The nuts and bolts of fluid de-escalation

Excerpt

Fluids are a key component of the initial resuscitation of critically ill patients. These are administered to compensate for external losses and relative hypovolemia but also for internal losses related to capillary leak. The effects of fluids are often transient, and frequently, their administration is to be repeated (see electronic supplementary material, ESM). Interstitial edema unavoidably results. When the situation improves, the patient usually eliminates the accumulated fluids spontaneously. In some conditions, it may appear attractive to actively promote active fluid withdrawal, for instance, in patients with severe acute respiratory distress syndrome (ARDS), stabilized sepsis, right ventricular dysfunction, or increased abdominal pressure. In all these conditions, the indication and timing of fluid removal varies. Many factors should be taken into account, including degree of fluid accumulation, resolution vs. persistence of capillary leakage, hemodynamic (in)stability and doses of vasopressors/inotropic agents. Unfortunately, fluid removal may be associated with hemodynamic compromise, and this should be prevented. To conduct fluid withdrawal safely, physicians should address a few questions. …