Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation

Fluid resuscitation strategy in patients with placenta previa accreta: a retrospective study

Objectives

Obstetric hemorrhage is the leading cause of maternal death worldwide. Placenta previa accreta is one of the major direct causes of postpartum hemorrhage, accounting for two-thirds of obstetric hemorrhage cases. Fluid resuscitation is a life-saving procedure for patients suffering from massive hemorrhage. This study aims at evaluating the risk factors of massive hemorrhage and appropriate fluid resuscitation strategy in patients with placenta previa accreta.

Methods

This study retrospectively analyzed the risk factors for massive hemorrhage, clinical characteristics, and perinatal outcomes of patients with placenta previa accreta. Maternal noninvasively evaluated hemodynamic indicators, including maternal heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and shock index, were collected and analyzed at nine time points, from the administration of anesthesia until the end of procedures, in patients diagnosed with placenta previa accreta and receiving different fluid supply volumes.

Results

Complicated with placenta increta/percreta and gestational age of delivery later than 37 weeks are two independent risk factors of massive hemorrhage in patients with placenta previa accreta. A total of 62.27% (170/273) patients diagnosed with placenta increta/percreta had massive hemorrhage, significantly higher than those diagnosed with placenta previa accreta (5.88%, 6/102). Patients delivered after 37 weeks of gestation had significantly higher ratios (86.84%, 99/114) of massive hemorrhage compared with those delivered between 36 and 36+6 weeks of gestation (35.39%, 63/178). Maternal SBP, DBP, and MAP started to decrease immediately after the baby was delivered and reached a relatively stable trough state at 15-30 min after delivery. No statistical differences were found in hemodynamic indicators, the occurrence of hypotension, or in-hospital days after the procedure among the transfusion volumes < 30 ml/kg, 30-80 ml/kg, and ≥ 80 ml/kg groups.

Conclusion

Patients with a suspected diagnosis of placenta previa accreta should plan to deliver before 37 weeks of gestation. The ability to identify concurrent placenta increta/percreta should be improved to schedule a reasonably rapid perioperative plan. Restrictive fluid resuscitation could achieve good effects in maintaining hemodynamic stability in patients with placenta previa accreta. A time period of 15-30 min after delivery is the critical stage for fluid resuscitation.

Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients

Purpose

By using inferior vena cava (IVC) measurements, clinicians can detect fluid status and responsiveness and find out the etiology of hypotension, acute heart failure, and sepsis easier. Pocket-sized ultrasound devices (PSUD) may take this advantage a few steps further by their lower costs, user-friendly interface, and easily applicable structure.In this study, we aimed to determine the diagnostic value of a PSUD compared with a standard ultrasound device (SD) for the measurement of IVC diameter (IVCD) and its respiratory variability.

Materials and methods

We measured the inspiratory, expiratory diameters of IVC, and calculated the inferior vena cava collapsibility index (IVCCI). We investigated 42 intensive care unit (ICU) patients.

Results

There was no difference in inspiratory (PSUD: 1.34 ± 0.67 cm; SD: 1.35 ± 0.68 cm) and expiratory (PSUD: 1.98 ± 0.53 cm; SD: 2.01 ± 0.49 cm) IVCD among measurements with PSUD and SD (p > 0.05). There was also no difference between IVCCI's measured with PSUD (39 ± 20%) and SD (39 ± 20%) (p > 0.05). The Bland-Altman analysis revealed that the width of 95% limits of agreement were similar for both devices. There was a good inter-device agreement among PSUD and SD for measurements of IVCD, and there was no difference between IVCCI's measured using both ultrasound devices.

Conclusion

We support that the idea of a PSUD is as reliable as a SD for IVC measurements.

How to cite this article

Inci K, Gürsel G. Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients. Indian J Crit Care Med 2024;28(4):369-374.

Inferior Vena Caval Measures Do Not Correlate with Carotid Artery Corrected Flow Time Change Measured Using a Wireless Doppler Patch in Healthy Volunteers

(1) Background: The inspiratory collapse of the inferior vena cava (IVC), a non-invasive surrogate for right atrial pressure, is often used to predict whether a patient will augment stroke volume (SV) in response to a preload challenge. There is a correlation between changing stroke volume (SV∆) and corrected flow time of the common carotid artery (ccFT∆). (2) Objective: We studied the relationship between IVC collapsibility and ccFT∆ in healthy volunteers during preload challenges. (3) Methods: A prospective, observational, pilot study in euvolemic, healthy volunteers with no cardiovascular history was undertaken in a local physiology lab. Using a tilt-table, we studied two degrees of preload augmentation from (a) supine to 30-degrees head-down and (b) fully-upright to 30-degrees head down. In the supine position, % of IVC collapse with respiration, sphericity index and portal vein pulsatility was calculated. The common carotid artery Doppler pulse was continuously captured using a wireless, wearable ultrasound system. (4) Results: Fourteen subjects were included. IVC % collapse with respiration ranged between 10% and 84% across all subjects. Preload responsiveness was defined as an increase in ccFT∆ of at least 7 milliseconds. A total of 79% (supine baseline) and 100% (head-up baseline) of subjects were preload-responsive. No supine venous measures (including IVC % collapse) were significantly related to ccFT∆. (5) Conclusions: From head-up baseline, 100% of healthy subjects were 'preload-responsive' as per the ccFT∆. Based on the 42% and 25% IVC collapse thresholds in the supine position, only 50% and 71% would have been labeled 'preload-responsive'.

Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond-Forrester Classification

Point of care ultrasound (POCUS) is a first-line tool to assess hemodynamically unstable patients, however, there is confusion surrounding intertwined concepts such as: "flow," "congestion," "fluid responsiveness (FR)," and "fluid tolerance." We argue that the Frank-Starling relationship is clarifying because it describes the interplay between "congestion" and "flow" on the x-axis and y-axis, respectively. Nevertheless, a single, simultaneous assessment of congestion and flow via POCUS remains a static approach. To expand this, we propose a two-step process. The first step is to place the patient on an ultrasonographic Diamond-Forrester plot. The second step is a dynamic assessment for FR (e.g., passive leg raise), which individualizes therapy across the arc of critical illness.

