American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Controversies
Do not drown the patient: appropriate fluid management in critical illness☆ Kees H. Polderman, MD, PhD⁎, Joseph Varon, MD Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA The University of Texas Health Science Center at Houston, Houston, TX, USA The University of Texas Medical Branch at Galveston, Galveston, TX, USA University General Hospital, Houston, TX, USA
a r t i c l e
i n f o
Article history: Received 29 November 2014 Received in revised form 28 January 2015 Accepted 29 January 2015 Available online xxxx
a b s t r a c t Administering intravenous fluids to support the circulation in critically ill patients has been a mainstay of emergency medicine and critical care for decades, especially (but not exclusively) in patients with distributive or hypovolemic shock. However, in recent years, this automatic use of large fluid volumes is beginning to be questioned. Analysis from several large trials in severe sepsis and/or acute respiratory distress syndrome have shown independent links between volumes of fluid administered and outcome; conservative fluid strategies have also been associated with lower mortality in trauma patients. In addition, it is becoming ever more clear that central venous pressure, which is often used to guide fluid administration, is a completely unreliable parameter of volume status or fluid responsiveness. Furthermore, 2 recently published large multicenter trials (ARISE and ProCESS) have discredited the “early goal-directed therapy” approach, which used prespecified targets of central venous pressure and venous saturation to guide fluid and vasopressor administration. This article discusses the risks of “iatrogenic submersion” and strategies to avoid this risk while still giving our patients the fluids they need. The key lies in combining good clinical judgement, awareness of the potential harm from excessive fluid use, restraint in reflexive administration of fluids, and use of data from sophisticated monitoring tools such as echocardiography and transpulmonary thermodilution. Use of smaller volumes to perform fluid challenges, monitoring of extravascular lung water, earlier use of norepinephrine, and other strategies can help further reduce morbidity and mortality from severe sepsis. © 2015 Elsevier Inc. All rights reserved.
One of the most challenging and controversial areas in the care of emergent and critically ill patients is the administration of intravenous fluids to support the circulation. This does not only apply to hemodynamically unstable patients. In clinical conditions such as subarachnoid hemorrhage, large volumes of fluid are often administered over prolonged periods to reduce the risk of vasospasm, often targeting a positive fluid balance or a specific central venous pressure (CVP) [1]. However, especially when a patient presents with a distributive or hypovolemic shock, rapid administration of fluids is one of the mainstays of treatment, one that has been recommended for decades. This applies to both the initial and later phases of treatment, especially in distributive shock. The 2012 “Surviving Sepsis Campaign” guidelines recom-
☆ Disclosures: Neither of the authors has a relevant conflict of interest to declare. ⁎ Corresponding author at: Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St, Scaife Hall/6th Floor, Pittsburgh, PA 15261. E-mail addresses: [email protected], [email protected] (K.H. Polderman).
mend an initial fluid challenge, followed by continued fluid administration if hypotension persists or blood lactate concentration exceeds 4 mmol/L [2]. Again, CVP is often used to guide fluid volume; this, in spite of abundant evidence showing that CVP is completely unreliable as a parameter of volume status or fluid responsiveness [2-5]. In 2001, a highly influential single-center study reported that fluid and vasopressor administration using prespecified targets including a CVP of 8 to 12 and venous saturation greater than 65% in the first 6 hours of sepsis could reduce mortality by 15.8% [6]. This approach was termed early goal-directed therapy (EGDT) [6]. Recently, 2 large multicentered studies (the ProCESS trial and the ARISE trial) failed to demonstrate any benefits of the EGDT approach [7,8]; in spite of this, current guidelines still recommend EGDT, and a recent statement on behalf of the “Surviving Sepsis Campaign” panel put out after publication of the ProCESS trial suggests that no change in guidelines will be forthcoming because “the ProCESS trial used protocolized care in all study groups,” and thus, its negative findings “do not invalidate the EGDT approach” [9].
