Maintenance fluid therapy and fluid creep impose more significant fluid, sodium, and chloride burdens than resuscitation fluids in critically ill patients: a retrospective study in a tertiary mixed ICU population

Abstract

PurposeResearch on intravenous fluid therapy and its side effects, volume, sodium, and chloride overload, has focused almost exclusively on the resuscitation setting. We aimed to quantify all fluid sources in the ICU and assess fluid creep, the hidden and unintentional volume administered as a vehicle for medication or electrolytes.MethodsWe precisely recorded the volume, sodium, and chloride burdens imposed by every fluid source administered to 14,654 patients during the cumulative 103,098 days they resided in our 45-bed tertiary ICU and simulated the impact of important strategic fluid choices on patients’ chloride burdens. In septic patients, we assessed the impact of the different fluid sources on cumulative fluid balance, an established marker of morbidity.ResultsMaintenance and replacement fluids accounted for 24.7% of the mean daily total fluid volume, thereby far exceeding resuscitation fluids (6.5%) and were the most important sources of sodium and chloride. Fluid creep represented a striking 32.6% of the mean daily total fluid volume [median 645 mL (IQR 308–1039 mL)]. Chloride levels can be more effectively reduced by adopting a hypotonic maintenance strategy [a daily difference in chloride burden of 30.8 mmol (95% CI 30.5–31.1)] than a balanced resuscitation strategy [daily difference 3.0 mmol (95% CI 2.9–3.1)]. In septic patients, non-resuscitation fluids had a larger absolute impact on cumulative fluid balance than did resuscitation fluids.ConclusionsInadvertent daily volume, sodium, and chloride loading should be avoided when prescribing maintenance fluids in view of the vast amounts of fluid creep. This is especially important when adopting an isotonic maintenance strategy.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5147-3) contains supplementary material, which is available to authorized users.

154 compared to 54 mmol per liter of sodium in intravenous maintenance fluid therapy for adult patients undergoing major thoracic surgery (TOPMAST): a single-center randomized controlled double-blind trial

“…Since all resuscitation crystalloids used during the study contained only 98 mmol/L of chloride, we confirm our previous finding that a chloride-poor resuscitation strategy alone does not protect patients from hyperchloremia if maintenance solutions and additional electrolytes are ill-considered [3]. Balanced solutions are preferred by many clinicians as their resuscitation, replacement and maintenance fluids of choice to reduce chloride burden.…”

“…They are routinely used in the daily care of hospitalized patients around the world. Evidence shows maintenance fluids are a more important source of potentially harmful fluid and electrolyte administration than resuscitation fluids, whose detrimental effects have received much more scientific attention [3]. Maintenance fluid therapy should also be viewed separately from replacement solutions, which are used to substitute lost fluids or ongoing losses and need to contain as much sodium as the fluids lost [1,2,4].…”

Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia?

“…Fluids as drug vehicles and flushes have been coined "fluid creep." 27 Fluid creep has previously been observed in critically ill infants and children 4 ; however, little emphasis has been placed on the significance of its contribution given the current research focus on restrictive resuscitation and maintenance fluid strategies. 28,29 The majority of patients in this study developed hyperchloremia within the first 72 hours of PICU admission.…”

Less Is More?—A Feasibility Study of Fluid Strategy in Critically Ill Children With Acute Respiratory Tract Infection

“…Age-dependent fluid strategies are defined by international guidelines for healthy children (19,20). Yet, fluid delivery typically fluctuates and specifically fluid during the maintenance phase of treatment of critically ill patients often far exceeds the normal fluid requirements (21). Based on clinical experience and feasibility, in this study protocol, we aimed for <70% of recommended intake in our intervention group (conservative fluid regimen), compared to at least 85% of recommended intakes in the control group (standard, liberal fluid regimen).…”