Where do we stand on Fluids? There have been a few interesting papers published recently, so I figured I'd get PulmCrit and EMNerd to discuss some of them as well as where we stand on fluids in 2022.
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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This is always an interesting topic. I would agree with the general sentiment that despite the lack of findings in the CLASSIC trial, there likely remains some benefit in a tighter control of fluid balances for ICU-based patients with sepsis. Likely there wasn’t enough of a volume differential to produce a finding and it may be that even the standard therapy group may land more on the restrictive end of the spectrum if compared to a non-research-setting standard ICU group. This trial also had a fairly high level of protocol deviations which may skew results towards a null finding. I… Read more »
Michael
Great comments as always!!
I keep coming back to the sticking point in our prior debates. If you substitute 20 ml/lkg for 30 then we are in full agreement. The 30 ml demand really has no good evidence behind it and was taken from nowhere. And there are signals of harm, Send you one meta-analysis during our debate. Here is another one:
30 ml in Fluid Overloaded
Hey Scott, thanks for the reply and sorry for my somewhat prolonged radio silence. Per our previous conversation on this topic, I do agree. One would have a hard time finding a difference in outcomes with a prespecified volume of 20 mL/kg vs 30 mL/kg. However, per your podcast, the critique on the existing guidelines seemed to go beyond this. Similar to the previous meta-analysis you had sent my way, this one is even more head scratching in nature. Our friends at AJEM should have done better here. -1) A “statistically non-significant increased odds of mortality” without any impact on… Read more »
Mike, Really don’t know what you mean–we could not have been more clear about 2 things: Most patients in the ED stage of sepsis can and should receive a fluid bolus. Almost any patient can tolerate 20 mls/kg.The studies under discussion on this podcast were about the ICU stage of sepsis AFTER this initial fluid resus. There is no evidence or basis for a jump from 20 mls to 30 mls The burden of proof lies with you on this one–you need to show that a required intervention is better than standard care. We have huge RCTs demonstrating this is… Read more »
Thanks for the reply, Scott. As I have mentioned in our previous discussions, it would be hard to argue the points you bring up. A mandate would ideally have a higher level of evidence attached to it. I can’t say I am a major fan of most mandates. Regarding SEP, there is an allowance for less than 30 mL/kg based on provider documentation. This is probably somewhat redundant, but I would argue there is some burden of proof on the side that seems to attach an overly cautious warning for fluids as recommended. There is this low-level dog whistle (sometimes… Read more »
well i think that is a good place to leave the fluid stuff, but “dog whistle,” seriously? Are you really using that term to mean here what is means in a poliyical realm. If so, that is rather derogatory.
Sorry, Scott. That wasn’t meant to be derogatory in the least. I didn’t mean an ounce of disrespect with that, truly. Just sort of meant that it seemed to ‘suggest’ fluid harms without more directly saying it. Perhaps some bad terminology. I think that term means something a lot different now than what it used to (at least to me).
gotcha, Michael!
Thank you for your kind words! I’m glad that we can have productive debates. Regarding the fluid administration rates in critically ill patients, I agree that there is some controversy about the optimal rate. While some studies have suggested that higher fluid administration rates may improve outcomes, others have indicated potential harms associated with aggressive fluid resuscitation. The meta-analysis you mentioned, which looked at fluid administration rates in fluid-overloaded patients, suggests that higher rates of fluid administration may be associated with increased mortality. However, it’s worth noting that this study has some limitations, including heterogeneity among the included trials and… Read more »