Please cite this article as: Polderman KH, Varon J, Donot drownthepatient: appropriatefluidmanagement in critical illness, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.051
2
K.H. Polderman, J. Varon / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table Diagnostic tools and methods to determine volume status and predict fluid responsiveness Clinical assessment
Devices needed
Comments
Blood pressure Heart rate Urinary output Capillary refill Peripheral temperature Neurological examination
Blood pressure cuff/arterial line Electrocardiogram/arterial line Urinary catheter N/A Temperature probe N/A
Cheap, easy to obtain; should be the basis of our assessments. However, supplemental information is often needed in more severely ill patients, especially in cases of shock with multiple causes.
Laboratory equipment (in laboratory or as point-of-care equipment)
Allows assessment of changes over time periods of several hours. Changes in lactate levels (or lack thereof) have been shown to correlate with outcome. Chlorine can be used to assess metabolic acidosis/chlorine overload.
Central venous catheter PA catheter, PiCCO, LidCO, FloTrac, echocardiography, USCOM
Poor prediction of volume status Fair prediction of volume status. Some devices (eg, FloTrac) are less reliable in patients with more severe critical illness. Fair to good prediction of volume status Fair prediction of volume status Good prediction of volume status Invasive; catheter must be removed within 96 h Fair to good prediction of volume status Good safety parameter for volume overload Fair to good prediction of volume status Good prediction of volume status
Biochemical parameters Base excess Serial lactate Serum creatinine/urea Serum chlorine
Hemodynamic monitoring CVP Cardiac output
Stroke volume variation Venous saturation Mixed venous saturation
Arterial line, PiCCO, LidCO, FloTrac Central venous and PA catheters PA catheter
Blood volume EVLW Intrathoracic blood volume Systolic/diastolic function
PiCCO, LidCO PiCCO PiCCO TEE/TTE, PiCCO, LidCO
FloTrac is a proprietary arterial waveform analysis and cardiac output monitoring system. Abbreviations: PA, pulmonary artery; PiCCO, pulse contour cardiac output; LidCO, lithium dilution cardiac output; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; USCOM, ultrasound cardiac output monitoring.
However, in recent years, a number of studies in emergency medicine and critical care have raised concerns over the practice of unrestrained fluid administration that has become so ingrained in daily practice. One of the first studies to address this issue was a clinical trial in children performed in Africa, designed to compare fluid bolus of albumin to normal saline with the hypothesis that albumin administration might improve outcome in sepsis [10]. Children receiving normal saline and albumin fluid bolus had similar outcomes, but mortality was significantly lower in children who had not received any fluid bolus [10]. As the study had been performed in poor countries in Africa, there were questions regarding the applicability of these findings to industrial countries with modern health care systems. The causes of infection, disease course, time to medical treatment, health care delivery systems, preexisting conditions, and many other factors are very different in Africa compared to Western countries. Although these criticisms are valid, other reports support the initial observations and lend credence to the hypothesis that excessive fluid administration can be detrimental. A post hoc analysis of the acute respiratory distress syndrome network (ARDS-NET) showed that a negative cumulative fluid balance at day 4 was associated with significantly lower mortality, independent of other measures of severity of illness including a diagnosis of sepsis [11]. This observation was confirmed in another study of patients with acute respiratory distress syndrome (ARDS) secondary to septic shock [12]. In fact, in this study, patients receiving fluid management considered “inadequate but conservative” had better outcomes than fluid administration considered “adequate but liberal” [12]. Similarly, in the Vasopressin vs. Norepinephrine Infusion in Patients with Septic Shock trial, a more positive fluid balance both early in resuscitation and cumulatively over 4 days was associated with increased risk of mortality in septic shock, corrected for other factors [13]. This does not just apply to sepsis. A recent meta-analysis of randomized controlled trials and cohort studies and cohort studies found that conservative fluid strategies were associated with lower mortality in trauma patients [14]. In addition, it is not only unrestrained crystalloid infusion that is being called into question; a recent study reported that transfusion of red blood cells was associated with significantly worse outcomes in patients with traumatic brain injury and no evidence of
