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Personalised fluid resuscitation in the ICU: still a fluid concept?

ABSTRACT: The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful.New data from basic, animal, and clinical research suggest that fluid resuscitation could be associated with significant harm. There are several important limitations and concerns regarding fluid bolus therapy as it is currently being used in clinical practice. These include, but are not limited to: the lack of an agreed definition; limited and short-lived physiological effects; no evidence of an effect on relevant patient outcomes; and the potential to contribute to fluid overload, specifically when fluid responsiveness is not assessed and when targets and safety limits are not used.Fluid administration in critically ill patients requires clinicians to integrate abnormal physiological parameters into a clinical decision-making model that also incorporates the likely diagnosis and the likely risk or benefit in the specific patient's context. Personalised fluid resuscitation requires careful attention to the mnemonic CIT TAIT: context, indication, targets, timing, amount of fluid, infusion strategy, and type of fluid.The research agenda should focus on experimental and clinical studies to: improve our understanding of the physiological effects of fluid infusion, e.g. on the glycocalyx; evaluate new types of fluids; evaluate novel fluid minimisation protocols; study the effects of a no-fluid strategy for selected patients and scenarios; and compare fluid therapy with other interventions. The adaptive platform trial design may provide us with the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous.

SUBMITTER: van Haren F

PROVIDER: S-EPMC5751583 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Personalised fluid resuscitation in the ICU: still a fluid concept?

van Haren Frank F

Critical care (London, England) 20171228 Suppl 3

The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful.New data from basic, animal, and cli ...[more]

PMID: 29297387

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Project description:BackgroundHalf of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes in children receiving CPR for bradycardia with poor perfusion; and (2) describe the incidence and time course of the development of pulselessness.MethodsPrespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of children (< 19 years) receiving CPR in 18 intensive care units in the United States. Index events (October 2016-March 2021) lasting ≥ 2 min with a documented initial rhythm of bradycardia with poor perfusion were included. Associations between early epinephrine (first 2 min of CPR) and outcomes were evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics. Among patients with arterial lines, intra-arrest blood pressure waveforms were reviewed to determine presence of a pulse during CPR interruptions. The temporal nature of progression to pulselessness was described and outcomes were compared between patients according to subsequent pulselessness status.ResultsOf 452 eligible subjects, 322 (71%) received early epinephrine. The early epinephrine group had higher pre-arrest severity of illness and vasoactive-inotrope scores. Early epinephrine was not associated with survival to discharge (aRR 0.97, 95%CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95%CI 0.82, 1.18). Among 186 patients with invasive blood pressure waveforms, 118 (63%) had at least 1 period of pulselessness during the first 10 min of CPR; 86 (46%) by 2 min and 100 (54%) by 3 min. Sustained return of spontaneous circulation was highest after bradycardia with poor perfusion (84%) compared to bradycardia with poor perfusion progressing to pulselessness (43%) and bradycardia with poor perfusion progressing to pulselessness followed by return to bradycardia with poor perfusion (62%) (p < 0.001).ConclusionsIn this cohort of pediatric CPR events with an initial rhythm of bradycardia with poor perfusion, we failed to identify an association between early bolus epinephrine and outcomes when controlling for illness severity. Most children receiving CPR for bradycardia with poor perfusion developed subsequent pulselessness, 46% within 2 min of CPR onset.

Project description:ObjectivesManual techniques of intravascular fluid administration are commonly used during paediatric resuscitation, although it is unclear which technique is most efficient in the hands of typical healthcare providers. We compared the rate of fluid administration achieved with the disconnect-reconnect and push-pull manual syringe techniques for paediatric fluid resuscitation in a simulated setting.MethodsThis study utilised a randomised crossover trial design and enrolled 16 consenting healthcare provider participants from a Canadian paediatric tertiary care centre. The study was conducted in a non-clinical setting using a model simulating a 15 kg child in decompensated shock. Participants administered 900 mL (60 mL/kg) of normal saline to the simulated patient using each of the two techniques under study. The primary outcome was the rate of fluid administration, as determined by two blinded independent video reviewers. We also collected participant demographic data and evaluated other secondary outcomes including total volume administered, number of catheter dislodgements, number of technical errors, and subjective and objective measures of provider fatigue.ResultsAll 16 participants completed the trial. The mean (SD) rate of fluid administration (mL/s) was greater for the disconnect-reconnect technique at 1.77 (0.145) than it was for the push-pull technique at 1.62 (0.226), with a mean difference of 0.15 (95% CI 0.055 to 0.251; p=0.005). There was no difference in mean volume administered (p=0.778) or participant self-reported fatigue (p=0.736) between techniques. No catheter dislodgement events occurred.ConclusionsThe disconnect-reconnect technique allowed for the fastest rate of fluid administration, suggesting that use of this technique may be preferable in situations requiring rapid resuscitation. These findings may help to inform future iterations of paediatric resuscitation guidelines.Trial registration numberThis trial was registered at ClinicalTrials.gov [NCT01774214] prior to enrolling the first participant.

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Personalised fluid resuscitation in the ICU: still a fluid concept?

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Personalised fluid resuscitation in the ICU: still a fluid concept?

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