Clinical outcomes of a prospective randomized comparison of bioreactance monitoring versus pulse-contour analysis in a stroke-volume based goal-directed fluid resuscitation protocol in brain-dead organ donors

Eighty percent of brain-dead (BD) organ donors develop hypotension and are frequently hypovolemic. Fluid resuscitation in a BD donor is controversial. We have previously published our 4-h goal-directed stroke volume (SV)-based fluid resuscitation protocol which significantly decreased time on vasopressors and increased transplanting four or more organs. The SV was measured by pulse-contour analysis (PCA) or an esophageal doppler monitor, both of which are invasive. Thoracic bioreactance (BR) is a non-invasive portable technology that measures SV but has not been studied in BD donors. We performed a randomized prospective comparative study of BR versus PCA technology in our fluid resuscitation protocol in BD donors. Eighty-four donors (53.1%) were randomized to BR and 74 donors to PCA (46.8%). The two groups were well matched based on 24 demographic, social, and initial laboratory factors, without any significant differences between them. There was no difference in the intravenous fluid infused over the 4-h study period [BR 2271 ± 823 vs. PCA 2230 ± 962 mL; p = .77]. There was no difference in the time to wean off vasopressors [BR 108.8 ± 61.8 vs. PCA 150.0 ± 68 min p = .07], nor in the number of donors off vasopressors at the end of the protocol [BR 16 (28.6%) vs. PCA 15 (29.4%); p = .92]. There was no difference in the total number of organs transplanted per donor [BR 3.25 ± 1.77 vs. PCA 3.22 ± 1.75; p = .90], nor in any individual organ transplanted. BR was equivalent to PCA in clinical outcomes and provides a simple, non-invasive, portable technology to monitor fluid resuscitation in organ donors.

Simultaneous venous-arterial Doppler during preload augmentation: illustrating the Doppler Starling curve

Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose-response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed.

Understanding nursing perceptions of intravenous fluid management practices

PURPOSE

Intravenous (IV) fluids are routinely used in hospitalized patients. As IV fluids are an everyday occurrence, their importance is often overlooked. Many patients receive large volumes of fluid during resuscitation to aid in the promotion of tissue perfusion. Nurses regularly administer IV fluids as part of maintenance infusions or as life-saving therapies and, therefore, need to understand these fluids' impact on their patients. Understanding nurses' existing perceptions of IV fluid management practices are crucial to improving practice.

METHODS

This study used an online survey to gather information on nursing perceptions of IV fluids. Four hundred and sixty-two Canadian nurses from diverse backgrounds were surveyed, including registered nurses, licensed practical nurses and student nurses.

RESULTS

The study found that the majority of participants agreed that IV fluids, including type, amount, and rationale for infusion, were important. They also agreed that fluids could impact patient outcomes. However, the study found that, despite recognizing the value and importance of fluid management, many nurses struggled with recognizing how to determine a patient's fluid status versus fluid responsiveness.

CONCLUSION

This study supports improving nursing education to understand better the differences between fluid volume status and volume responsiveness. Our study also provides evidence that nurses need access to more sophisticated tools to conduct dynamic assessments and better meet patients' needs.

Measuring the accuracy of cardiac output using POCUS: the introduction of artificial intelligence into routine care

Background

Shock management requires quick and reliable means to monitor the hemodynamic effects of fluid resuscitation. Point-of-care ultrasound (POCUS) is a relatively quick and non-invasive imaging technique capable of capturing cardiac output (CO) variations in acute settings. However, POCUS is plagued by variable operator skill and interpretation. Artificial intelligence may assist healthcare professionals obtain more objective and precise measurements during ultrasound imaging, thus increasing usability among users with varying experience. In this feasibility study, we compared the performance of novice POCUS users in measuring CO with manual techniques to a novel automation-assisted technique that provides real-time feedback to correct image acquisition for optimal aortic outflow velocity measurement.

Methods

28 junior critical care trainees with limited experience in POCUS performed manual and automation-assisted CO measurements on a single healthy volunteer. CO measurements were obtained using left ventricular outflow tract (LVOT) velocity time integral (VTI) and LVOT diameter. Measurements obtained by study subjects were compared to those taken by board-certified echocardiographers. Comparative analyses were performed using Spearman’s rank correlation and Bland–Altman matched-pairs analysis.

Results

Adequate image acquisition was 100% feasible. The correlation between manual and automated VTI values was not significant (p = 0.11) and means from both groups underestimated the mean values obtained by board-certified echocardiographers. Automated measurements of VTI in the trainee cohort were found to have more reproducibility, narrower measurement range (6.2 vs. 10.3 cm), and reduced standard deviation (1.98 vs. 2.33 cm) compared to manual measurements. The coefficient of variation across raters was 11.5%, 13.6% and 15.4% for board-certified echocardiographers, automated, and manual VTI tracing, respectively.

Conclusions

Our study demonstrates that novel automation-assisted VTI is feasible and can decrease variability while increasing precision in CO measurement. These results support the use of artificial intelligence-augmented image acquisition in routine critical care ultrasound and may have a role for evaluating the response of CO to hemodynamic interventions. Further investigations into artificial intelligence-assisted ultrasound systems in clinical settings are warranted.