shock if the initial hemoglobin was greater than 10 g/dL [15]. Twenty years ago, Bickell et al [16] challenged the practice of early fluid resuscitation in patients with penetrating injuries, suggesting that this practice might be linked to increased bleeding and adverse outcomes. This issue still remains controversial [17]. In this issue of The American Journal of Emergency Medicine, Sirvent [18] reports on the effects of fluid administration at the onset of severe sepsis and septic shock. The author found that the accumulated positive fluid balance in the first 48, 72, and 96 hours was significantly associated with increased mortality [18]. These results are in keeping with the results discussed above and remind us again of the risks of “iatrogenic submersion.” How can we avoid this risk, while still giving our patients the fluids that they may need? In our view, the key lies in a multipronged approach, using clinical judgment along with sophisticated monitoring tools to guide our treatment. The first step is awareness and restraint: awareness that excessive fluid administration could be harmful, and restraint in the restraint in the reflexive administration of fluids. If a patient does not respond to a bolus of fluid, we should think twice before giving yet more fluids or trying yet another fluid challenge; instead, we might consider earlier initiation of pressors or perhaps accepting less ambitious target values. Especially, we should not target specific CVPs to guide treatment; rather, a combination of clinical and biochemical parameters and more sophisticated hemodynamic monitoring (echocardiography, cardiac output, extravascular lung water [EVLW], and stroke volume variation) can be used to better tailor our therapeutic approach (see Table). Fluid responsiveness can be assessed with smaller volumes (100-250 mL administered rapidly, rather than 500-1000 mL as is common practice). Monitoring of EVLW may be a valuable safety parameter to prevent fluid overload. A recent study in ARDS patients suggests that high EVLW is an independent risk factor for mortality in ARDS [19]. This approach may also apply to less sick patients; to take the earlier example of subarachnoid hemorrhage, a recent randomized controlled trial reported significantly improved outcomes using preload volume and cardiac output (monitored by transpulmonary thermodilution) to guide treatments compared to patients where “traditional” parameters such as fluid balance and CVP were used [20]. Noninvasive devices such
Please cite this article as: Polderman KH, Varon J, Donot drownthepatient: appropriatefluidmanagement in critical illness, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.051
K.H. Polderman, J. Varon / American Journal of Emergency Medicine xxx (2015) xxx–xxx
as continuous wave Doppler ultrasound cardiac output monitoring may also have a useful role in cardiac output monitoring [21,22]. Mortality was significantly lower in all arms of the ProCESS trial than in the initial EGDT study [6,7]. In the EGDT arm of the ProCESS trial, the use of vasopressors in the first 6 hours was double (54.9% vs 27.4%), and the volume infused in the first 72 hours half (7.22 vs 13.44 L) compared to the EGDT study. This suggests that more restrictive fluid management is feasible even when using a judicious EGDT approach. We urge the readers to take to heart the important lessons of Sirvent and from previous trials and not to use too much of a good thing.
References [1] Meyer R, Deem S, Yanez ND, Souter M, Lam A, Treggiari MM. Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. Neurocrit Care 2011;14:24–36. [2] Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637. [3] Shippy CR, Appel PL, Shoemaker WC. Reliability of clinical monitoring to assess blood volume in critically ill patients. Crit Care Med 1984;12:107–12. [4] Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007;35:64–8. [5] Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013;41:1774–81. [6] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. [7] The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683–93. [8] ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496–506.
