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Fluid overload is an almost universal finding in the critically ill, despite little evidence to justify fluid therapy within the intensive care unit after initial resuscitation.
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Hemodynamic responses to fluid administration are unpredictable and short lived, which may contribute to recurrent fluid administration.
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Positive fluid balances have been consistently associated with adverse outcomes and organ dysfunction in critical illness.
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Structural and functional changes in the endothelium and
Fluid Overload
Section snippets
Key points
Introduction: association between fluid overload and adverse outcomes in critical illness
When delivered correctly for the right reasons and at the appropriate time, intravenous fluid can be lifesaving. However, in established critical illness, a combination of increased fluid intake and relatively reduced urine output frequently results in accumulation of excess fluid within the body (Table 1). In particular, critically ill patients with sepsis frequently receive very large volumes of fluid resulting in significantly positive fluid balances; for example, in a retrospective analysis
Development of fluid overload: a patient-physician interaction
Given very significant adverse associations of fluid overload, the authors think there is a clinical imperative to minimize the extent and impact of fluid overload in the ICU. To achieve this, clinicians need to appreciate how and why such degrees of fluid overload occur. Because almost all fluid inputs are under direct control of the clinical team, we first have to consider how and why we give fluid therapy in the ICU and the evidence underlying this practice.
Conventional management of
Pathogenesis of fluid overload
Fluid overload can be defined as a pathologic accumulation of water and dissolved electrolytes in the body beyond that seen in healthy individuals. In general, this excess fluid accumulates as extracellular fluid in expandable interstitial compartments as interstitial edema and as macroscopic fluid collections in the thorax (pleural effusions) or abdomen (ascites). Thus, fluid overload is predominantly a syndrome of interstitial edema and total of body sodium excess (the predominant
Controlling Fluid Intake
Equipped with an appreciation of the causes and consequences of fluid overload, clinicians can adopt a more systematic approach to fluid management in the ICU. Thus, the process has to commence with the rationale management of fluid resuscitation to minimization initial fluid accumulation. In brief, recent conceptual models of resuscitation of the critically ill have emphasized sequential phases of fluid resuscitation.101 In this approach, fluid therapy is provided emergently during very acute
Summary
In the critically ill, fluid overload is widely prevalent and has been consistently associated with adverse outcomes and organ dysfunction. Although some degree of fluid accumulation is an almost inevitable consequence of early resuscitation requirements and obligate fluid intakes, many patients receive multiple fluid boluses to ill-defined indications and with, at best, very short-term hemodynamic effects. Once accrued, fluid overload is challenging to resolve, as structural changes in the
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Disclosures: Dr J.R. Prowle has received speakers and consultant’s fees from Baxter and institutional funding from NIKKISO Europe GmbH, both manufactures of continuous renal replacement therapy technology.