starches | ||||||||
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Lactated Ringer’s | Acetated Ringer’s | Hartmann’s | PlasmaLyte | Sterofundin ISOa | ELO-MEL isoton | Isoplex | Gelaspan | Hextend | Tetraspan | |
Na+ [mEq/L] | 130 | 132 | 131 | 140 | 145 | 140 | 145 | 151 | 143 | 140 |
K+ [mEq/L] | 4 | 4 | 5 | 5 | 4 | 5 | 4 | 4 | 3 | 4 |
Ca2+ [mEq/L] | 3 | 3 | 4 | – | 5 | 5 | – | 2 | 5 | 5 |
Mg2+ [mEq/L] | – | – | 3 | 3 | 2 | 3 | 1.8 | 2 | 0.9 | 2 |
Cl− [mEq/L] | 109 | 110 | 111 | 98 | 127 | 108 | 105 | 103 | 124 | 118 |
Lactate [mEq/L] | 28 | – | 29 | – | – | – | 25 | – | 28 | – |
Acetate [mEq/L] | – | 29 | – | 27 | 24 | 45 | – | 24 | – | 24 |
Malate [mEq/L] | – | – | – | – | 5 | – | – | – | – | 5 |
Gluconate [mEq/L] | – | – | – | 23 | – | – | – | – | – | – |
Dextrose [g L-1] | – | – | – | – | – | – | – | – | – | – |
Gelatin [g/L] | – | – | – | – | – | – | 40 | 40 | – | – |
HES [g/L] | – | – | – | – | – | – | – | – | 60 | 60 |
Dextran [g/L] | – | – | – | – | – | – | – | – | – | – |
In-vivo SID [mEq/L] | 28 | 29 | 29 | 50 | 29 | 45 | 45.8 | 56 | 28 | 29b |
Osmolarity [mOsm/L] | 278 | 277 | 279 | 294 | 309 | 302 | 284 | 284 | 307 | 297 |
The case for balanced solutions
Albumin
The basics
The case for albumin
The case against albumin
Perioperative fluid management
Fluid management before surgery
Fluid management during surgery
Fluid management after surgery
Fluid overload
The problem with fluid overload in the perioperative setting
The problem with fluid overload in the Intensive Care Unit
Is deresuscitation/de-escalation the solution?
The 4 phases of fluid therapy and the R.O.S.E. or S.O.S.D. concept
Resuscitation (R) | Optimization (O) | Stabilization (S) | Evacuation (E) | ||
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HIT | First | Second | Second | Third | Fourth |
Cause | Inflammatory insult, e.g., sepsis, severe acute pancreatitis (SAP), burns, trauma, etc. | Ischemia and reperfusion | Ischemia and reperfusion | GIPS (global increased permeability syndrome) | Hypoperfusion |
Phase | Ebb | Flow | Flow/no flow | No flow | No flow |
Type | Severe shock | Unstable | Stable | Recovering | Unstable |
Example | Septic shock, major trauma, hemorrhagic shock, ruptured abdominal aortic aneurysm, severe acute pancreatitis, severe burns (> 25% TBSA) | Intra- and perioperative goal-directed therapy, less severe burns (< 25% TBSA), diabetic keto-acidosis, severe gastro-intestinal losses (vomiting, gastroenteritis) | Postoperative patient (nil per mouth or combination of total enteral plus parenteral nutrition), abdominal vacuum-assisted closure, replacement of losses in less-severe pancreatitis | Patient on full enteral feed in recovery phase of critical illness, polyuric phase after recovering from acute tubular necrosis | Patient with cirrhosis and anasarca edema (GIPS) and no Flow state, hepatosplanchnic hypoperfusion |
Question | When to start fluids? | When to stop fluids? | When to stop fluids? | When to start unloading? | When to stop unloading? |
Subquestion | Benefits of fluids? | Risks of fluids? | Risks of fluids? | Benefits of unloading? | Risks of unloading? |
O2 transport | Convective problems | Euvolemia, normal diffusion | Diffusion problems | Euvolemia, normal diffusion | Convective problems |
Fluids | Mandatory | Biomarker of critical illness | Biomarker of critical illness | Toxic | |
Fluid therapy | Rapid bolus (4 ml/kg/10–15 min) | Titrate maintenance fluids, conservative use of fluid bolus | Minimal maintenance if oral intake inadequate, provide replacement fluids | Oral intake if possible Avoid unnecessary IV fluids | Avoid hypoperfusion |
Fluid balance | Positive | Neutral | Neutral/negative | Negative | Neutral |
Result | Life saving (rescue, salvage) | Organ rescue (maintenance) | Organ support (homeostasis) | Organ recovery (removal) | Organ support |
Targets | Macrohemodynamics (MAP, CO); lactate; volumetric preload (LVEDAI); functional hemodynamics; fluid responsiveness (PLR, EEO) | Organ macroperfusion (MAP, APP, CO, ScvO2); volumetric preload (GEDVI, RVEDVI); GEF correction; R/L shunt; think of polycompartment syndrome, CARS | Organ function (EVLWI, PVPI, IAP, APP); biomarkers (NGAL, cystatin-C, citrullin); capillary leak markers (colloid oncotic pressure, osmolality, CLI, RLI); daily and cumulative FB, body weight | Organ function evolution (P/F ratio, EVLWI, IAP, APP, PVPI) Body composition (ECW, ICW, TBW, VE) | Organ microperfusion (pHi, ScvO2, lactate, ICG-PDR); Biomarkers; Negative cumulative fluid balance |
Monitoring tools | Arterial-line, central venous-line, PPV or SVV (manual or via monitor), uncalibrated CO, TTE, TEE | Calibrated CO (TPTD, PAC) | Calibrated CO (TPTD); Balance; BIA (ECW, ICW, TBW, VE) | Calibrated CO (TPTD); balance; BIA; DE-escalation | LiMON, Gastric tonometry, micro-dialysis |
Goals | Correct shock (EAFM—early adequate fluid management) | Maintain tissue perfusion | Aim for zero or negative fluid balance (LCFM—late conservative fluid management) | Mobilize fluid accumulation (LGFR—late goal-directed fluid removal = emptying) or DE-resuscitation | Maintain tissue perfusion |
Timeframe | Minutes | Hours | Days | Days to weeks | Weeks |
Resuscitation phase (R) or salvage phase (S)
Optimization phase (O)
Stabilization phase (S)
Evacuation phase (E) or de-escalation phase (D)
Fluid management in trauma and burns
Fluid management in acute hemorrhagic shock following trauma
Fluid management in burns
Type of fluid | Recommendation |