3
[9] Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to ProCESS trial. Updated May 19, 2014 http://www.survivingsepsis.org/SiteCollectionDocuments/ SSC-RespondsProcess-Trial.pdf. [Accessed November 28, 2014]. [10] Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483–95. [11] Rosenberg AL, Dechert RE, Park PK, Bartlett RH, NIH NHLBI ARDS Network. Review of a large clinical series: association of cumulative fluid balance on outcome in acute lung injury: a retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009;24:35–46. [12] Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009;136:102–9. [13] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [14] Wang CH, Hsieh WH, Chou HC, Huang YS, Shen JH, Yeo YH, et al. Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies. Crit Care Med 2014;42:954–62. [15] Elterman J, Brasel K, Brown S, et al. Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes. J Trauma Acute Care Surg 2013;75:8–14. [16] Bickell WH, Wall Jr MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105–9. [17] Kwan I, Bunn F, Chinnock P, Roberts I. Timing and volume of fluid administration for patients with bleeding. Cochrane Database Syst Rev 2014;3:CD002245. [18] Sirvent JM. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2015. [19] Jozwiak M, Silva S, Persichini R, et al. Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome. Crit Care Med 2013;41:472–80. [20] Mutoh T, Kazumata K, Terasaka S, Taki Y, Suzuki A, Ishikawa T. Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage. Stroke 2014;45:1280–4. [21] Udy AA, Altukroni M, Jarrett P, Roberts JA, Lipman J. A comparison of pulse contour wave analysis and ultrasonic cardiac output monitoring in the critically ill. Anaesth Intensive Care 2012;40:631–7. [22] Chong SW, Peyton PJ. A meta-analysis of the accuracy and precision of the ultrasonic cardiac output monitor (USCOM). Udy AA1, Altukroni M, Jarrett P, Roberts JA, Lipman J Anaesthesia 2012;67:1266–71.
Please cite this article as: Polderman KH, Varon J, Donot drownthepatient: appropriatefluidmanagement in critical illness, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.051
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Controversies
Do not drown the patient: appropriate fluid management in critical illness☆ Kees H. Polderman, MD, PhD⁎, Joseph Varon, MD Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA The University of Texas Health Science Center at Houston, Houston, TX, USA The University of Texas Medical Branch at Galveston, Galveston, TX, USA University General Hospital, Houston, TX, USA
a r t i c l e
i n f o
Article history: Received 29 November 2014 Received in revised form 28 January 2015 Accepted 29 January 2015 Available online xxxx
a b s t r a c t Administering intravenous fluids to support the circulation in critically ill patients has been a mainstay of emergency medicine and critical care for decades, especially (but not exclusively) in patients with distributive or hypovolemic shock. However, in recent years, this automatic use of large fluid volumes is beginning to be questioned. Analysis from several large trials in severe sepsis and/or acute respiratory distress syndrome have shown independent links between volumes of fluid administered and outcome; conservative fluid strategies have also been associated with lower mortality in trauma patients. In addition, it is becoming ever more clear that central venous pressure, which is often used to guide fluid administration, is a completely unreliable parameter of volume status or fluid responsiveness. Furthermore, 2 recently published large multicenter trials (ARISE and ProCESS) have discredited the “early goal-directed therapy” approach, which used prespecified targets of central venous pressure and venous saturation to guide fluid and vasopressor administration. This article discusses the risks of “iatrogenic submersion” and strategies to avoid this risk while still giving our patients the fluids they need. The key lies in combining good clinical judgement, awareness of the potential harm from excessive fluid use, restraint in reflexive administration of fluids, and use of data from sophisticated monitoring tools such as echocardiography and transpulmonary thermodilution. Use of smaller volumes to perform fluid challenges, monitoring of extravascular lung water, earlier use of norepinephrine, and other strategies can help further reduce morbidity and mortality from severe sepsis. © 2015 Elsevier Inc. All rights reserved.
