Aiming for zero fluid accumulation: First, do no harm

Orlando R. Perez Nieto; Adrian Wong; Jorge Lopez Fermin; Eder I. Zamarron Lopez; Jose A. Meade Aguilar; Ernesto Deloya Tomas; Jorge D. Carrion Moya; Gabriela Castillo Gutierrez; Maria G. Olvera Ramos; Xiomara García Montes; Manuel Alberto Guerrero Gutiérrez; Fernando George Aguilar; Jesús Salvador Sánchez Díaz; Raúl Soriano Orozco; Eduardo Ríos Argaiz; Thierry Hernandez-Gilsoul; Roberto Secchi del Rio; Silvio Antonio Ñamendys-Silva; Manu L.N.G. Malbrain

doi:10.5114/ait.2021.105252

eISSN: 1731-2531
ISSN: 1642-5758

Anaesthesiology Intensive Therapy

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abstract:

Review paper

Aiming for zero fluid accumulation: First, do no harm

Orlando R. Perez Nieto

¹

,

Adrian Wong

^{2, 3}

,

Jorge Lopez Fermin

¹

,

Eder I. Zamarron Lopez

⁴

,

Jose A. Meade Aguilar

^{5, 6}

,

Ernesto Deloya Tomas

¹

,

Jorge D. Carrion Moya

¹

,

Gabriela Castillo Gutierrez

¹

,

Maria G. Olvera Ramos

¹

,

Xiomara García Montes

⁷

,

Manuel Alberto Guerrero Gutiérrez

⁸

,

Fernando George Aguilar

⁹

,

Jesús Salvador Sánchez Díaz

⁷

,

Raúl Soriano Orozco

¹⁰

,

Eduardo Ríos Argaiz

⁶

,

Thierry Hernandez-Gilsoul

⁶

,

Roberto Secchi del Rio

¹

,

Silvio Antonio Ñamendys-Silva

⁸

,

Manu L.N.G. Malbrain

^{3, 11}

General Hospital of San Juan del Río, Querétaro, México

Department of Intensive Care Medicine, Kings’s College, London, UK

International Fluid Academy, Lovenjoel, Belgium

Regional General Hospital IMSS, #6. Cd. Madero, Tamps, México

Faculty of Medicine, Autonomous University of San Luis Potosí, SLP, México

National Institute of Medical Sciences and Nutrition “Salvador Zubirán”, CDMX, México

Specialty Hospital UMAE 14 IMSS Veracruz, México

National Institute of Cancerology, CDMX, México

Regional Hospital of High Specialty Health City, Chiapas, México

10.

High Specialty Hospital T1, IMSS, Leon, Gto, México

11.

Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium

Anaesthesiol Intensive Ther 2021; 53, 2: 162–178

DOI: https://doi.org/10.5114/ait.2021.105252

Online publish date: 2021/04/13

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Critically ill patients are often presumed to be in a state of “constant dehydration” or in need of fluid, thereby justifying a continuous infusion with some form of intravenous (IV) fluid, despite their clinical data suggesting otherwise. Overzealous fluid administration and subsequent fluid accumulation and overload are associated with poorer outcomes. Fluids are drugs, and their use should be tailored to meet the patient’s individualized needs; fluids should never be given as routine maintenance unless indicated. Before prescribing any fluids, the physician should consider the patient’s characteristics and the nature of the illness, and assess the risks and benefits of fluid therapy.

Decisions regarding fluid therapy present a daily challenge in many hospital departments: emergency rooms, regular wards, operating rooms, and intensive care units. Traditional fluid prescription is full of paradigms and unnecessary routines as well as malpractice in the form of choosing the wrong solutions for maintenance or not meeting daily requirements. Prescribing maintenance fluids for patients on oral intake will lead to fluid creep and fluid overload. Fluid overload, defined as a 10% increase in cumulative fluid balance from baseline weight, is an independent predictor for morbidity and mortality, and thus hospital cost. In the last decade, increasing evidence has emerged supporting a restrictive fluid approach.

In this manuscript, we aim to provide a pragmatic description of novel concepts related to the use of IV fluids in critically ill patients, with emphasis on the different indications and common clinical scenarios. We also discuss active deresuscitation, or the timely cessation of fluid administration, with the intention of achieving a zero cumulative fluid balance.

keywords:

Aiming for zero fluid accumulation: First, do no harm

fluid therapy, oedema, fluid overload, solution, infusion, maintenance, resuscitation, de-escalation, deresuscitation