Fluid Therapy: Double-Edged Sword during Critical Care?

Jan Benes, Mikhail Kirov, Vsevolod Kuzkov, Mitja Lainscak, Zsolt Molnar, Gorazd Voga, Xavier Monnet, Jan Benes, Mikhail Kirov, Vsevolod Kuzkov, Mitja Lainscak, Zsolt Molnar, Gorazd Voga, Xavier Monnet

Abstract

Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years. The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects. We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing.

Figures

Figure 1
Figure 1
Cardiac function curve. There is a family of cardiac function curves depending on the ventricular contractility. If the ventricles are functioning on the steep part of cardiac function curve, changes in cardiac preload induced by mechanical ventilation, end-expiratory occlusion (EEO), passive leg raising (PLR), or “mini fluid challenge” result in significant changes in stroke volume. This is not the case if the ventricles are functioning on the steep part of cardiac function curve.
Figure 2
Figure 2
Decision-making algorithm of fluid administration. ∗Very initial phase of septic shock, when no fluid has been administered yet: in case of haemorrhagic shock or in case of hypovolemic shock due to diarrhoea, vomiting, or ketoacidosis, for instance.
Figure 3
Figure 3
The risks of insufficient and excessive fluid resuscitation. GIPS—global increased permeability syndrome.
Figure 4
Figure 4
Four phases of hemodynamic treatment in relation to cumulative fluid balance.
Figure 5
Figure 5
Decision algorithm for fluid loading in optimization phase.

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Source: PubMed

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