Fluid Therapy for Critically Ill Adults With Sepsis

Abstract

ImportanceApproximately 20% to 30% of patients admitted to an intensive care unit have sepsis. While fluid therapy typically begins in the emergency department, intravenous fluids in the intensive care unit are an essential component of therapy for sepsis.ObservationsFor patients with sepsis, intravenous fluid can increase cardiac output and blood pressure, maintain or increase intravascular fluid volume, and deliver medications. Fluid therapy can be conceptualized as 4 overlapping phases from early illness through resolution of sepsis: resuscitation (rapid fluid administered to restore perfusion); optimization (the risks and benefits of additional fluids to treat shock and ensure organ perfusion are evaluated); stabilization (fluid therapy is used only when there is a signal of fluid responsiveness); and evacuation (excess fluid accumulated during treatment of critical illness is eliminated). Among 3723 patients with sepsis who received 1 to 2 L of fluid, 3 randomized clinical trials (RCTs) reported that goal-directed therapy administering fluid boluses to attain a central venous pressure of 8 to 12 mm Hg, vasopressors to attain a mean arterial blood pressure of 65 to 90 mm Hg, and red blood cell transfusions or inotropes to attain a central venous oxygen saturation of at least 70% did not decrease mortality compared with unstructured clinical care (24.9% vs 25.4%; P = .68). Among 1563 patients with sepsis and hypotension who received 1 L of fluid, an RCT reported that favoring vasopressor treatment did not improve mortality compared with further fluid administration (14.0% vs 14.9%; P = .61). Another RCT reported that among 1554 patients in the intensive care unit with septic shock treated with at least 1 L of fluid compared with more liberal fluid administration, restricting fluid administration in the absence of severe hypoperfusion did not reduce mortality (42.3% vs 42.1%; P = .96). An RCT of 1000 patients with acute respiratory distress during the evacuation phase reported that limiting fluid administration and administering diuretics improved the number of days alive without mechanical ventilation compared with fluid treatment to attain higher intracardiac pressure (14.6 vs 12.1 days; P < .001), and it reported that hydroxyethyl starch significantly increased the incidence of kidney replacement therapy compared with saline (7.0% vs 5.8%; P = .04), Ringer lactate, or Ringer acetate.Conclusions and RelevanceFluids are an important component of treating patients who are critically ill with sepsis. Although optimal fluid management in patients with sepsis remains uncertain, clinicians should consider the risks and benefits of fluid administration in each phase of critical illness, avoid use of hydroxyethyl starch, and facilitate fluid removal for patients recovering from acute respiratory distress syndrome.

Performance of handheld ultrasound devices in diagnosis of pulmonary hypertension and right heart dysfunction in ICU patients

“…These results are promising because it is difficult to obtain images with good image quality in ICU settings, especially in intubated patients and patients with COPD. Additionally, as we explained in the introduction section, right heart evaluation of ICU patients is very important for many reasons including monitoring whether the ventilator pressure settings are safe for right heart and evaluating the patient's fluid status during mechanical ventilation 1–6 . Our results suggest that the use of handheld ultrasound devices may be useful in the evaluation of RHD and PHT.…”

“…Additionally, as we explained in the introduction section, right heart evaluation of ICU patients is very important for many reasons including monitoring whether the ventilator pressure settings are safe for right heart and evaluating the patient's fluid status during mechanical ventilation. [1][2][3][4][5][6] Our results suggest that the use of handheld ultrasound devices may be useful in the evaluation of RHD and PHT. Therefore, HHUD would be a reliable tool that allows evaluation of ICU patients' right heart function easily, frequently, and accurately in daily practice.…”

“…On the other hand, due to the right ventricle (RV) ’s inability to fill the left chambers, it is difficult to evaluate the fluid responsiveness in patients with RHD, and RHD was frequently observed with a negative effect on the response to a fluid challenge even in the case of significant pulse pressure variation (PPV) 1,5 . Additionally, some test results like PPV and stroke volume variation for identifying whether a fluid challenge is likely to increase cardiac output may be influenced and show false positive results in patients with RHD 6 . Therefore, RV function is to be always kept in mind when managing fluid therapy.…”

“…1,5 Additionally, some test results like PPV and stroke volume variation for identifying whether a fluid challenge is likely to increase cardiac output may be influenced and show false positive results in patients with RHD. 6 Therefore, RV function is to be always kept in mind when managing fluid therapy.…”

Fluid dynamics of life: exploring the physiology and importance of water in the critical illness

“…In patients experiencing a state of shock, there is a redistribution of TBW and intravascular blood volume ( 91 ). Furthermore, the use of vasoactive agents like norepinephrine contributes to reduced blood flow in the superior mesenteric artery and the gastrointestinal tract microcirculation, such as in the jejunal mucosa, where a decrease of approximately 70% is observed ( 91 , 92 ).…”