Fluid management and deresuscitation practices: A survey of critical care physicians

Abstract

Accumulation of a positive fluid balance is common in critically ill patients, and is associated with adverse outcomes, including mortality. However, there are few randomised clinical trials to guide clinicians as to the most appropriate fluid strategy following initial resuscitation and on the use of deresuscitation (removal of accumulated fluid using diuretics and/or renal replacement therapy). To inform the design of randomised trials, we surveyed critical care physicians with regard to perceptions of fluid overload in critical care, self-reported practice, acceptability of a variety of approaches to deresuscitation, appropriate safety parameters, and overall acceptability of a randomised trial of deresuscitation. Of 524 critical care specialists completing the survey, the majority practiced in mixed medical/surgical intensive care units in the United Kingdom. Most (309 of 363 respondents, 85%) believed fluid overload to be a modifiable source of morbidity; there was strong support (395 of 457, 86%) for a randomised trial of deresuscitation in critical illness. Marked practice variability was evident among respondents. In a given clinical scenario, self-reported practice ranged from the administration of fluid (N = 59, 14%) to the administration of a diuretic (N = 285, 67%). The majority (95%) considered it appropriate to administer diuretics for fluid overload in the setting of noradrenaline infusion and to continue to administer diuretics despite mild dysnatraemias, hypotension, metabolic alkalosis, and hypokalaemia. The majority of critical care physicians view fluid overload as a common and modifiable source of morbidity; deresuscitation is widely practiced, and there is widespread support for randomised trials of deresuscitation in critical illness.

Keywords: Critical illness; critical care; deresuscitation; diuretics; fluid therapy; water–electrolyte balance.

Figure 1.

Case vignette 1. COPD: chronic obstructive pulmonary disease; CVP: central venous pressure; ICU: intensive care unit; MAP: mean arterial pressure; PEEP: positive end-expiratory pressure; WBC: white blood cells.

Figure 2.

Case vignette 2. CVP: central venous pressures.

Figure 3.

Strategies for prevention or treatment of fluid overload. CVP: central venous pressure; ICU: intensive care unit.

Figure 4.

Reponses to the question ‘Recognising that the decision to initiate a deresuscitation strategy (using diuretics and/or dialysis to target a negative fluid balance) is complex and patient-dependent, how important do you consider each of the following indications for deresuscitation?’ N = 393. IV: intravenous; MAP: mean arterial pressure.

Figure 5.

Response to common side effects of diuretics. (a) Metabolic alkalosis (bicarbonate > 30 mmol/l), (b) mild hypokalaemia (K + 3.0–3.5 mmol/l), (c) mild hypotension (MAP 55–65 mmHg), and (d) mild hypernatraemia (sodium 145–150 mmol/l).