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Review
. 2024 Jul 20;14(1):115.
doi: 10.1186/s13613-024-01336-9.

Fluid accumulation syndrome in sepsis and septic shock: pathophysiology, relevance and treatment-a comprehensive review

Carmen Andrea Pfortmueller  1 , Wojciech Dabrowski  2 , Rob Wise  3   4   5 , Niels van Regenmortel  6   7 , Manu L N G Malbrain  2   8   9
Affiliations
Review

Fluid accumulation syndrome in sepsis and septic shock: pathophysiology, relevance and treatment-a comprehensive review

Carmen Andrea Pfortmueller et al. Ann Intensive Care. .

Erratum in

Abstract

In this review, we aimed to comprehensively summarize current literature on pathophysiology, relevance, diagnosis and treatment of fluid accumulation in patients with sepsis/septic shock. Fluid accumulation syndrome (FAS) is defined as fluid accumulation (any degree, expressed as percentage from baseline body weight) with new onset organ-failure. Over the years, many studies have described the negative impact of FAS on clinically relevant outcomes. While the relationship between FAS and ICU outcomes is well described, uncertainty exists regarding its diagnosis, monitoring and treatment. A stepwise approach is suggested to prevent and treat FAS in patients with septic shock, including minimizing fluid intake (e.g., by limiting intravenous fluid administration and employing de-escalation whenever possible), limiting sodium and chloride administration, and maximizing fluid output (e.g., with diuretics, or renal replacement therapy). Current literature implies the need for a multi-tier, multi-modal approach to de-resuscitation, combining a restrictive fluid management regime with a standardized early active de-resuscitation, maintenance fluid reduction (avoiding fluid creep) and potentially using physical measures such as compression stockings.Trial registration: Not applicable.

Keywords: De-resuscitation; Fluid accumulation; Fluids; Monitoring; Resuscitation; Safety.

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Conflict of interest statement

The authors declare no competing interests. CAPs report grants from Orion Pharma, Abbott Nutrition International, B. Braun Medical AG, CSEM AG, Edwards Lifesciences Services GmbH, Kenta Biotech Ltd, Maquet Critical Care AB, Omnicare Clinical Research AG, Nestle, Pierre Fabre Pharma AG, Pfizer, Bard Medica S.A., Abbott AG, Anandic Medical Systems, Pan Gas AG Healthcare, Bracco, Hamilton Medical AG, Fresenius Kabi, Getinge Group Maquet AG, Dräger AG, Teleflex Medical GmbH, Glaxo Smith Kline, Merck Sharp and Dohme AG, Eli Lilly and Company, Baxter, Boehringer-Ingelheim, Aseptuva, Astellas, Astra Zeneca, CSL Behring, Novartis, Covidien, and Nycomed outside the submitted work. The money was paid into departmental funds; no personal financial gain applied. NVR received unrestricted educational grants (paid to institution) by Baxter Heatlhcare and speaker’s fees from Baxter and Nestlé Healthcare. He resided in advisory boards organized by Baxter Healthcare. MLNGM is co-founder, past-President and current Treasurer of WSACS (The Abdominal Compartment Society, http://www.wsacs.org). He is member of the medical advisory Board of Pulsion Medical Systems (part of Getinge group), Serenno Medical, Potrero Medical, Sentinel Medical and Baxter. He consults for BBraun, Becton Dickinson, ConvaTec, Maltron, Spiegelberg, Medtronic, MedCaptain, and Holtech Medical, and received speaker's fees from PeerVoice and Nestlé. He holds stock options for Serenno and Potrero. He is co-founder and President of the International Fluid Academy (IFA). The IFA (http://www.fluidacademy.org ) is integrated within the not-for-profit charitable organization iMERiT, International Medical Education and Research Initiative, under Belgian law.

Figures

Textbox 1
Textbox 1
Critical appraisal of FAS definition. FB: fluid balance
Fig. 1
Fig. 1
Potential adverse consequences of fluid accumulation. Adapted with permission from Malbrain et al. according to the Open Access CC BY License 4.0 [–17]. Effects mentioned are related to the setting of sepsis, capillary leak and fluid accumulation. I.e. the numbness refers to the presence of peripheral edema and anasarca that may cause skin conduction disturbances, compression of nerves, reduced blood flow and reduced mobility. Additionally, severe and prolonged fluid imbalances can lead to a range of health issues and complications, including electrolyte imbalances, which may indirectly affect the body's ability to respond to stress, including the production of cortisol by the adrenal glands. APP: abdominal perfusion pressure (MAP minus IAP), RSB: rapid shallow breathing, HCS: hepatic congestion, GRV: gastro-esophageal reflux, CARS: cardiac-renal syndrome, AKI: acute kidney injury, JVP: jugular venous pressure, HJR: hepato-jugular reflux
Fig. 2
Fig. 2
The 4 phases conceptual ROSE model and deleterious effects of fluid accumulation syndrome. Adapted with permission from Malbrain et al. according to the Open Access CC BY Licence 4. 0 [–17]. Artwork kindly provided by Dr Ricardo Castro, Pontificia Universidad Católica de Chile, Chile. IAP: intra-abdominal pressure, BIA: bio-impedance analysis, COP: colloid oncotic pressure, ECW/ICW: extracellular/intracellular water, EVLWI: extra-vascular lung water index, GEDVI: global end-diastolic volume index, IVCCI: inferior vena cava collapsibility index, LVEDAI: left ventricular end-diastolic area index, MAP: mean arterial pressure, OCS: ocular compartment syndrome, PAOP: pulmonary artery occlusion pressure. PLR: passive leg raising, PPV: pulse pressure variation, PVPI: pulmonary vascular permeability index, RVEDVI: right ventricular end-diastolic volume index, RVR: renal vascular resistance, ScvO2: central venous oxygen saturation, SvO2: mixed venous oxygen saturation, SV: stroke volume, SVV: stroke volume variation
See this image and copyright information in PMC

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