Fluid Stewardship During Critical Illness: A Call to Action

Abstract

Intravenous fluids (IVFs) are the most common drugs administered in the intensive care unit. Despite the ubiquitous use, IVFs are not benign and carry significant risks associated with under- or overadministration. Hypovolemia is associated with decreased organ perfusion, ischemia, and multi-organ failure. Hypervolemia and volume overload are associated with organ dysfunction, delayed liberation from mechanical ventilation, and increased mortality. Despite appropriate provision of IVF, adverse drug effects such as electrolyte abnormalities and acid–base disturbances may occur. The management of volume status in critically ill patients is both dynamic and tenuous, a process that requires frequent monitoring and high clinical acumen. Because patient-specific considerations for fluid therapy evolve across the continuum of critical illness, a standard approach to the assessment of fluid needs and prescription of IVF therapy is necessary. We propose the principle of “fluid stewardship,” guided by 4 rights of medication safety: right patient, right drug, right route, and right dose. The successful implementation of fluid stewardship will aid pharmacists in making decisions regarding IVF therapy to optimize hemodynamic management and improve patient outcomes. Additionally, we highlight several areas of focus for future research, guided by the 4 rights construct of fluid stewardship.

Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients

“…Managing volume status in patients with critical illness is a dynamic and delicate exercise that necessitates frequent monitoring and sound clinical judgment 21 .The "fluid balance method" is the approach most widely used for managing volume replacement by fluid infusion during intensive care or perioperatively. Perceived needs and losses are summarized continuously and volume is substituted with crystalloids and colloids in proportion to their respective plasma-volumeexpanding properties.…”

“…It is well known that fluid overload, positive fluid balance, morbidity and mortality are interrelated. Organ dysfunction, prolonged mechanical ventilation, and higher mortality may result from volume overload and hypervolemia 21,22 . When compared with zero fluid balance, positive fluid balance after cardiac surgery was associated with increased incidence of acute kidney injury (AKI) 30 , suggesting that fluid retention may be causally interrelated with AKI, contributing to renal retention and weight gain.…”

“…The scope of this narrative review is to describe current volume resuscitation strategies and the roles of HSA solutions. It focuses on hypovolemia and its correction in perioperative and critically ill patients, as opposed to hypervolemia, which can also have detrimental effects in these patients 21,22 . It is important to emphasize that fluid therapy is context-dependent and management varies across different clinical settingsdata cannot therefore be easily extrapolated to other patient populations which may be distinct.…”

Factors Affecting Weaning Failure in Critically-Ill Patients Undergoing Emergency Gastrointestinal Surgery

“…It is known that induced thoracic hypervolemia increases mechanical respiratory workload and airway pressure, even in normal individuals (25). It is also well known that hypervolemia and volume overload are associated with increased organ dysfunction in critically ill patients, increased weaning time and total time of weaning, as well as an increase in infectious complications and mortality (26). The effects of hypervolemia on the outcomes of critically ill patients have been investigated in medical patients, although there is a paucity of studies in this field.…”

“…The effects of hypervolemia on the outcomes of critically ill patients have been investigated in medical patients, although there is a paucity of studies in this field. In a study involving 144 patients underwent emergency surgery, Barmparas et al (26) could find no effect of positive fluid balance on total mortality (11% negative fluid balance vs 15.5% positive fluid balance, p = 0.422), but when evaluated together with other accompanying factors, negative fluid balance was found to provide survival benefit by 70% in the first five days of surgery and negative fluid balance on the first day of surgery provided survival benefit, but also reduced infectious complications [95% confidence interval 0.63 (0.45, 0.88); p= 0.006 and 0.64 (0.46, 0.90); p=0.010 respectively) (26). In the same study, MV time and length of ICU stay were found to be longer in patients with a positive fluid balance and prolonged MV was found to be an independent risk factor for mortality in of surgical patients.…”