Pathophysiology of fluid administration in critically ill patients

Fluid administration is a cornerstone of treatment of critically ill patients. The aim of this review is to reappraise the pathophysiology of fluid therapy, considering the mechanisms related to the interplay of flow and pressure variables, the systemic response to the shock syndrome, the effects of different types of fluids administered and the concept of preload dependency responsiveness. In this context, the relationship between preload, stroke volume (SV) and fluid administration is that the volume infused has to be large enough to increase the driving pressure for venous return, and that the resulting increase in end-diastolic volume produces an increase in SV only if both ventricles are operating on the steep part of the curve. As a consequence, fluids should be given as drugs and, accordingly, the dose and the rate of administration impact on the final outcome. Titrating fluid therapy in terms of overall volume infused but also considering the type of fluid used is a key component of fluid resuscitation. A single, reliable, and feasible physiological or biochemical parameter to define the balance between the changes in SV and oxygen delivery (i.e., coupling "macro" and "micro" circulation) is still not available, making the diagnosis of acute circulatory dysfunction primarily clinical.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Assessing Fluid Intolerance with Doppler Ultrasonography: A Physiological Framework

Ultrasonography is becoming the favored hemodynamic monitoring utensil of emergentologists, anesthesiologists and intensivists. While the roles of ultrasound grow and evolve, many clinical applications of ultrasound stem from qualitative, image-based protocols, especially for diagnosing and managing circulatory failure. Often, these algorithms imply or suggest treatment. For example, intravenous fluids are opted for or against based upon ultrasonographic signs of preload and estimation of the left ventricular ejection fraction. Though appealing, image-based algorithms skirt some foundational tenets of cardiac physiology; namely, (1) the relationship between cardiac filling and stroke volume varies considerably in the critically ill, (2) the correlation between cardiac filling and total vascular volume is poor and (3) the ejection fraction is not purely an appraisal of cardiac function but rather a measure of coupling between the ventricle and the arterial load. Therefore, management decisions could be enhanced by quantitative approaches, enabled by Doppler ultrasonography. Both fluid ‘responsiveness’ and ‘tolerance’ are evaluated by Doppler ultrasound, but the physiological relationship between these constructs is nebulous. Accordingly, it is argued that the link between them is founded upon the Frank–Starling–Sarnoff relationship and that this framework helps direct future ultrasound protocols, explains seemingly discordant findings and steers new routes of enquiry.

Continuous Renal-Replacement Therapy in Critically Ill Children: Practice Changes and Association With Outcome

OBJECTIVES

This study was designed to evaluate practice changes and outcomes over a 10-year period in a large single-center PICU cohort that received continuous renal-replacement therapy.

DESIGN

Retrospective study design.

SETTING

A multidisciplinary tertiary PICU of a university-affiliated hospital in Guangzhou, China.

PATIENTS

All critically ill children who were admitted to our PICU from January 2010 to December 2019 and received continuous renal-replacement therapy were included in this study.

MEASUREMENTS AND MAIN RESULTS

A total of 289 patients were included in the study. Of the two study periods, 2010-2014 and 2015-2019, the proportion of continuous renal-replacement therapy initiation time greater than 24 hours was significantly reduced ([73/223] 32.73% vs. [40/66] 60.60%, p < 0.001), the percentage of fluid overload at continuous renal-replacement therapy initiation was lower (3.8% [1.6-7.2%] vs. 12.1% [6.6-23.3%], p < 0.001), the percentage of regional citrate anticoagulation protocol was increased ([223/223] 100% vs. [15/66] 22.7%, p < 0.001), and the ICU survival rate was significantly improved ([24/66] 36.4% vs. [131/223] 58.7%, p = 0.001) in the latter period compared with the former. In addition, subgroup analysis found that survival were higher in patients with continuous renal-replacement therapy initiation time less than 24 hours, regional citrate anticoagulation protocol, and fluid overload less than 10%.

CONCLUSIONS

The survival rate of patients received continuous renal-replacement therapy treatment in our center has improved over past 10 years, and some changes have taken place during these periods. Among them, early initiation of continuous renal-replacement therapy, lower fluid overload, and regional citrate anticoagulation method seems to be related to the improvement of outcome. Ongoing evaluation of the practice changes and quality improvement of continuous renal-replacement therapy for critically ill pediatric patients still need attention.

Perioperative Hemodynamic Monitoring: An Overview of Current Methods

Perioperative hemodynamic monitoring is an essential part of anesthetic care. In this review, we aim to give an overview of methods currently used in the clinical routine and experimental methods under development. The technical aspects of the mentioned methods are discussed briefly. This review includes methods to monitor blood pressures, for example, arterial pressure, mean systemic filling pressure and central venous pressure, and volumes, for example, global end-diastolic volume (GEDV) and extravascular lung water. In addition, monitoring blood flow (cardiac output) and fluid responsiveness (preload) will be discussed.

Inferior Vena Cava Collapsibility Index: Clinical Validation and Application for Assessment of Relative Intravascular Volume

Accurate assessment of relative intravascular volume is critical to guide volume management of patients with acute or chronic kidney disorders, particularly those with complex comorbidities requiring hospitalization or intensive care. Inferior vena cava (IVC) diameter variability with respiration measured by ultrasound provides a dynamic noninvasive point-of-care estimate of relative intravascular volume. We present details of image acquisition, interpretation, and clinical scenarios to which IVC ultrasound can be applied. The variation in IVC diameter over the respiratory or ventilatory cycle is greater in patients who are volume responsive than those who are not volume responsive. When 2 recent prospective studies of spontaneously breathing patients (n = 214) are added to a prior meta-analysis of 181 patients, for a total of 7 studies of 395 spontaneously breathing patients, IVC collapsibility index (CI) had a pooled sensitivity of 71% and specificity of 81% for predicting volume responsiveness, which is similar to a pooled sensitivity of 75% and specificity of 82% for 9 studies of 284 mechanically ventilated patients. IVC maximum diameter <2.1 cm, that collapses >50% with or without a sniff is inconsistent with intravascular volume overload and suggests normal right atrial pressure (0-5 mmHg). Inferior vena cava collapsibility (IVC CI) < 20% with no sniff suggests increased right atrial pressure and is inconsistent with overt hypovolemia in spontaneously breathing or ventilated patients. These IVC CI cutoffs do not appear to vary greatly depending on whether patients are breathing spontaneously or are mechanically ventilated. Patients with lower IVC CI are more likely to tolerate ultrafiltration with hemodialysis or improve cardiac output with ultrafiltration. Our goal for IVC CI generally ranges from 20% to 50%, respecting potential biases to interpretation and overriding clinical considerations. IVC ultrasound may be limited by factors that affect IVC diameter or collapsibility, clinical interpretation, or optimal visualization, and must be interpreted in the context of the entire clinical situation.

