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Orellana G, Josef V, Parchim NF, Mitchell JA. Current state of sepsis resuscitation in critical care. Int Anesthesiol Clin 2023; 61:43-54. [PMID: 37622346 DOI: 10.1097/aia.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Gabriela Orellana
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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2
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Macdonald S. Fluid Resuscitation in Patients Presenting with Sepsis: Current Insights. Open Access Emerg Med 2022; 14:633-638. [PMID: 36471825 PMCID: PMC9719278 DOI: 10.2147/oaem.s363520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/23/2022] [Indexed: 04/05/2024] Open
Abstract
Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid. The rationale is to restore circulating fluid volume and optimise stroke volume. It is acknowledged that there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design. In the past decade, evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation. Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation, however, translating these findings to other settings is not possible. This uncertainty has led to variation in practice with some advocating a more conservative fluid strategy coupled with the earlier introduction of vasopressors for haemodynamic support. This question is the subject of several ongoing clinical trials. This article summarises the current state of the evidence for IV fluid resuscitation in septic shock and provides guidance for practitioners in the face of our evolving understanding of this important area.
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Affiliation(s)
- Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
- Emergency Department, Royal Perth Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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3
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Macdonald S, Peake SL, Corfield AR, Delaney A. Fluids or vasopressors for the initial resuscitation of septic shock. Front Med (Lausanne) 2022; 9:1069782. [PMID: 36507525 PMCID: PMC9729725 DOI: 10.3389/fmed.2022.1069782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.
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Affiliation(s)
- Stephen Macdonald
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Emergency Medicine, Royal Perth Hospital, Perth, WA, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Sandra L. Peake
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Alasdair R. Corfield
- Consultant Emergency Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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4
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Saoraya J, Wongsamita L, Srisawat N, Musikatavorn K. The effects of a limited infusion rate of fluid in the early resuscitation of sepsis on glycocalyx shedding measured by plasma syndecan-1: a randomized controlled trial. J Intensive Care 2021; 9:1. [PMID: 33402229 PMCID: PMC7784279 DOI: 10.1186/s40560-020-00515-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 12/29/2022] Open
Abstract
Background Aggressive fluid administration is recommended in the resuscitation of septic patients. However, the delivery of a rapid fluid bolus might cause harm by inducing degradation of the endothelial glycocalyx. This research aimed to examine the effects of the limited infusion rate of fluid on glycocalyx shedding as measured by syndecan-1 in patients with sepsis-induced hypoperfusion. Methods A prospective, randomized, controlled, open-label trial was conducted between November 2018 and February 2020 in an urban academic emergency department. Patients with sepsis-induced hypoperfusion, defined as hypotension or hyperlactatemia, were randomized to receive either the standard rate (30 ml/kg/h) or limited rate (10 ml/kg/h) of fluid for the first 30 ml/kg fluid resuscitation. Subsequently, the fluid rate was adjusted according to the physician’s discretion but not more than that of the designated fluid rate for the total of 6 h. The primary outcome was differences in change of syndecan-1 levels at 6 h compared to baseline between standard and limited rate groups. Secondary outcomes included adverse events, organ failure, and 90-day mortality. Results We included 96 patients in the intention-to-treat analysis, with 48 assigned to the standard-rate strategy and 48 to the limited-rate strategy. The median fluid volume in 6 h in the limited-rate group was 39 ml/kg (interquartile range [IQR] 35–52 ml/kg) vs. 53 ml/kg (IQR 46–64 ml/kg) in the standard-rate group (p < 0.001). Patients in the limited-rate group were less likely to received vasopressors (17% vs 42%; p = 0.007) and mechanical ventilation (20% vs 41%; p = 0.049) during the first 6 h. There were no significantly different changes in syndecan-1 levels at 6 h between the two groups (geometric mean ratio [GMR] in the limited-rate group, 0.82; 95% confidence interval [CI], 0.66–1.02; p = 0.07). There were no significant differences in adverse events, organ failure outcomes, or mortality between the two groups. Conclusions In sepsis resuscitation, the limited rate of fluid resuscitation compared to the standard rate did not significantly reduce changes in syndecan-1 at 6 h. Trial registration Thai Clinical Trials Registry number: TCTR20181010001. Registered 8 October 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=4064 Supplementary Information The online version contains supplementary material available at 10.1186/s40560-020-00515-7.
