Changing paradigm in intravenous fluid resuscitation in sepsis and critical illnesses

Abstract

Intravenous (IV) fluid resuscitation, pioneered in 1832, is now one of the most common medical interventions in hospitalized patients. Up until the end of the 20th century, IV fluid prescriptions have been considered ancillary, benign interventions and rarely tested in good-quality randomized clinical trials (RCTs). Robust clinical research evidence emerging in the past decade and a half, however, has revealed counterintuitive findings. The emerging research has consistently demonstrated harm, including higher mortality, and questionable clinical benefits associated with protocolized aggressive fluid resuscitation, as espoused in the early goal-directed therapy. Conservative fluid management has been shown to be associated with better outcomes in most clinical settings. Recent RCTs have also revealed clinically relevant pharmacological differences between types of IV fluids, especially pertaining to predictable harms associated with some commonly used IV fluids. Concerns have emerged over risks of metabolic acidosis and renal failure associated with the use of normal saline. Balanced solutions have been found to be safe across a wide spectrum of conditions. Better understanding of the complex pathophysiology of sepsis and critical illnesses and recognition of newer concepts such as profound disruption of the endothelial glycocalyx layer leading to profound leakiness of vessels question the basic premise of injection of large quantities of IV fluids during resuscitation.

Keywords

• Conservative late fluid management
• early goal-directed therapy
• endothelial glycocalyx
• mean circulatory filling pressure
• myocardial depression
• stressed volume
• unstressed volume
• vascular leakiness
• vasoplegia