Implications of Continuous Noninvasive Finger Cuff Arterial Pressure Device Use during Cesarean Delivery for Goal-Directed Fluid Therapy Preload Optimization: A Randomized Controlled Trial

Background

Although fixed-volume conventional fluid preloading protocol fails to attenuate postspinal hypotension during cesarean delivery, the effect of goal-directed fluid therapy (GDFT) remains less explored. Continuous noninvasive finger cuff arterial pressure monitoring using devices such as the ClearSight System can provide the noninvasive stroke volume value, enabling clinicians to perform GDFT before spinal anesthesia; however, the efficacy of GDFT requires further elucidation.

Method

In total, 71 consecutive full-term pregnant women were randomly divided into a control group (n = 34) and a GDFT group (n = 37). Before spinal anesthesia, the control group received a fixed dose (1000 mL) of crystalloid fluid, but the GDFT group received repeated 3 mL/kg body weight of crystalloid fluid challenges within 3 minutes with a 1-minute interval between each fluid challenge based on the stroke volume incremental changes obtained using the ClearSight System (targeting a stroke volume increase of ≥5% after a fluid challenge). The primary outcome was the incidence of postspinal hypotension. The secondary outcomes were total fluid volume, vasopressor dosage, hemodynamic parameter changes, maternal adverse effects, and neonatal profiles.

Result

Women in the GDFT group received more fluid than did those in the control group (1132 ± 108 vs. 1247 ± 202 mL; p = 0.0044), but the incidence of postspinal hypotension (79.4% vs. 73.0%,; p = 0.5864) and norepinephrine dose (12.5 ± 10.6 vs. 15.1 ± 12.8 mcg, respectively; p = 0.3512) was comparable between the two groups. Fewer women in the GDFT group experienced nausea (61.76% vs. 35.14%; p = 0.0332). Neonatal outcomes (Apgar score and umbilical blood analysis) were comparable and typical in both groups.

Conclusion

ClearSight-guided GDFT did not ameliorate postspinal hypotension but may reduce nausea. This trial is registered with NCT03013140.

Implementing a Goal-Directed Therapy Protocol for Fluid Resuscitation in the Cardiovascular Intensive Care Unit

BACKGROUND

Balancing fluid administration and titration of vasoactive medications is critical to preventing postoperative complications in cardiac surgical patients.

OBJECTIVE

To evaluate the impact of implementing a goal-directed therapy protocol in the cardiovascular intensive care unit on total intravenous fluids administered on the day of surgery, rates of acute kidney injury, and hospital length of stay.

METHODS

A fluid resuscitation protocol using dynamic assessment of fluid responsiveness with stroke volume index was developed, and nurses were prepared for its implementation using simulation training.

RESULTS

After implementation of the new protocol, the total amount of intravenous fluids administered on the day of surgery was significantly reduced (P = .003). There were no significant changes in hospital length of stay (P = .83) or rates of acute kidney injury (P = .86). There were significant increases in nurses' knowledge of (P < .001) and confidence in (P < .001) fluid resuscitation and titration of vasoactive medications after simulation training.

CONCLUSIONS

Use of a fluid resuscitation protocol resulted in a reduction in the amount of intravenous fluids administered on the day of surgery. The simulation training increased nurses' knowledge of and confidence in fluid resuscitation and titration of vasoactive medications.

Administration of Corticosteroids, Ascorbic Acid, and Thiamine Improves Oxygenation after Thoracoscopic Esophagectomy

PURPOSE

The activity of corticosteroids, ascorbic acid, and thiamine against oxidative and inflammatory responses was evaluated in patients undergoing esophagectomy. This study was undertaken to investigate the effect of this combined therapy on lung dysfunction following esophagectomy.

METHODS

In this retrospective before-after study, we compared the clinical course of consecutive patients undergoing thoracoscopic esophagectomy treated with the combination of corticosteroids, ascorbic acid, and thiamine between June and December 2018 with a control group treated with corticosteroids alone between January 2016 and May 2018. Outcomes included oxygenation (arterial partial pressure of oxygen (PaO2)/fractional concentration of inspired oxygen (FiO2) ratios), duration of mechanical ventilation and intensive care unit (ICU) length of stay.

RESULTS

In all, 17 patients were included in this study (6 in the combination therapy group and 11 patients in the control group). Mean PaO2/FiO2 ratios in the combined therapy group were significantly higher than in the control group at all points during the observation period (p <0.001). In the combined therapy group, the duration of mechanical ventilation and ICU stay were significantly shorter (p <0.001, p = 0.009).

CONCLUSIONS

This study suggests that combined therapy including corticosteroids, ascorbic acid, and thiamine may be effective in improving oxygenation after esophagectomy. Additional studies are required to confirm these preliminary findings.

A novel supplemental maneuver to predict fluid responsiveness in critically ill patients: blood pump-out test performed before renal replacement therapy

Background

Passive leg raising (PLR) test, known as reversible increasing venous return, could predict hemodynamic intolerance induced by renal replacement therapy (RRT). Oppositely, blood drainage procedure at the start of RRT cuts down intravascular capacity which is likely to have changes in fluid responsiveness has been little studied. Our study aimed to determine whether blood drainage procedure, defined as blood pump-out test, which is essential and inevitable at the beginning of RRT could predict fluid responsiveness in critically ill patients.

Methods

Critically ill patients underwent RRT with pulse contour analysis were included. During PLR, an increase of cardiac output (CO, derived from pulse contour analysis) ≥10% compared to baseline was considered responders as the gold standard. BPT was performed at a constant speed after the increase of CO induced by PLR returned to baseline and the maximal of CO within 2 minutes was recorded. Then area under ROC curve of CO changes to identify responders from non-responders in BPT was calculated based on the results from PLR test.

