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The Great(est) Fluid Debate
Resuscitation fluids save lives in humans with life-threatening hypovolaemia. The fluid of choice should have biochemical characteristics close to the type of fluid lost and replaced at a rate and volume sufficient to correct severe fluid deficit. Then stop and consider the early use of catecholamines. There are few indications to give critically ill patients resuscitation fluids after 24 hours of admission. There is no place for synthetic colloids of non-physiological crystalloids. The effects of unnecessary fluids last well beyond the initial resuscitation period and are associated with adverse effects and harm to the patient. Fluids are toxic drugs and must be used with great care.
The Great(est) Fluid Debate
- 1. The greatest fluiddebate @DogICUma @toddrice_ICU @JAMyburgh
- 2. The greatest fluiddebate @srrezaie @DogICUma @toddrice_ICU @JAMyburgh
- 3. The greatest fluidchat @DogICUma @toddrice_ICU @JAMyburgh
- 4. 45 year olddiabetic male Severe generalised abdominal pain Vomiting Rigors Calls an ambulance
- 6. High heart rate –140bpm High fever – 39°C Low blood pressure – 78/40
- 8.
- 9. Fluids first vs. Fluids +pressors vs. Pressors first
- 11. An echo ismandatory vs. An echo is generally helpful vs. An echo is generally unhelpful
- 12.
- 13. 8L +ve &8kg heavier On mod. dose noradrenaline Intravascularly deplete
- 14.
Editor's Notes
- #2 The title of this session is ‘the greatest fluid debate’ but we are all friends here and agree about everything all of the time so, it’s really more of a chat.
- #3 We hope you will get involved. Please send questions and comments to the Twitter moderator
- #4 We hope you will get involved.
- #5 Ambulance comes. Patient looks sick.
- #8 The sick patient arrives in hospital.
- #9 The provisional diagnosis here is septic shock with a primary abdominal source
- #10 “So, you might have noticed that this icon is called ‘saline drip’. I want to put that to one side for now. John / Todd – let’s start with a philosophical discussion. In general terms, tell us which camp you belong to and why?” Among other things, I think that this would be an opportunity to talk about the CENSER trial: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201806-1034OC & the REFRESH pilot RCT: https://link.springer.com/article/10.1007%2Fs00134-018-5433-0 There are also couple of recent retrospective studies that highlight the association between duration of hypotension and mortality that could be mentioned: https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-018-0448-9 https://link.springer.com/article/10.1007%2Fs00134-018-5218-5 We could a twitter Poll or take some comments from Twitter here.
- #11 While the philosophical discussion is ongoing, the emergency physician swoops in with an ultrasound machine and says, “look, the patient is hypovolaemic and needs volume”. Todd/John – any thoughts or comments. “Vigorous empty ventricle from low SVR and from hypovolaemia look the same – my view is that this echo actually does not help much apart from confirming appearances are consistent with septic shock. Still don’t know whether this means we should give fluid.”
- #12 ...and where do you stand on this spectrum. Twitter comments / questions? Twitter poll?
- #13 “So, let’s just say you decide to give a fluid bolus. Let’s talk about this. Todd, you go first...” Twitter comments? Live Twitter Poll?
- #14 Some time later the patient, who has been to the OR and had a gangrenous perforated appendix chopped out, is in the ICU. Using your expert clinical judgement you decide that the patient has a combination of total body fluid overload and intravascular depletion. Where do you stand on fluid boluses for this patient? Twitter comments? Live Twitter Poll? Once the time comes to take fluid away, where do you stand on diuretics? Twitter comments? Live Twitter Poll?