Fluid management in the ICU: has the tide turned?

In 1832, Thomas Latta successfully administered intravenous fluid to patients with severe dehydration who had contracted cholera during the pandemics of the 19th century, the first recorded successful application of “saline drip” methodology [1]. More than 150 years hence, fluid management remains a core task for clinicians in intensive care units (ICU). The indications for fluid therapy have expanded greatly and are now used not only to treat significant fluid losses, but also to avoid fluid depletion (so-called maintenance fluid) and as a means of delivering medication, electrolytes and nutrition. Perhaps the most common use of fluids in the ICU is to “optimise the circulation” in patients with suspected haemodynamic compromise. Fluid management in the ICU involves not only the management of fluid input but also the management of fluid output, including the administration of diuretics and, in the case of severe kidney failure, dialysis. Current thinking regarding fluid management might be well represented by the Surviving Sepsis Campaign guideline for continued fluid therapy beyond an initial challenge: ‘Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic or static variables’ [2]. The wording of this recommendation puts more emphasis on the potential benefit than the potential harm of fluids and arguably promotes the liberal use of fluids. This is in keeping with the common view of clinicians, who have tended to focus more on the risks to patients of being fluid deficient than on the risks of being fluid overloaded. …