Results

Sixty-five patients were enrolled. Thirty-one/sixty-five patients (47.7%) were considered responders during PLR. And after analysis by ROC curve, a decrease in CO greater than 11.0% during BPT predicted fluid responsiveness with 70.9% sensitivity and 76.5% specificity. The highest area under the curve (AUC) was found for an increase in CO (0.74±0.06; 95% CI: 0.62 to 0.84).

Conclusions

BPT could be a supplement to PLR, providing a novel maneuver to predict fluid responsiveness in critically ill patients underwent RRT. (Trial registration: ChiCTR-DDD-17010534). Registered 30 January 2017 (retrospective registration).

Does End-Expiratory Occlusion Test Predict Fluid Responsiveness in Mechanically Ventilated Patients? A Systematic Review and Meta-Analysis

BACKGROUND

We performed a systematic review and meta-analysis of studies investigating the end-expiratory occlusion (EEO) test induced changes in cardiac index (CI) and in arterial pressure as predictors of fluid responsiveness in adults receiving mechanical ventilation.

METHODS

MEDLINE, EMBASE, Cochrane Database, and Chinese database were screened for relevant original and review articles. The meta-analysis determined the pooled sensitivity, specificity, diagnostic odds ratio, area under the receiver operating characteristic curve (AUROC), and threshold for the EEO test assessed with CI and arterial pressure. In addition, heterogeneity and subgroup analyses were performed.

RESULTS

We included 13 studies involving 479 adult patients and 523 volume expansion. Statistically significant heterogeneity was identified, and meta-regression indicated that prone position was the major sources of heterogeneity. After removal of the study performed in prone position, heterogeneity became nonsignificant. EEO-induced changes in CI (or surrogate) are accurate for predicting fluid responsiveness in semirecumbent or supine patients, with excellent pooled sensitivity of 92% (95% CI, 0.88-0.95, I = 0.00%), specificity of 89% (95% CI, 0.83-0.93, I = 34.34%), and a summary AUROC of 0.95 (95% CI, 0.93-0.97). The mean threshold was an EEO-induced increase in CI (or surrogate) of more than 4.9 ± 1.5%. EEO test exhibited better diagnostic performance in semirecumbent or supine patients than prone patients, with higher AUROC (0.95 vs. 0.65; P < 0.001). In addition, EEO test exhibited higher specificity (0.93 vs. 0.83, P < 0.001) in patients ventilated with low tidal volume compared with normal or nearly normal tidal volume. However, EEO test was less accurate when its hemodynamic effects were detected on arterial pressure. EEO-induced changes in arterial pressure exhibited a lower sensitivity (0.88 vs. 0.92; P = 0.402), specificity (0.77 vs. 0.90; P = 0.019), and AUROC (0.87 vs. 0.96; P < 0.001) compared with EEO-induced changes in CI (or surrogate).

CONCLUSIONS

EEO test is accurate to predict fluid responsiveness in semirecumbent or supine patients but not in prone patients. EEO test exhibited higher specificity in patients ventilated with low tidal volume, and its accuracy is better when its hemodynamic effects are assessed by direct measurement of CI than by the arterial pressure.

Effect of initial infusion rates of fluid resuscitation on outcomes in patients with septic shock: a historical cohort study

Background

Fluid resuscitation has become the cornerstone of early septic shock management, but the optimal fluid rate is still not well studied. The goal of this investigation is to examine the relationship between fluid resuscitation rate and septic shock resolution.

Method

We retrospectively studied adult (≥ 18 years) patients with septic shock, defined based on sepsis III definition, from January 1, 2006, through May 31, 2018, in the medical intensive care unit (MICU) of Mayo Clinic Rochester. The fluid resuscitation time was defined as the time required to infuse the initial fluid bolus of 30 ml/kg, based on the recommendations of the 2016 surviving sepsis campaign. The cohort was divided into four groups based on the average fluid rate (group 1 ≥ 0.5, group 2 0.25–0.49, group 3 0.17–0.24, and group 4 < 0.17 ml/kg/min). The primary outcome was the time to shock reversal. Multivariable regression analyses were conducted to account for potential confounders.

Result

A total of 1052 patients met eligibility criteria and were included in the analysis. The time-to-shock reversal was significantly different among the groups (P < .001). Patients in group 1 who received fluid resuscitation at a faster rate had a shorter time to shock reversal (HR = 0.78; 95% CI 0.66–0.91; P = .01) when compared with group 4 with a median (IQR) time-to-shock reversal of 1.7 (1.5, 2.0) vs. 2.8 (2.6, 3.3) days, respectively. Using 0.25 ml/kg/min as cutoff, the higher fluid infusion rate was associated with a shorter time to shock reversal (HR = 1.22; 95% CI 1.06–1.41; P = .004) and with decreased odds of 28-day mortality (HR = 0.71; 95% CI 0.60–0.85; P < .001).

Conclusion

In septic shock patients, initial fluid resuscitation rate of 0.25–0.50 ml/kg/min (i.e., completion of the initial 30 ml/kg IV fluid resuscitation within the first 2 h), may be associated with early shock reversal and lower 28-day mortality compared with slower rates of infusion.

Emergency department non-invasive cardiac output study (EDNICO): an accuracy study

BACKGROUND

There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assess here the accuracy of five non-invasive methods in detecting fluid responsiveness in the ED: (1) common carotid artery blood flow, (2) suprasternal aortic Doppler, (3) bioreactance, (4) plethysmography with digital vascular unloading method, and (5) inferior vena cava collapsibility index. Left ventricular outflow tract echocardiography derived velocity time integral is the reference standard. This follows an assessment of feasibility and repeatability of these methods in the same cohort of ED patients.

METHODS

This is a prospective observational study of non-invasive methods for assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Sensitivity and specificity of each method in determining the fluid responsiveness status of participants is determined in comparison to the reference standard.

