Precision fluid and vasoactive drug therapy for critically ill patients

Abstract

There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low‐quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.

Developing precision‐based multidisciplinary pharmacotherapy management plans in the critically ill

“…Acute weight gain in the hospital may be the result of fluid resuscitation. If rapid serum levels are needed, a bolus dose may be considered 3 …”

“…Step‐by‐step adjustment can be determined with any necessary revisions while considering the progression of the disease state as well as the potential emergence of new ones. Additional challenges may include the influence of any mechanical support devices or unique patient presentations such as excessive fluid overload or bowel obstructions, for example, that can also influence medication pharmacokinetic properties and require modifications 3 . The presence of the device and any modifications in its use, including implementation and removal, should be considered.…”

“…If rapid serum levels are needed, a bolus dose may be considered. 3 Assess the drugs Vd. If it is close to the blood volume (e.g., 5 L) and the drug is a large molecule, dosing on ideal body weight may be a consideration (e.g., Intravenous Immune Globulin or IVIG).…”

“…example, that can also influence medication pharmacokinetic properties and require modifications. 3 The presence of the device and any modifications in its use, including implementation and removal, should be considered.…”

“…One skill in making an adjustment different than the implemented management plan is to state that despite a previous recommendation, a change may be necessary based on new information that is now available. Descriptions of this for fluid/vasoactive agents, pain/sedation/delirium, thrombosis/hemostasis, anticonvulsants or transplantation are provided in other publications in this precision‐based edition 3,5,8–11 …”