Fluid resuscitation practice patterns in intensive care units of the USA: a cross-sectional survey of critical care physicians

Timothy E Miller, Martin Bunke, Paul Nisbet, Charles S Brudney, Timothy E Miller, Martin Bunke, Paul Nisbet, Charles S Brudney

Abstract

Background: Fluid resuscitation is a cornerstone of intensive care treatment, yet there is a lack of agreement on how various types of fluids should be used in critically ill patients with different disease states. Therefore, our goal was to investigate the practice patterns of fluid utilization for resuscitation of adult patients in intensive care units (ICUs) within the USA.

Methods: We conducted a cross-sectional online survey of 502 physicians practicing in medical and surgical ICUs. Survey questions were designed to assess clinical decision-making processes for 3 types of patients who need volume expansion: (1) not bleeding and not septic, (2) bleeding but not septic, (3) requiring resuscitation for sepsis. First-choice fluid used in fluid boluses for these 3 patient types was requested from the respondents. Descriptive statistics were performed using a Kruskal-Wallis test to evaluate differences among the physician groups. Follow-up tests, including t tests, were conducted to evaluate differences between ICU types, hospital settings, and bolus volume.

Results: Fluid resuscitation varied with respect to preferences for the factors to determine volume status and preferences for fluid types. The 3 most frequently preferred volume indicators were blood pressure, urine output, and central venous pressure. Regardless of the patient type, the most preferred fluid type was crystalloid, followed by 5 % albumin and then 6 % hydroxyethyl starches (HES) 450/0.70 and 6 % HES 600/0.75. Surprisingly, up to 10 % of physicians still chose HES as the first choice of fluid for resuscitation in sepsis. The clinical specialty and the practice setting of the treating physicians also influenced fluid choices.

Conclusions: Practice patterns of fluid resuscitation varied in the USA, depending on patient characteristics, clinical specialties, and practice settings of the treating physicians.

Keywords: Albumin; Bleeding; Colloids; Crystalloids; Fluid resuscitation; Intensive care unit; Sepsis; Survey.

Figures

Fig. 1
Fig. 1
Volume status indicators and diagnostic tools used in assessing fluid needs. Superscripts A, S, C, and P denote differences between specialties that are statistically significant at P < 0.05
Fig. 2
Fig. 2
Fluid choices for patient who needs volume expansion but is not bleeding and not septic (patient type 1). First choice of intravenous fluids in response to the question, “Which of the following is your first choice for a patient who needs volume expansion but is not bleeding and not septic?” Superscripts A, S, C, and P denote differences between specialties that are statistically significant at P < 0.05. HES, hydroxyethyl starch
Fig. 3
Fig. 3
Fluid choices for patient who needs volume expansion in the presence of blood loss when blood transfusion is not indicated (adequate Hb) and patient is not septic (patient type 2). First choice of intravenous fluids in response to the question, “Which of the following is your first choice for a patient who needs volume expansion in the presence of blood loss when blood transfusion is not indicated (adequate Hb) and patient is not septic?” Superscripts A, S, C, and P denote differences between specialties that are statistically significant at P < 0.05. HES, hydroxyethyl starch
Fig. 4
Fig. 4
Fluid choices for patient who needs volume expansion for resuscitation in sepsis (patient type 3). First choice of intravenous fluids in response to the question, “Which of the following is your first choice for a patient who needs volume expansion for resuscitation in sepsis?” Superscripts A, S, C, and P denote differences between specialties that are statistically significant at P < 0.05. HES, hydroxyethyl starch
Fig. 5
Fig. 5
Rankings of the importance of certain colloid traits when colloids are used for volume expansion. Colloid traits assessed are as follows: (a) more sustained volume expansion; (b) faster volume expansion; (c) less interstitial edema; (d) better respiratory function; (e) less weight gain
Fig. 6
Fig. 6
First choice of IV fluids for (a) patient type 1, (b) patient type 2, and (c) patient type 3 as reported by practice settings. “Albumin” group includes 5 % albumin and 25 % albumin. “HES” group includes HES 6 % 450/070, HES 6 % 600/0.75, and HES 6 % 130/0.4. This dataset does not include physicians from Veterans Affairs hospitals due to small sample (n = 13). Superscripts U and N denote differences between practice settings that are statistically significant at P < 0.05. HES, hydroxyethyl starch

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