RESULTS

Thirty-three patient data sets were included for analysis. The specificity and sensitivity to detect fluid responders was 46.2 and 45% for common carotid artery blood flow (CCABF), 61.5 and 63.2% for suprasternal artery Doppler (SSAD), 46.2 and 50% for bioreactance, 50 and 41.2% for plethysmography vascular unloading technique (PVUT), and 63.6 and 47.4% for inferior vena cava collapsibility index (IVCCI), respectively. Analysis of agreement with Cohen's Kappa - 0.08 for CCABF, 0.24 for SSAD, - 0.04 for bioreactance, - 0.08 for PVUT, and 0.1 for IVCCI.

CONCLUSION

In this study, non-invasive methods were not found to reliably identify fluid responders. Non-invasive methods of identifying fluid responders are likely to play a key role in improving patient outcome in the ED in fluid depleted states such as sepsis. These results have implications for future studies assessing the accuracy of such methods.

Fluid resuscitation in trauma: what are the best strategies and fluids?

BACKGROUND

Traumatic injuries pose a global health problem and account for about 10% global burden of disease. Among injured patients, the major cause of potentially preventable death is uncontrolled post-traumatic hemorrhage.

MAIN BODY

This review discusses the role of prehospital trauma care in low-resource/remote settings, goals, principles and evolving strategies of fluid resuscitation, ideal resuscitation fluid, and post-resuscitation fluid management. Management of fluid resuscitation in few special groups is also discussed.

CONCLUSIONS

Prehospital trauma care systems reduce mortality in low-resource/remote settings. Delayed resuscitation seems a better option when transport time to definitive care is shorter whereas goal-directed resuscitation with low-volume crystalloid seems a better option if transport time is longer. Few general recommendations regarding the choice of fluid are provided. Adhering to evidence-based clinical practice guidelines and local modifications based on patient population, available resources, and expertise will improve patient outcomes.

Sepsis 2019: What Surgeons Need to Know

The definition of sepsis continues to be as dynamic as the management strategies used to treat this. Sepsis-3 has replaced the earlier systemic inflammatory response syndrome (SIRS)-based diagnoses with the rapid Sequential Organ Failure Assessment (SOFA) score assisting in predicting overall prognosis with regards to mortality. Surgeons have an important role in ensuring adequate source control while recognizing the threat of carbapenem-resistance in gram-negative organisms. Rapid diagnostic tests are being used increasingly for the early identification of multi-drug-resistant organisms (MDROs), with a key emphasis on the multidisciplinary alert of results. Novel, higher generation antibiotic agents have been developed for resistance in ESKCAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) organisms while surgeons have an important role in the prevention of spread. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial has challenged the previous paradigm of length of antibiotic treatment whereas biomarkers such as procalcitonin are playing a prominent role in individualizing therapy. Several novel therapies for refractory septic shock, while still investigational, are gaining prominence rapidly (such as vitamin C) whereas others await further clinical trials. Management strategies presented as care bundles continue to be updated by the Surviving Sepsis Campaign, yet still remain controversial in its global adoption. We have broadened our temporal and epidemiologic perspective of sepsis by understanding it both as an acute, time-sensitive, life-threatening illness to a chronic condition that increases the risk of mortality up to five years post-discharge. Artificial intelligence, machine learning, and bedside scoring systems can assist the clinician in predicting post-operative sepsis. The public health role of the surgeon is key. This includes collaboration and multi-disciplinary antibiotic stewardship at a hospital level. It also requires controlling pharmaceutical sales and the unregulated dispensing of antibiotic agents globally through policy initiatives to control emerging resistance through prevention.

Assessing Fluid Resuscitation in Adults with Sepsis Who Are Not Mechanically Ventilated: a Systematic Review of Diagnostic Test Accuracy Studies

BACKGROUND

Fluid resuscitation is a widely used intervention that is mandated in the management of sepsis. While its use can be life-saving, its overuse is associated with harm. Despite this, the best means of assessing a need for fluid resuscitation in an acute medical setting is unclear.

OBJECTIVE

To assess studies of diagnostic tests that identify the need for fluid resuscitation in adults with sepsis, as defined by the presence of fluid responsiveness.

DESIGN

Protocol registration was performed in advance (PROSPERO:CRD42017048651). Research database searches were performed alongside additional searches to identify grey literature. Diagnostic test accuracy studies that assessed any fluid assessment tool were identified independently by two authors, before data extraction and quality assessments were performed.

PARTICIPANTS

Adults with sepsis, without intensive care organ support, who would be appropriate for admission to an acute medical unit.

KEY RESULTS

Of the 26,841 articles that were screened, 14 studies were identified for inclusion, involving a combined total of 594 patients. Five categories of index test were identified: inferior vena cava collapsibility index (IVCCI), haemodynamic change with passive leg raise, haemodynamic change with respiration, haemodynamic change with intravenous fluid administration, and static assessment tools. Due to the high level of clinical heterogeneity affecting all aspects of study design, quantitative analysis was not feasible. There was a lack of consensus on reference tests to determine fluid responsiveness.

CONCLUSION

While fluid resuscitation is considered a key part of the management of sepsis, evidence to support fluid assessment in awake adults is lacking. This review has highlighted a number of research recommendations that should be addressed as a matter of urgency if patient harm is to be avoided.

Resuscitation Guided by Volume Responsiveness Does Not Reduce Mortality in Sepsis: A Meta-Analysis

Supplemental Digital Content is available in the text.

Resuscitation with IV fluids is a critical component in the management of sepsis. Although the optimal volume of IV fluid is unknown, there is evidence that excessive administration can be deleterious. Static measures of volume status have not proven to be meaningful resuscitative endpoints. Determination of volume responsiveness has putative benefits over static measures, but its effect on outcomes is unknown. The goal of this systematic review and meta-analysis was to determine if resuscitation with a volume responsiveness-guided approach leads to improved outcomes in septic patients.