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Affiliation(s)
- Jutamas Saoraya
- Division of Academic Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Lipda Wongsamita
- Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, and Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellent Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Khrongwong Musikatavorn
- Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand. .,Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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5
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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6
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Saoraya J, Musikatavorn K, Puttaphaisan P, Komindr A, Srisawat N. Intensive fever control using a therapeutic normothermia protocol in patients with febrile early septic shock: A randomized feasibility trial and exploration of the immunomodulatory effects. SAGE Open Med 2020; 8:2050312120928732. [PMID: 32547753 PMCID: PMC7271676 DOI: 10.1177/2050312120928732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 04/30/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives: Fever control has been shown to reduce short-term mortality in patients with
septic shock. This study aimed to explore the feasibility of early intensive
fever control in patients with septic shock and to assess the
immunomodulatory effects of this intervention. Methods: In this single-center, randomized, open-label trial, febrile patients with
septic shock presenting to the emergency department were assigned to either
a standard fever control or therapeutic normothermia group. Therapeutic
normothermia involved intensive fever control in maintaining normothermia
below 37°C. The primary outcome was the feasibility of fever control for
24 h. Secondary outcomes included changes in immunomodulatory biomarkers and
adverse events. Results: Fifteen patients were enrolled and analyzed. Fever control was comparable in
both groups, but significantly more patients in the therapeutic normothermia
group experienced shivering (p = 0.007). Both groups
demonstrated increased C-reactive protein and unchanged neutrophil
chemotaxis and CD11b expression. The therapeutic normothermia group revealed
significant decreased IL-6 and IL-10. The standard fever control group
significantly expressed increased monocytic human leukocyte antigen. There
were no significant differences between the groups in terms of
immunomodulation. Conclusions: Therapeutic normothermia was feasible in patients with febrile septic shock
but was not superior to standard fever control in terms of average body
temperature and host defense function. Shivering was more frequent in the
therapeutic normothermia group. Trial registration: Thai Clinical Trials Registry number: TCTR20160321001
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Affiliation(s)
- Jutamas Saoraya
- Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Khrongwong Musikatavorn
- Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.,Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Patima Puttaphaisan
- Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Atthasit Komindr
- Department of Emergency Medicine, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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7
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Lindén-Søndersø A, Jungner M, Spångfors M, Jan M, Oscarson A, Choi S, Kander T, Undén J, Griesdale D, Boyd J, Bentzer P. Survey of non-resuscitation fluids administered during septic shock: a multicenter prospective observational study. Ann Intensive Care 2019; 9:132. [PMID: 31776712 PMCID: PMC6881490 DOI: 10.1186/s13613-019-0607-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/17/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The indication, composition and timing of administration of non-resuscitation fluid in septic shock have so far received little attention and accordingly the potential to reduce this source of fluid is unknown. The objective of the study was to quantify and characterize non-resuscitation fluid administered to patients with septic shock. METHODS This prospective observational study was performed in eight intensive care units in Sweden and Canada during 4 months in 2018. Adult patients with septic shock within 24 h of admission to the intensive care unit were eligible for inclusion. Non-resuscitation fluids were defined as fluids other than colloids, blood products and crystalloids at a rate ≥ 5 ml/kg/h. Indication, volume and type of fluid were recorded during the first 5 days after admission. A maximum of 30 patients could be included per centre. To estimate the potential to reduce administration of non-resuscitation fluid, a pragmatic "restrictive" protocol for administration of non-resuscitation fluids was devised based on the most restrictive practice already in place for non-resuscitation fluids at any of the participating centres. Data are presented as median (interquartile range [IQR]). RESULTS A total of 200 patients were included in the study and the 30-day mortality was 35%. Patients