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1. Normal saline | Given the fact that fluid resuscitation in burn management requires large volumes, the use of saline cannot be recommended in a burn resuscitation protocol |
2. Balanced crystalloid | Based on the available evidence, balanced crystalloid solutions are a pragmatic initial resuscitation fluid in the majority of acutely ill (and burn) patients |
3. Semi-synthetic colloids | Given the recent data concerning the use of semi-synthetic colloids (and starches in particular), their use in critically ill patients, including burn patients, cannot be recommended |
4. Albumin | Based on the available evidence the use of albumin 20% can be recommended in severe burns, especially in the deresuscitation phase guided by indices of capillary leak, body weight, (cumulative) fluid balance, fluid overload, extravascular lung water and IAP |
5. Hypertonic solutions | To this day, there is insufficient evidence to reach consensus regarding the safety of hypertonic saline in burn resuscitation. Whenever using hypertonic saline in clinical practice, however, close monitoring of sodium levels is highly advised |
Take home messages and considerations prior to IV fluid prescription
Stage of evaluation | Audit standard |
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1. Assessment | The patient’s fluid balance (via fluid chart with input and output) is assessed on admission in the hospital and on a day-by-day basis The patient’s weight is assessed within the last 3 days of fluid prescription The patient’s fluid and electrolyte needs are assessed as part of every ward review The assessment of the patient’s fluid status (hypo/eu/hypervolemia) includes the use of clinical judgement, vital signs and fluid balance with urine output Recent lab results with urea and electrolytes (within 24 h of fluid prescription) If possible sodium balance should be reported |
2. Indication | A. Resuscitation For patients in need of fluid resuscitation: The cause of the fluid deficit is identified An assessment of shock or hypoperfusion was made A fluid bolus of 4 mL/kg of balanced crystalloids is given Fluid responsiveness is assessed with functional hemodynamics, passive leg raising test or end-expiratory occlusion test, or a combination Mean arterial pressure and cardiac output are monitored continuously via pulse contour analysis allowing assessment of beat-to-beat variations Patients who have received initial fluid resuscitation are reassessed within 30 min Care is upgraded in patients who have already been given > 2000 mL of crystalloids and still need fluid resuscitation after reassessment Patients who have not had > 2000 mL of crystalloids and who still need fluid resuscitation after reassessment receive 2–4 mL/kg of crystalloids and have a further reassessment |
B. Maintenance If patients need IV fluids for routine maintenance alone, the initial prescription is restricted to 25–30 mL/kg/day (1 mL/kg/h) of water and Approximately 1 mmol/kg/day of potassium (K+) and Approximately 1–1.5 mmol/kg/day of sodium (Na+) and Approximately 1 mmol/kg/day of chloride and Approximately 50–100 g/day (1–1.5 g/kg/day) of glucose to limit starvation ketosis Definition of inappropriateness in case of electrolyte disturbances Solutions not containing adequate amount of sodium in case of hyponatremia (Na < 135 mmol/L) Solutions not containing adequate amount of potassium in case of hypokalemia (K < 3.5 mmol/L) Solutions containing too much sodium in case of hypernatremia (Na > 145 mmol/L) Solutions containing too much potassium in case of hypokalemia (K > 5 mmol/L) The amount of fluid intake via other sources should be subtracted from the basic maintenance need of 1 ml/kg/h: Enteral or parenteral nutrition Fluid creep (see further) | |
C. Replacement and redistribution If patients have ongoing abnormal losses or a complex redistribution problem, the fluid therapy is adjusted for all other sources of fluid and electrolyte losses (e.g., normal saline may be indicated in patients with metabolic alkalosis due to gastro-intestinal losses) | |
D. Fluid creep All sources of fluids administered need to be detailed: crystalloids, colloids, blood products, enteral and parenteral nutritional products, and oral intake (water, tea, soup, etc.) Precise data on the concentrated electrolytes added to these fluids or administered separately need to be collected Fluid creep is defined as the sum of the volumes of these electrolytes, the small volumes to keep venous lines open (saline or glucose 5%), and the total volume used as a vehicle for medication | |
3. Prescription | The following information is included in the IV fluid prescription: The type of fluid The rate of fluid infusion The volume or dose of fluid The IV fluid prescription is adapted to current electrolyte disorders and other sources of fluid intake |
4. Management | Patients have an IV fluid management plan, including a fluid and electrolyte prescription over the next 24 h The prescription for a maintenance IV fluid only changes after a clinical exam, a change in dietary intake or evaluation of laboratory results |
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Drug—which fluid.
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Dose—calculate how much to give.
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Duration—duration of the IV fluid therapy.
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De-escalation—stop it as soon as possible.