Emergency department non-invasive cardiac output study (EDNICO): a feasibility and repeatability study

Background

There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assessed six non-invasive fluid responsiveness monitoring methods which measure cardiac output directly or indirectly for their feasibility and repeatability of measurements in the ED: (1) left ventricular outflow tract echocardiography derived velocity time integral, (2) common carotid artery blood flow, (3) suprasternal aortic Doppler, (4) bioreactance, (5) plethysmography with digital vascular unloading method, and (6) inferior vena cava collapsibility index.

Methods

This is a prospective observational study of non-invasive methods of assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Feasibility of each method was determined by the proportion of clinically interpretable measurements from the number of measurement attempts. Repeatability was determined by comparing the mean difference of two paired measurements in a fluid steady state (after participants received an intravenous fluid bolus).

Results

76 patients were recruited in the study. A total of 207 fluid responsiveness measurement sets were analysed. Feasibility rates were 97.6% for bioreactance, 91.3% for vascular unloading method with plethysmography, 87.4% for common carotid artery blood flow, 84.1% for inferior vena cava collapsibility index, 78.7% for LVOT VTI, and 76.8% for suprasternal aortic Doppler. The feasibility rates difference between bioreactance and all other methods was statistically significant.

Conclusion

Our study shows that non-invasive fluid responsiveness monitoring in the emergency department may be feasible with selected methods. Higher repeatability of measurements were observed in non-ultrasound methods. These findings have implications for further studies specifically assessing the accuracy of such non-invasive cardiac output methods and their effect on patient outcome in the ED in fluid depleted states such as sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0586-6) contains supplementary material, which is available to authorized users.

Non-invasive hemodynamic evaluation by Doppler echocardiography

The approach for treating a hemodynamically unstable patient remains a diagnostic and therapeutic challenge. Stabilization of the patient should be rapid and effective, but there is not much room for error. This narrow window of intervention makes it necessary to use rapid and accurate hemodynamic evaluation methods. Echocardiography is the method of choice for the bedside evaluation of patients in circulatory shock. In fact, it was intensive care physicians who recognized the potential of Doppler echocardiography for the initial approach to patients in circulatory failure. An echocardiogram allows rapid anatomical and functional cardiac evaluation, which may include non-invasive hemodynamic evaluation using a Doppler study. Such an integrated study may provide data of extreme importance for understanding the mechanisms underlying the hemodynamic instability of the patient to allow the rapid institution of appropriate therapeutic measures. In the present article, we describe the most relevant echocardiographic findings using a practical approach for critical patients with hemodynamic instability.

Cardiac Index Changes With Fluid Bolus Therapy in Children With Sepsis-An Observational Study

OBJECTIVES

Fluid bolus therapy is the initial recommended treatment for acute circulatory failure in sepsis, yet it is unknown whether this has the intended effect of increasing cardiac index. We aimed to describe the effect of fluid bolus therapy on cardiac index in children with sepsis.

DESIGN

A prospective observational cohort study.

SETTING

The Emergency Department of The Royal Children's Hospital, Melbourne, VIC, Australia.

PATIENTS

A convenience sample of children meeting international consensus criteria for sepsis with acute circulatory failure.

INTERVENTION

Treating clinician decision to administer fluid bolus therapy.

MEASUREMENTS AND MAIN RESULTS

Transthoracic echocardiography was recorded immediately before, 5 minutes after, and 60 minutes after fluid bolus therapy. Cardiac index was calculated by a pediatric cardiologist blinded to the timing of the echocardiogram. Cardiac index was calculated for 49 fluid boluses in 41 children. The median change in cardiac index 5 minutes after a fluid bolus therapy was +18.0% (interquartile range, 8.6-28.1%) and after 60 minutes was -6.0% (interquartile range, -15.2% to 3.0%) relative to baseline. Thirty-one of 49 fluid boluses (63%) resulted in an increase in cardiac index of greater than 10% at 5 minutes, and these participants were considered fluid responsive. This was sustained in four of 31 (14%) at 60 minutes. No association between change in cardiac index at 5 or 60 minutes and age, baseline mean arterial blood pressure, fluid bolus volume, and prior volume of fluid bolus therapy was found on linear regression.

CONCLUSIONS

Fluid bolus therapy for pediatric sepsis is associated with a transient increase in cardiac index. Fluid responsiveness is variable and, when present, not sustained. The efficacy of fluid bolus therapy for achieving a sustained increase in cardiac index in children with sepsis is limited.

Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis

OBJECTIVE

The intent of fluid bolus therapy (FBT) is to increase cardiac output and tissue perfusion, yet only 50% of septic children are fluid responsive. We evaluated respiratory variation of inferior vena cava (IVC) diameter as a predictor of fluid responsiveness.

METHODS

A prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Patients were spontaneously ventilating children treated with FBT for sepsis-induced acute circulatory failure. IVC ultrasound was performed prior to FBT. Trans-thoracic echocardiography was performed prior to, 5 and 60 min after FBT. IVC collapsibility index and stroke distance were calculated by a blinded Paediatric Emergency Physician and blinded Paediatric Cardiologist, respectively.

RESULTS

Thirty-nine fluid boluses were recorded in 33 children, 28/39 (72%) of which met criteria for fluid responsiveness at 5 min, which was sustained in 2/28 (7%) of initial fluid responders at 60 min. Sensitivity and specificity (95% confidence interval) of IVC collapsibility index were 0.44 (0.25-0.65) and 0.33 (0.10-0.65) with an area under the receiver operator characteristics curve (95% confidence interval) of 0.38 (0.23-0.55) at 5 min. Test characteristics 60 min after fluid bolus administration were not meaningful because of the infrequency of sustained fluid responsiveness in this patient group. There was no significant correlation between IVC collapsibility and fluid responsiveness at 5 or 60 min.

CONCLUSIONS

IVC collapsibility has poor test characteristics for predicting fluid responsiveness in spontaneously ventilating children with sepsis.

