Thread by @VTA_Symposium

First session of Saturday's session of #VTA23 - Dr Jacqui Brown on 'Personalised Fluid Management' #critcare #FOAMcc

The first buffered IV fluids were administed during the cholera epidemic in the UK in 1832. However, fluid therapy only entered main stream medical practice around the first world war. #VTA23

However, some time has passed since then. We have entered the era of personalised on individualised fluid management. There are many paradigms that can assist with this - ROSE, 7 D's, etc...
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Some NB definitions
Fluid Bolus - a volume of fluid given to a patient
Fluid Challenge - dynamic fluid challenge - a rapid administration of small amount of fluid to assess fluid responsiveness.
Fluid Responsiveness - an increase in cardiac output >10% after a bolus
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Fluid Tolerance - the degree to which a patient can tolerate administration of fluids
Fluid Accumulation Syndrome - cumulative accumulation of fluid resulting in organ dysfunction
Fluid Overload - >10% accumulation of fluid, based on baseline body weight
doi.org/10.1016/j.jcrc…

ROSE - Phases of Fluid Administration
Resuscitation Phase - this is the phase of patient rescue. The trigger for starting fluid here is the presence of shock - whether sepsis, burns, etc...
Time is short (minutes), but you end up with a fluid balance.
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Optimisation Phase - here you have organ rescue, focus is on maintaining tissue perfusion and preventing fluid overload. Guided by fluid responsiveness. The trigger to decrease fluids - unresponsiveness.
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Stabilisation Phase - here you have organ support. Conservative fluid management is instituted for maintenance and replacement. The idea is to achieve negative fluid balance.
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Evacuation Phase - organ recovery is occurring. Stopping IV fluids and fluid removal (either passive or active) and a negative fluid balance are key.
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The concept of Fluid Stewardship emerges. Treating the fluid like a valuable drug, and preventing overuse and misuse.
This has been encapsulated into the 7 Ds by the International Fluid Academy:
fluidacademy.org
doi.org/10.1016/j.kint…
#VTA23 #fluidisadrug

What are our basal maintenance requirements
- Water - 1ml/kg/hr
- Glucose - 1-1.5mg/kg/hr
Remember that the fluid gained from 'fluid creep' should count towards this when looking at your maintenance infusions. #VTA23

Drug - Fluid Composition
The ideal fluid doesn't exist. What you need depends on the phase of fluid therapy, and the particular characteristics of the patient. The pharmacokinetics and pharmacodynamics of fluids should be kept in mind. #VTA23

Its important to remember whether a particular fluid is hypotonic, isotonic or hypertonic.
Hypotonic - e.g. 5% DW
Isotonic - e.g. 0.9% NaCl, Buffered solutions such as Ringer's Lactate or Balsol
Hypertonic - e.g. 3% NaCl
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Regarding buffered solution, which have decreased chloride that is replaced by another anion such as lactate, acetate or bicarbonate, in order to maintain electr
SMART and SALTED showed decreased renal adverse events and worse mortality with these vs 0.9% NaCl.
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De-escalation - Decreasing the amount of fluid administration.
De-resuscitation - Active fluid removal in patients with fluid overload.
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Another quoted paper on fluid creep in the ICU - a must read.
doi.org/10.1007/s00134…
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