UMEM Educational Pearls

 

The European Society of Intensive Care Medicine (ESICM) recently released a review with recommendations from an expert panel for the use of IV fluids in the resuscitation of patients with acute circulatory dysfunction, especially in settings where invasive monitoring methods and ultrasound may not be available.

 

Points made by the panel include: 

• Circulatory dysfunction should be identified not only by HR and BP, but by other indicators of poor perfusion: altered mentation, decreased urine output, and skin abnormalities (poor skin turgor, mottling, delayed capillary refill)

• The absence of arterial hypotension does not preclude hypovolemia

• The lack of an increase in MAP (especially in patients with decreased vascular tone) does not exclude positive response to IVF

• The purpose of IVF administration is to improve tissue perfusion by increasing cardiac output

• Fluid "loading" as the rapid administration of large volumes of fluid to treat overt hypovolemia, while a fluid "challenge" is a test of fluid responsiveness

• In elderly patients or those with arteriosclerosis or chronic arterial hypertension, a low pulse pressure (e.g. less than 40 mmHg) indicates that stroke volume is low. PP = SBP - DBP

 

Recommendations from the panel include:

• The early measurement of lactate to incorporate in the assessment of perfusion

• The use of crystalloids as initial resuscitation fluid (unless blood products are indicated)

• When overt hypovolemia is unclear, the use of a fluid challenge of 150-350mL IVF within 15 minutes to help assess fluid responsiveness

• Avoidance of using jugular venous distension alone as a guide for resuscitation

• Avoidance of using acute urine output response alone as a guide for resuscitation, as renal response to fluids can be delayed

• A recommendation against using CVP as a target for resuscitation; if CVP is being measured, a rapid increase with IVF should suggest poor fluid tolerance

• Individualizing fluid resuscitation to the patient's current presentation, underlying comorbidities, and response to fluids

 

Bottom Line: Utilize all the information you have about your patient to determine whether or not they require IVF, and reevaluate their physical and biochemical (lactate) response to fluids to ensure appropriate IVF administration and avoid volume overload. 

 

 

References

Cecconi M, Hernandez G, Dunser M, et al. Intensive Care Med. 2018. https://doi-org.proxy-hs.researchport.umd.edu/10.1007/s00134-018-5415-2