received a total of 7870 (4060-12,340) ml of non-resuscitation fluids and 2820 (1430-4580) of resuscitation fluids during the observation period. Median volumes of non-resuscitation and resuscitation fluids were similar at day 1 (1620 [710-2320] and 1590 [520-3000]) ml, respectively) and non-resuscitation fluids represented the largest source of fluid from day 2 and onwards after admission to the ICU. Vehicles for drugs such as vasoactive drugs and antibiotics constituted the largest fraction of non-resuscitation fluids (2400 [1270-4030] ml) during the 5-day observation period. Modelling suggested that volume of non-resuscitation fluids could be reduced by 2840 (1270-4900) ml during the first 5 days of admission to the ICU, mainly through reducing maintenance fluids. CONCLUSIONS Non-resuscitation fluids constitute the major fraction of fluids administered in the ICU to patients suffering from septic shock and may represent the largest modifiable target to reduce fluid overload.
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Affiliation(s)
- Anja Lindén-Søndersø
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Charlotte Yhlens gata 10, 251 87, Helsingborg, Sweden
| | - Mårten Jungner
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Martin Spångfors
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Kristianstad Hospital, Lund University, Lund, Sweden
| | - Mohammed Jan
- Anesthesia Department, College of Medicine, Taibah University, Madinah, Saudi Arabia.,Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Adam Oscarson
- Department of Operation and Intensive Care, Hallands Hospital, Halmstad, Sweden
| | - Sally Choi
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kander
- Department of Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Hallands Hospital, Halmstad, Sweden
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - John Boyd
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Peter Bentzer
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Charlotte Yhlens gata 10, 251 87, Helsingborg, Sweden. .,Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Helsingborg Hospital, Lund University, Lund, Sweden.
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8
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Long E, Babl FE, Oakley E, Hopper S, Sheridan B, Duke T. Does fluid bolus therapy increase blood pressure in children with sepsis? Emerg Med Australas 2019; 32:54-60. [DOI: 10.1111/1742-6723.13336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/25/2019] [Accepted: 05/26/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Elliot Long
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Franz E Babl
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Ed Oakley
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Sandy Hopper
- Department of Emergency MedicineThe Royal Children's Hospital Melbourne Victoria Australia
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
| | - Bennett Sheridan
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne Victoria Australia
- Department of CardiologyThe Royal Children's Hospital Melbourne Victoria Australia
| | - Trevor Duke
- Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics, Faculty of MedicineDentistry and Health Sciences, The University of Melbourne Melbourne Victoria Australia
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne Victoria Australia
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9
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Observational study in healthy volunteers to define interobserver reliability of ultrasound haemodynamic monitoring techniques performed by trainee doctors. Eur J Emerg Med 2019; 26:217-223. [DOI: 10.1097/mej.0000000000000533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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11
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Harris T, Coats TJ, Elwan MH. Fluid therapy in the emergency department: an expert practice review. Emerg Med J 2018; 35:511-515. [DOI: 10.1136/emermed-2017-207245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 04/13/2018] [Accepted: 05/06/2018] [Indexed: 01/04/2023]
Abstract
Intravenous fluid therapy is one of the most common therapeutic interventions performed in the ED and is a long-established treatment. The potential benefits of fluid therapy were initially described by Dr W B O’Shaughnessy in 1831 and first administered to an elderly woman with cholera by Dr Thomas Latta in 1832, with a marked initial clinical response. However, it was not until the end of the 19th century that medicine had gained understanding of infection risk that practice became safer and that the practice gained acceptance. The majority of fluid research has been performed on patients with critical illness, most commonly sepsis as this accounts for around two-thirds of shocked patients treated in the ED. However, there are few data to guide clinicians on fluid therapy choices in the non-critically unwell, by far our largest patient group. In this paper, we will discuss the best evidence and controversies for fluid therapy in medically ill patients.
