Current opinion in critical care
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Currently available crystalloids were designed over a century ago for dehydration and not for the treatment of hemorrhagic shock. Information regarding fluids used for resuscitation has grown and thus resuscitation has changed radically in the last two decades. Artificial fluids such as crystalloids and other solutions typically used for resuscitation are now recognized to be inflammatory when infused at high volumes to replace blood. ⋯ Seemingly innocuous fluids have a dose effect and can be detrimental. Crystalloids can create inflammation when used at high volumes and may be the reason for the sequelae seen after massive resuscitation. This has led to the recognition that whole blood is extremely complex and does much more than carry oxygen. Resuscitation has changed recently with the adoption of damage control resuscitation which is the practice of allowing permissive hypotension, minimizing crystalloids and early aggressive use of blood products. This has led to a decrease in multiple organ dysfunction syndrome and acute respiratory distress syndrome.
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Fluid boluses are a key element of hemodynamic resuscitation, but overuse of fluids also can be harmful. It is thus important to understand how fluids actually improve clinical problems and how one can predict fluid responsiveness. It is also important to understand potential limitations of fluid therapy. ⋯ Assessment of changes in cardiac output, either directly or indirectly, is a key component of managing fluid therapy. Avoiding harm with the use of fluids requires understanding what is physiologically possible.
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To discuss the role of microcirculatory abnormalities in critically ill patients and the link between systemic hemodynamics and microvascular perfusion. ⋯ Microvascular alterations frequently occur in critically ill patients and these may be implicated in the development of organ failure and are associated with outcome. The link between systemic hemodynamics and microcirculation is relatively loose.