One of the most challenging and controversial areas in the care of emergent and critically ill patients is the administration of intravenous fluids to support the circulation. This does not only apply to hemodynamically unstable patients. In clinical conditions such as subarachnoid hemorrhage, large volumes of fluid are often administered over prolonged periods to reduce the risk of vasospasm, often targeting a positive fluid balance or a specific central venous pressure (CVP) [1]. However, especially when a patient presents with a distributive or hypovolemic shock, rapid administration of fluids is one of the mainstays of treatment, one that has been recommended for decades. This applies to both the initial and later phases of treatment, especially in distributive shock. The 2012 “Surviving Sepsis Campaign” guidelines recom-
☆ Disclosures: Neither of the authors has a relevant conflict of interest to declare. ⁎ Corresponding author at: Department of Critical Care Medicine, University of Pittsburgh Medical Center, 3550 Terrace St, Scaife Hall/6th Floor, Pittsburgh, PA 15261. E-mail addresses: [email protected], [email protected] (K.H. Polderman).
mend an initial fluid challenge, followed by continued fluid administration if hypotension persists or blood lactate concentration exceeds 4 mmol/L [2]. Again, CVP is often used to guide fluid volume; this, in spite of abundant evidence showing that CVP is completely unreliable as a parameter of volume status or fluid responsiveness [2-5]. In 2001, a highly influential single-center study reported that fluid and vasopressor administration using prespecified targets including a CVP of 8 to 12 and venous saturation greater than 65% in the first 6 hours of sepsis could reduce mortality by 15.8% [6]. This approach was termed early goal-directed therapy (EGDT) [6]. Recently, 2 large multicentered studies (the ProCESS trial and the ARISE trial) failed to demonstrate any benefits of the EGDT approach [7,8]; in spite of this, current guidelines still recommend EGDT, and a recent statement on behalf of the “Surviving Sepsis Campaign” panel put out after publication of the ProCESS trial suggests that no change in guidelines will be forthcoming because “the ProCESS trial used protocolized care in all study groups,” and thus, its negative findings “do not invalidate the EGDT approach” [9].
Please cite this article as: Polderman KH, Varon J, Donot drownthepatient: appropriatefluidmanagement in critical illness, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.051
2
K.H. Polderman, J. Varon / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table Diagnostic tools and methods to determine volume status and predict fluid responsiveness Clinical assessment
Devices needed
Comments
Blood pressure Heart rate Urinary output Capillary refill Peripheral temperature Neurological examination
Blood pressure cuff/arterial line Electrocardiogram/arterial line Urinary catheter N/A Temperature probe N/A
Cheap, easy to obtain; should be the basis of our assessments. However, supplemental information is often needed in more severely ill patients, especially in cases of shock with multiple causes.
Laboratory equipment (in laboratory or as point-of-care equipment)
Allows assessment of changes over time periods of several hours. Changes in lactate levels (or lack thereof) have been shown to correlate with outcome. Chlorine can be used to assess metabolic acidosis/chlorine overload.
Central venous catheter PA catheter, PiCCO, LidCO, FloTrac, echocardiography, USCOM
Poor prediction of volume status Fair prediction of volume status. Some devices (eg, FloTrac) are less reliable in patients with more severe critical illness. Fair to good prediction of volume status Fair prediction of volume status Good prediction of volume status Invasive; catheter must be removed within 96 h Fair to good prediction of volume status Good safety parameter for volume overload Fair to good prediction of volume status Good prediction of volume status
Biochemical parameters Base excess Serial lactate Serum creatinine/urea Serum chlorine
Hemodynamic monitoring CVP Cardiac output
Stroke volume variation Venous saturation Mixed venous saturation
Arterial line, PiCCO, LidCO, FloTrac Central venous and PA catheters PA catheter
Blood volume EVLW Intrathoracic blood volume Systolic/diastolic function
PiCCO, LidCO PiCCO PiCCO TEE/TTE, PiCCO, LidCO
FloTrac is a proprietary arterial waveform analysis and cardiac output monitoring system. Abbreviations: PA, pulmonary artery; PiCCO, pulse contour cardiac output; LidCO, lithium dilution cardiac output; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; USCOM, ultrasound cardiac output monitoring.
