How I personalize fluid therapy in septic shock?

Abstract

During septic shock, fluid therapy is aimed at increasing cardiac output and improving tissue oxygenation, but it poses two problems: it has inconsistent and transient efficacy, and it has many well-documented deleterious effects. We suggest that there is a place for its personalization according to the patient characteristics and the clinical situation, at all stages of circulatory failure. Regarding the choice of fluid for volume expansion, isotonic saline induces hyperchloremic acidosis, but only for very large volumes administered. We suggest that balanced solutions should be reserved for patients who have already received large volumes and in whom the chloremia is rising. The initial volume expansion, intended to compensate for the constant hypovolaemia in the initial phase of septic shock, cannot be adapted to the patient’s weight only, as suggested by the Surviving Sepsis Campaign, but should also consider potential absolute hypovolemia induced by fluid losses. After the initial fluid infusion, preload responsiveness may rapidly disappear, and it should be assessed. The choice between tests used for this purpose depends on the presence or absence of mechanical ventilation, the monitoring in place and the risk of fluid accumulation. In non-intubated patients, the passive leg raising test and the mini-fluid challenge are suitable. In patients without cardiac output monitoring, tests like the tidal volume challenge, the passive leg raising test and the mini-fluid challenge can be used as they can be performed by measuring changes in pulse pressure variation, assessed through an arterial line. The mini-fluid challenge should not be repeated in patients who already received large volumes of fluids. The variables to assess fluid accumulation depend on the clinical condition. In acute respiratory distress syndrome, pulmonary arterial occlusion pressure, extravascular lung water and pulmonary vascular permeability index assess the risk of worsening alveolar oedema better than arterial oxygenation. In case of abdominal problems, the intra-abdominal pressure should be taken into account. Finally, fluid depletion in the de-escalation phase is considered in patients with significant fluid accumulation. Fluid removal can be guided by preload responsiveness testing, since haemodynamic deterioration is likely to occur in patients with a preload dependent state.

Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

“…The recent CLOVERS and CLASSIC trials found that fluid-liberal vs fluid-restrictive, vasopressor-early approaches result in similar patient outcomes. However, these trials have been criticized for their generalized approach to resuscitation, leading experts to call for personalization . At this time, there is no standard, accepted strategy for personalization.…”

“…However, these trials have been criticized for their generalized approach to resuscitation, leading experts to call for personalization. 22 , 23 At this time, there is no standard, accepted strategy for personalization. Many have suggested that clinical factors may help guide resuscitation.…”

Dynamic changes of hepatic vein Doppler velocities predict preload responsiveness in mechanically ventilated critically ill patients

“…Even though the fluid challenge has been praised as a gold-standard technique, both the physiological determinants of PLR (± 300 ml of autotransfusion) and the diagnostic accuracy of its’ derived measurements (sensitivities and specificities > 85%) [ 24 ], provide a comparable alternative. This approach has already been used in the contemporary literature of diagnostic accuracy of preload responsiveness tests [ 46 , 47 ], and has the added benefit of avoiding potential deleterious fluids [ 48 , 49 ] to patients which are preload unresponsive. Another potential criticism could be the use of non-calibrated CO monitors such as those used in this study.…”

Fluid removal tolerance during the de-escalation phase: is preload unresponsiveness the best guiding candidate?

“…We read with great interest the recent article by Monnet et al [ 1 ] extensively reviewing the various facets of personalized fluid therapy during septic shock. Subsequently, we would like to discuss the management of fluid removal guided by preload responsiveness, specifically regarding the net ultrafiltration (UFnet) set-up in critically-ill patients with continuous renal replacement therapy (CRRT).…”