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12
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Gelbart B. Fluid Bolus Therapy in Pediatric Sepsis: Current Knowledge and Future Direction. Front Pediatr 2018; 6:308. [PMID: 30410875 PMCID: PMC6209667 DOI: 10.3389/fped.2018.00308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,The University of Melbourne, Melbourne, VIC, Australia
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13
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van Haren F. Personalised fluid resuscitation in the ICU: still a fluid concept? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:313. [PMID: 29297387 PMCID: PMC5751583 DOI: 10.1186/s13054-017-1909-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful.New data from basic, animal, and clinical research suggest that fluid resuscitation could be associated with significant harm. There are several important limitations and concerns regarding fluid bolus therapy as it is currently being used in clinical practice. These include, but are not limited to: the lack of an agreed definition; limited and short-lived physiological effects; no evidence of an effect on relevant patient outcomes; and the potential to contribute to fluid overload, specifically when fluid responsiveness is not assessed and when targets and safety limits are not used.Fluid administration in critically ill patients requires clinicians to integrate abnormal physiological parameters into a clinical decision-making model that also incorporates the likely diagnosis and the likely risk or benefit in the specific patient's context. Personalised fluid resuscitation requires careful attention to the mnemonic CIT TAIT: context, indication, targets, timing, amount of fluid, infusion strategy, and type of fluid.The research agenda should focus on experimental and clinical studies to: improve our understanding of the physiological effects of fluid infusion, e.g. on the glycocalyx; evaluate new types of fluids; evaluate novel fluid minimisation protocols; study the effects of a no-fluid strategy for selected patients and scenarios; and compare fluid therapy with other interventions. The adaptive platform trial design may provide us with the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous.
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Affiliation(s)
- Frank van Haren
- University of Canberra, Canberra, Australia. .,Australian National University, Canberra, Australia. .,Intensive Care Unit, Canberra Hospital, Canberra, Australia.
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14
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Glassford NJ, Gelbart B, Bellomo R. Coming full circle: thirty years of paediatric fluid resuscitation. Anaesth Intensive Care 2017; 45:308-319. [PMID: 28486889 DOI: 10.1177/0310057x1704500306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
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Affiliation(s)
- N J Glassford
- Registrar and Clinical Research Fellow, Department of Intensive Care, Austin Hospital, PhD Candidate, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, Victoria
| | - B Gelbart
- Staff Specialist, Department of Intensive Care, Royal Children's Hospital, Honorary Fellow, Murdoch Childrens Research Institute, Melbourne, Victoria
| | - R Bellomo
- Director of Intensive Care Research, Department of Intensive Care, Austin Hospital, Co-director and Honorary Professor, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Professor of Intensive Care, School of Medicine, The University of Melbourne, Melbourne, Victoria
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15
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Macdonald SPJ, Taylor DM, Keijzers G, Arendts G, Fatovich DM, Kinnear FB, Brown SGA, Bellomo R, Burrows S, Fraser JF, Litton E, Ascencio-Lane JC, Anstey M, McCutcheon D, Smart L, Vlad I, Winearls J, Wibrow B. REstricted Fluid REsuscitation in Sepsis-associated Hypotension (REFRESH): study protocol for a pilot randomised controlled trial. Trials 2017; 18:399. [PMID: 28851407 PMCID: PMC5576288 DOI: 10.1186/s13063-017-2137-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 08/03/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Guidelines recommend an initial intravenous (IV) fluid bolus of 30 ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this. Accumulating observational data suggest harm associated with the injudicious use of fluids in sepsis. There is currently equipoise regarding liberal or restricted fluid-volume resuscitation as first-line treatment for sepsis-related hypotension. A randomised trial comparing these two approaches is, therefore, justified. METHODS/DESIGN The REstricted Fluid REsuscitation in Sepsis-associated Hypotension trial (REFRESH) is a multicentre, open-label, randomised, phase II clinical feasibility trial. Participants will be patients presenting to the emergency