However, in recent years, a number of studies in emergency medicine and critical care have raised concerns over the practice of unrestrained fluid administration that has become so ingrained in daily practice. One of the first studies to address this issue was a clinical trial in children performed in Africa, designed to compare fluid bolus of albumin to normal saline with the hypothesis that albumin administration might improve outcome in sepsis [10]. Children receiving normal saline and albumin fluid bolus had similar outcomes, but mortality was significantly lower in children who had not received any fluid bolus [10]. As the study had been performed in poor countries in Africa, there were questions regarding the applicability of these findings to industrial countries with modern health care systems. The causes of infection, disease course, time to medical treatment, health care delivery systems, preexisting conditions, and many other factors are very different in Africa compared to Western countries. Although these criticisms are valid, other reports support the initial observations and lend credence to the hypothesis that excessive fluid administration can be detrimental. A post hoc analysis of the acute respiratory distress syndrome network (ARDS-NET) showed that a negative cumulative fluid balance at day 4 was associated with significantly lower mortality, independent of other measures of severity of illness including a diagnosis of sepsis [11]. This observation was confirmed in another study of patients with acute respiratory distress syndrome (ARDS) secondary to septic shock [12]. In fact, in this study, patients receiving fluid management considered “inadequate but conservative” had better outcomes than fluid administration considered “adequate but liberal” [12]. Similarly, in the Vasopressin vs. Norepinephrine Infusion in Patients with Septic Shock trial, a more positive fluid balance both early in resuscitation and cumulatively over 4 days was associated with increased risk of mortality in septic shock, corrected for other factors [13]. This does not just apply to sepsis. A recent meta-analysis of randomized controlled trials and cohort studies and cohort studies found that conservative fluid strategies were associated with lower mortality in trauma patients [14]. In addition, it is not only unrestrained crystalloid infusion that is being called into question; a recent study reported that transfusion of red blood cells was associated with significantly worse outcomes in patients with traumatic brain injury and no evidence of
shock if the initial hemoglobin was greater than 10 g/dL [15]. Twenty years ago, Bickell et al [16] challenged the practice of early fluid resuscitation in patients with penetrating injuries, suggesting that this practice might be linked to increased bleeding and adverse outcomes. This issue still remains controversial [17]. In this issue of The American Journal of Emergency Medicine, Sirvent [18] reports on the effects of fluid administration at the onset of severe sepsis and septic shock. The author found that the accumulated positive fluid balance in the first 48, 72, and 96 hours was significantly associated with increased mortality [18]. These results are in keeping with the results discussed above and remind us again of the risks of “iatrogenic submersion.” How can we avoid this risk, while still giving our patients the fluids that they may need? In our view, the key lies in a multipronged approach, using clinical judgment along with sophisticated monitoring tools to guide our treatment. The first step is awareness and restraint: awareness that excessive fluid administration could be harmful, and restraint in the restraint in the reflexive administration of fluids. If a patient does not respond to a bolus of fluid, we should think twice before giving yet more fluids or trying yet another fluid challenge; instead, we might consider earlier initiation of pressors or perhaps accepting less ambitious target values. Especially, we should not target specific CVPs to guide treatment; rather, a combination of clinical and biochemical parameters and more sophisticated hemodynamic monitoring (echocardiography, cardiac output, extravascular lung water [EVLW], and stroke volume variation) can be used to better tailor our therapeutic approach (see Table). Fluid responsiveness can be assessed with smaller volumes (100-250 mL administered rapidly, rather than 500-1000 mL as is common practice). Monitoring of EVLW may be a valuable safety parameter to prevent fluid overload. A recent study in ARDS patients suggests that high EVLW is an independent risk factor for mortality in ARDS [19]. This approach may also apply to less sick patients; to take the earlier example of subarachnoid hemorrhage, a recent randomized controlled trial reported significantly improved outcomes using preload volume and cardiac output (monitored by transpulmonary thermodilution) to guide treatments compared to patients where “traditional” parameters such as fluid balance and CVP were used [20]. Noninvasive devices such
Please cite this article as: Polderman KH, Varon J, Donot drownthepatient: appropriatefluidmanagement in critical illness, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.051
K.H. Polderman, J. Varon / American Journal of Emergency Medicine xxx (2015) xxx–xxx
as continuous wave Doppler ultrasound cardiac output monitoring may also have a useful role in cardiac output monitoring [21,22]. Mortality was significantly lower in all arms of the ProCESS trial than in the initial EGDT study [6,7]. In the EGDT arm of the ProCESS trial, the use of vasopressors in the first 6 hours was double (54.9% vs 27.4%), and the volume infused in the first 72 hours half (7.22 vs 13.44 L) compared to the EGDT study. This suggests that more restrictive fluid management is feasible even when using a judicious EGDT approach. We urge the readers to take to heart the important lessons of Sirvent and from previous trials and not to use too much of a good thing.