Passive Leg Raising: Simple and Reliable Technique to Prevent Fluid Overload in Critically ill Patients

Background:

Dynamic measures, the response to stroke volume (SV) to fluid loading, have been used successfully to guide fluid management decisions in critically ill patients. However, application of dynamic measures is often inaccurate to predict fluid responsiveness in patients with arrhythmias, ventricular dysfunction or spontaneously breathing critically ill patients. Passive leg raising (PLR) is a simple bedside maneuver that may provide an accurate alternative to guide fluid resuscitation in hypovolemic critically ill patients.

Methods:

Pertinent medical literature for fluid responsiveness in the critically ill patient published in English was searched over the past three decades, and then the search was extended as linked citations indicated.

Results:

Thirty-three studies including observational studies, randomized control trials, systemic review, and meta-analysis studies evaluating fluid responsiveness in the critically ill patient met selection criteria.

Conclusions:

PLR coupled with real-time SV monitors is considered a simple, noninvasive, and accurate method to determine fluid responsiveness in critically ill patients with high sensitivity and specificity for a 10% increase in SV. The adverse effect of albumin on the mortality of head trauma patients and chloride-rich crystalloids on mortality and kidney function needs to be considered when choosing the type of fluid for resuscitation.

Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study

BACKGROUND

The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries.

METHODS

In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome.

RESULTS

There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001).

CONCLUSIONS

Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.

Helping prometheus: liver protection in acute hemorrhagic shock

Acute hemorrhagic hypovolemic shock is caused by a significant high blood loss and leads to hemodynamic instability. The decrease in intravascular volume results in cellular hypoxia and finally in damage to organs such as the liver and the kidney. The liver plays a decisive role in the development or prevention of multiple organ failure after hemorrhagic shock. Despite the large number of experimental studies, the knowledge of pathophysiological mechanisms in the liver after hemorrhagic shock is incomplete. The aim of this mini review was to provide an overview of the pathophysiological changes in liver function after acute hemorrhagic shock and to address treatment options to improve liver perfusion.

Sepsis: Current Definition, Pathophysiology, Diagnosis, and Management

Sepsis is a clinical syndrome that results from the dysregulated inflammatory response to infection that leads to organ dysfunction. The resulting losses to society in terms of financial burden, morbidity, and mortality are enormous. We provide a review of sepsis, its underlying pathophysiology, and guidance for diagnosis and management of this common disease. Current established treatments include appropriate antimicrobial agents to target the underlying infection, optimization of intravascular volume to improve stroke volume, vasopressors to counteract vasoplegic shock, and high-quality supportive care. Appropriate implementation of established treatments combined with novel therapeutic approaches promises to continue to decrease the impact of this disease.

Focused Real-Time Ultrasonography for Nephrologists

We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.

Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database

PURPOSE

The optimal strategy of fluid resuscitation in the early hours of severe sepsis and septic shock is controversial, with both an aggressive and conservative approach being recommended.

METHODS

We used the 2013 Premier Hospital Discharge database to analyse the administration of fluids on the first ICU day, in 23,513 patients with severe sepsis and septic shock, who were admitted to an ICU from the emergency department. Day 1 fluid was grouped into categories 1 L wide, starting with 1-1.99 L up to ≥9 L, to examine the effect of day 1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5 L of fluids on day 1, using patient age and acute conditions present on admission. Patients were grouped by the requirement for mechanical ventilation and the presence or absence of shock. We assessed trends in the difference between actual and expected mortality, in the low fluid range (1-5 L day 1 fluids) and the high fluid range (5 to ≥9 L day 1 fluids) categories, using weighted linear regression controlling for the effects of sample size and variation within the day 1 fluid category.

RESULTS

Day 1 fluid administration averaged 4.4 L being lowest in the group with no mechanical ventilation and no shock (3.6 L) and highest (5.4 L) in the group receiving mechanical ventilation and in shock. The administration of day 1 fluids was remarkably consistent on the basis of hospital size, teaching status, rural/urban location, and region of the country. The hospital mortality in the entire cohort was 25.8%, with a mean ICU and hospital length of stay of 5.1 and 9.1 days, respectively. In the entire cohort, low volume resuscitation (1-4.99 L) was associated with a small but significant reduction in mortality, of -0.7% per litre (95% CI -1.0%, -0.4%; p = 0.02). However, in patients receiving high volume resuscitation (5 to ≥9 L), the mortality increased by 2.3% (95% CI 2.0, 2.5%; p = 0.0003) for each additional litre above 5 L. Total hospital cost increased by $999 for each litre of fluid above 5 L (adjusted R ² = 92.7%, p = 0.005).

CONCLUSION

The mean amount of fluid administered to patients with severe sepsis and septic shock in the USA during the first ICU day is less than that recommended by the Surviving Sepsis Campaign guidelines. The administration of more than 5 L of fluid during the first ICU day is associated with a significantly increased risk of death and significantly higher hospital costs.

Pediatric Acute Respiratory Distress Syndrome: Fluid Management in the PICU

The administration of an appropriate volume of intravenous fluids, while avoiding fluid overload, is a major challenge in the pediatric intensive care unit. Despite our efforts, fluid overload is a very common clinical observation in critically ill children, in particular in those with pediatric acute respiratory distress syndrome (PARDS). Patients with ARDS have widespread damage of the alveolar-capillary barrier, potentially making them vulnerable to fluid overload with the development of pulmonary edema leading to prolonged course of disease. Indeed, studies in adults with ARDS have shown that an increased cumulative fluid balance is associated with adverse outcome. However, age-related differences in the development and consequences of fluid overload in ARDS may exist due to disparities in immunologic response and body water distribution. This systematic review summarizes the current literature on fluid imbalance and management in PARDS, with special emphasis on potential differences with adult patients. It discusses the adverse effects associated with fluid overload and the corresponding possible pathophysiological mechanisms of its development. Our intent is to provide an incentive to develop age-specific fluid management protocols to improve PARDS outcomes.