Nordic survey on assessment and treatment of fluid overload in intensive care

Abstract

IntroductionFluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU.Materials and methodsWe developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022.ResultsWe received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05–0.50 mcg/kg/min) when administering loop diuretics.ConclusionSelf-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.

Goal‐directed fluid removal with furosemide versus placebo in intensive care patients with fluid overload: A randomised, blinded trial (GODIF trial—First version)

“…At present there is no gold standard for measuring fluid status. In clinical practice of ICU physicians, parameters such as fluid balance, body weight, and clinical examination are most frequently used as surrogate measures of fluid status 3,5,19 . A combination of the three parameters might be more precise compared to one parameter alone.…”

“…Fluid overload is a well-known risk factor for mortality in critically ill patients. 1 Fluid overload in this population is often treated with loop diuretics, [2][3][4][5] but the evidence for this clinical practice is sparse. 6,7 Clinical guidelines in this field are lacking.…”

Furosemide versus placebo for fluid overload in intensive care patients—The randomised GODIF trial second version: Statistical analysis plan

“…The practice of treating fluid overload with diuretics is common. [31][32][33] Systematic reviews found very low and uncertain evidence for administering diuretics to patients with fluid overload in the ICU or septic shock patients. 4,5 This large international, randomised, blinded, clinical GODIF trial investigating protocolised fluid removal with furosemide versus placebo in stable adult ICU patients with moderate to severe fluid overload was designed to gain more high-quality evidence in the field.…”

“…Several RCTs are currently investigating the question further for septic shock patients (NCT05179499; NCT04569942). The practice of treating fluid overload with diuretics is common 31–33 . Systematic reviews found very low and uncertain evidence for administering diuretics to patients with fluid overload in the ICU or septic shock patients 4,5 .…”

Fluid Responsiveness Is Associated with Successful Weaning after Liver Transplant Surgery

“…This recently defined concept describes the degree to which a patient can tolerate fluid administration without causing organ dysfunction [6]. Thus, a positive fluid balance alone may not warrant reversal; its clinical impact is significant when associated with fluid overload, a condition that precedes organ dysfunction [5,7] and correlates with elevated morbidity and mortality [8][9][10][11]. Regrettably, most characterizations of fluid overload only define it arithmetically as a gain of 5-10% from admission weight without functional considerations [5,7].…”