References [1] Meyer R, Deem S, Yanez ND, Souter M, Lam A, Treggiari MM. Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. Neurocrit Care 2011;14:24–36. [2] Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580–637. [3] Shippy CR, Appel PL, Shoemaker WC. Reliability of clinical monitoring to assess blood volume in critically ill patients. Crit Care Med 1984;12:107–12. [4] Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med 2007;35:64–8. [5] Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013;41:1774–81. [6] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. [7] The ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014;370:1683–93. [8] ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, Bellomo R, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496–506.
3
[9] Surviving Sepsis Campaign. Surviving Sepsis Campaign responds to ProCESS trial. Updated May 19, 2014 http://www.survivingsepsis.org/SiteCollectionDocuments/ SSC-RespondsProcess-Trial.pdf. [Accessed November 28, 2014]. [10] Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483–95. [11] Rosenberg AL, Dechert RE, Park PK, Bartlett RH, NIH NHLBI ARDS Network. Review of a large clinical series: association of cumulative fluid balance on outcome in acute lung injury: a retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009;24:35–46. [12] Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009;136:102–9. [13] Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259–65. [14] Wang CH, Hsieh WH, Chou HC, Huang YS, Shen JH, Yeo YH, et al. Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies. Crit Care Med 2014;42:954–62. [15] Elterman J, Brasel K, Brown S, et al. Transfusion of red blood cells in patients with a prehospital Glasgow Coma Scale score of 8 or less and no evidence of shock is associated with worse outcomes. J Trauma Acute Care Surg 2013;75:8–14. [16] Bickell WH, Wall Jr MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105–9. [17] Kwan I, Bunn F, Chinnock P, Roberts I. Timing and volume of fluid administration for patients with bleeding. Cochrane Database Syst Rev 2014;3:CD002245. [18] Sirvent JM. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med 2015. [19] Jozwiak M, Silva S, Persichini R, et al. Extravascular lung water is an independent prognostic factor in patients with acute respiratory distress syndrome. Crit Care Med 2013;41:472–80. [20] Mutoh T, Kazumata K, Terasaka S, Taki Y, Suzuki A, Ishikawa T. Early intensive versus minimally invasive approach to postoperative hemodynamic management after subarachnoid hemorrhage. Stroke 2014;45:1280–4. [21] Udy AA, Altukroni M, Jarrett P, Roberts JA, Lipman J. A comparison of pulse contour wave analysis and ultrasonic cardiac output monitoring in the critically ill. Anaesth Intensive Care 2012;40:631–7. [22] Chong SW, Peyton PJ. A meta-analysis of the accuracy and precision of the ultrasonic cardiac output monitor (USCOM). Udy AA1, Altukroni M, Jarrett P, Roberts JA, Lipman J Anaesthesia 2012;67:1266–71.
Please cite this article as: Polderman KH, Varon J, Donot drownthepatient: appropriatefluidmanagement in critical illness, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.051
