Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Sep 2014
ReviewWhat's new in volume therapy in the intensive care unit?
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. During the past decade, a number of important studies have been published which provide clinicians with improved knowledge regarding the timing, the type and the amount of fluid they should give to their critically ill patients. However, despite the fact that many thousands of patients have been enrolled in these trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. ⋯ Fluid therapy impacts relevant patient-related outcomes. Clinicians should adopt an individualized strategy based on the clinical scenario and best available evidence. One size does not fit all.
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Best Pract Res Clin Anaesthesiol · Sep 2014
ReviewDirect markers of organ perfusion to guide fluid therapy: when to start, when to stop.
Up until now, the discussion in the literature as to the choice of fluids is almost completely restricted to the composition, with little to no attention paid to the importance of hemodynamic end points to achieve a desired optimal volume. The determination of fluid volume is left to the discretion of the attending physician with only surrogate markers as guidance the initiation and cessation of fluid therapy. In this article, we aim to discuss the available literature on existing clinical and experimental criteria for the initiation and cessation of fluid therapy. Furthermore, we present recent data that have become available after the introduction of direct in vivo microscopy of the microcirculation at the bedside, and discuss its potential influence on the existing paradigms and controversies in fluid therapy.
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The human organism consists of evolutionary conserved mechanisms to prevent death from hypovolaemia. Intravenous fluid therapy to support these mechanisms had first been published about 180 years ago. The present review depicts the evolution of fluid therapy from early, not well-defined solutions up to modern balanced fluids. ⋯ It is therefore unclear whether negative data on colloids in some trials reflect real harm or rather inadequate use. Future studies should focus on optimal protocols for initiation, dosing and discontinuation of fluid therapy in specific disease entities. Moreover, the practice of de-resuscitation after fluid-based haemodynamic stabilization should be further investigated.
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Fluid therapy is a core concept in the management of perioperative and critically ill patients for maintenance of intravascular volume and organ perfusion. Recent evidence regarding the vascular barrier and its role in terms of vascular leakage has led to a new concept for fluid administration. ⋯ In daily practice, the assessment of individual thresholds in order to optimize cardiac preload and avoid hypovolaemia or deleterious fluid overload remains a challenge. Liberal versus restrictive fluid management has been challenged by recent evidence, and the ideal approach appears to be goal-directed fluid therapy.