departments of Australian metropolitan hospitals with suspected sepsis and a systolic blood pressure of < 100 mmHg, persisting after a 1000-ml fluid bolus with isotonic crystalloid. Participants will be randomised to either a second 1000-ml fluid bolus (standard care) or maintenance rate fluid only, with the early commencement of a vasopressor infusion to maintain a mean arterial pressure of > 65 mmHg, if required (restricted fluid). All will receive further protocolised fluid boluses (500 ml or 250 ml, respectively), if required during the 6-h study period. The primary outcome measure is total volume administered in the first 6 h. Secondary outcomes include fluid volume at 24 h, organ support 'free days' to day 28, 90-day mortality, and a range of feasibility and process-of-care measures. Participants will also undergo serial measurement, over the first 24 h, of biomarkers of inflammation, endothelial cell activation and glycocalyx degradation for comparison between the groups. DISCUSSION This is the first randomised trial examining fluid volume for initial resuscitation in septic shock in an industrialised country. A pragmatic, open-label design will establish the feasibility of undertaking a large, international, multicentre trial with sufficient power to assess clinical outcomes. The embedded biomarker study aims to provide mechanistic plausibility for a larger trial by defining the effects of fluid volume on markers of systemic inflammation and the vascular endothelium. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Registry, ID: ACTRN12616000006448. Registered on 12 January 2016.
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Affiliation(s)
- Stephen P. J. Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Royal Perth Hospital, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - David McD Taylor
- Emergency Department, Austin Hospital, Melbourne, VIC Australia
- Department of Medicine, University of Melbourne, Melbourne, VIC Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, QLD Australia
- School of Medicine, Bond University, Gold Coast, QLD Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Fiona Stanley Hospital, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Daniel M. Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Royal Perth Hospital, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Frances B. Kinnear
- Emergency and Children’s Services, The Prince Charles Hospital, Brisbane, QLD Australia
| | - Simon G. A. Brown
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Emergency Department, Royal Hobart Hospital, Hobart, TAS Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC Australia
- School of Medicine, University of Melbourne, Melbourne, VIC Australia
| | - Sally Burrows
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA Australia
| | - John F. Fraser
- School of Medicine, Bond University, Gold Coast, QLD Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD Australia
- School of Medicine, University of Queensland, Brisbane, QLD Australia
| | - Edward Litton
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA Australia
| | | | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, WA Australia
| | - David McCutcheon
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
- Emergency Department, Armadale Health Service, Perth, WA Australia
| | - Lisa Smart
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA Australia
- Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA Australia
| | - Ioana Vlad
- Emergency Department, Sir Charles Gairdner Hospital, Perth, WA Australia
| | - James Winearls
- School of Medical Sciences, Griffith University, Gold Coast, QLD Australia
- School of Medicine, University of Queensland, Brisbane, QLD Australia
- Department of Intensive Care, Gold Coast University Hospital, Gold Coast, QLD Australia
| | - Bradley Wibrow
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, WA Australia
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Glassford NJ, Bellomo R. The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores. Korean J Crit Care Med 2017; 32:106-123. [PMID: 31723625 PMCID: PMC6786718 DOI: 10.4266/kjccm.2017.00192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/05/2017] [Indexed: 01/18/2023] Open
Abstract
Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.
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Affiliation(s)
- Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Australia.,School of Medicine, The University of Melbourne, Melbourne, Australia
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17
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Glassford NJ, Bellomo R. The Complexities of Intravenous Fluid Research: Questions of Scale, Volume, and Accumulation. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.00934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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