The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid!

Marik, Paul E.; Malbrain, Manu L N G

doi:10.5603/ait.a2017.0056

Cited by 31 publications

(15 citation statements)

References 40 publications

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“…As such, it has been disseminated internationally as the standard of care for early sepsis management. Recently, a trio of trials (ProCESS [ 51 ], ARISE [ 52 ] and ProMISe [ 53 ]), while reporting an all-time low sepsis mortality, showed no improvement in outcomes with EGDT, questioning the need and pointing towards the potential dangers of protocolized care for patients with severe and septic shock [ 54 , 55 ]. A recent study employing a combined Bayesian and frequentist methodological approach to evaluate 12 randomized trials and 31 observational studies found that EGDT was potentially harmful in the patients with the highest disease severity [ 56 ].…”

Section: The Four Phases Of Fluid Therapymentioning

confidence: 99%

“…In fact, rather than infusing a predefined given amount of fluid, the goal should be individualized for every patient, based on the evaluation of the need for fluids and on the patient’s premorbid conditions [ 16 , 55 , 61 – 64 ]. In this phase, on an individual basis for each patient, we try to find an answer to the first question: “When to start fluid therapy?”…”

Section: The Four Phases Of Fluid Therapymentioning

confidence: 99%

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Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy

Malbrain

Regenmortel

Saugel

et al. 2018

Ann. Intensive Care

418

306

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In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose and timing of intravenous fluid administration. There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications and for parenteral nutrition. In this paradigm-shifting review, we discuss different fluid management strategies including early adequate goal-directed fluid management, late conservative fluid management and late goal-directed fluid removal. In addition, we expand on the concept of the “four D’s” of fluid therapy, namely drug, dosing, duration and de-escalation. During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase and the evacuation phase. The four questions are “When to start intravenous fluids?”, “When to stop intravenous fluids?”, “When to start de-resuscitation or active fluid removal?” and finally “When to stop de-resuscitation?” In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.

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Section: The Four Phases Of Fluid Therapymentioning

confidence: 99%

Section: The Four Phases Of Fluid Therapymentioning

confidence: 99%

Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy

Malbrain

Regenmortel

Saugel

et al. 2018

Ann. Intensive Care

418

306

View full text Add to dashboard Cite

show abstract

“…In addition, four phases of fluid therapy, regarding early or late conservative fluid management, have been suggested [8]. However, there are controversies regarding the optimal timing of fluid resuscitation among early adequate goal-directed fluid management (e.g., 4 mL/kg/15 min-30 mL/kg/3 h) [9], late conservative fluid management (defined as 2 consecutive negative FBs) [10], and late goal-directed fluid removal [11][12][13]. Thus, the optimal fluid management strategy remains controversial, and there are insufficient studies regarding the outcomes of these strategies.…”

Section: Introductionmentioning

confidence: 99%

Association of perioperative weight-based fluid balance with 30-day mortality and acute kidney injury among patients in the surgical intensive care unit

Song

Hwan

et al. 2019

J Anesth

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Purpose Perioperative positive fluid balance has negative effects on short-term outcomes, such as surgical complications, although the associations with postoperative mortality remain unclear. This study evaluated the associations of perioperative fluid balance (FB) with 30-day mortality and acute kidney injury (AKI) after postoperative intensive care unit (ICU) admission. Methods This retrospective study evaluated data from adult patients who were admitted to the ICU after surgery during 2012-2016. Weight-based cumulative FB (%) was calculated for 3 time periods [postoperative day (POD) 0 (24 h), 0-1 (48 h), and 0-2 (72 h)] and was categorized as positive (≥ 5%), mild to moderate positive (5-10%), severe positive (> 10%), normal (0-5%), or negative (< 0%). Results Data from 7896 patients were included in the analysis. The multivariable Cox regression model revealed that increased 30-day mortality was associated with positive FB groups (≥ 5%) compared to normal FB groups (0-5%) during 3 time periods [hazard ratio (HR) on

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“…There are protocols for intravenous fluid therapy [22], but their uniform application implies giving the same volume to different patients and in different circumstances. To address the uniqueness of each patient and situation, rather than infusing a predefined amount of fluid, the goal should be to tailor fluid infusion based on a needs analysis [23,24].…”

Section: Introductionmentioning

confidence: 99%

Bio-electrical impedance analysis for perioperative fluid evaluation in open major abdominal surgery

Ciumanghel

Grigoraş

Siriopol

et al. 2019

J Clin Monit Comput

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Water retention and intercompartmental redistribution occur frequently in association with adverse postoperative outcomes, yet the available strategies for non-invasive assessment are limited. One such approach for evaluating body water composition in various circumstances is bio-electrical impedance analysis (BIA). This study aims to appraise the usefulness of the Body Composition Monitor (BCM, Fresenius Medical Care, Germany) in assessing body fluid composition and intercompartmental shifts before and after open major abdominal surgery. This prospective, clinician blinded observational study enrolled all the patients scheduled consecutively for elective major open abdominal surgery during a 1-year period starting from January 1st, 2016. BIA parameters-total body water (TBW), extracellular water (ECW), intracellular water (ICW), absolute fluid overload (AFO), and relative fluid overload (RFO) were measured before and after surgery. The results were compared with fluid balance and outcome parameters such as organ dysfunction, ICU-and hospital length of stay (-LOS). The study population included 71 patients aged 60.2 ± 12 of whom 60.6% men and with a BMI of 26.3 ± 5.1 kg/m 2 . Postoperative acute kidney injury, respiratory dysfunction, and infections occurred in 14.0%, 19.7% and 28.1% of cases, respectively. The median LOS in ICU was 20 h and the hospital-LOS was 10 days. Positive intraoperative fluid balance (2.4 ± 1.0 L) resulted in a significant increase of TBW (1.4 ± 2.4 L) and of ECW (1.4 ± 1.2 L). Intraoperative fluid balance significantly correlated with TBW change (r = 0.23, p = 0.04) and with AFO change (r = 0.31, p < 0.01). A significant correlation was found between pre-and postoperative AFO and RFO on one hand, and ICU-LOS on the other. BIA may be a useful tool for the perioperative assessment of volume status.

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The SEP-1 quality mandate may be harmful: How to drown a patient with 30 mL per kg fluid!

Cited by 31 publications

References 40 publications

Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy

Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy

Association of perioperative weight-based fluid balance with 30-day mortality and acute kidney injury among patients in the surgical intensive care unit

Bio-electrical impedance analysis for perioperative fluid evaluation in open major abdominal surgery

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