The 4-indications of Fluid Therapy: Resuscitation, Replacement, Maintenance and Nutrition Fluids, and Beyond

Malbrain, M.L.N.G. et al. (2024). The 4-indications of Fluid Therapy: Resuscitation, Replacement, Maintenance and Nutrition Fluids, and Beyond. In: Malbrain, M.L., Wong, A., Nasa, P., Ghosh, S. (eds) Rational Use of Intravenous Fluids in Critically Ill Patients. Springer, Cham. https://doi.org/10.1007/978-3-031-42205-8_8

Summary of "The 4 Indications of Fluid Therapy: Resuscitation, Replacement, Maintenance, and Nutrition"

Abstract

Intravenous (IV) fluid administration is critical in managing critically ill patients. Despite the many questions about fluid type, properties, speed, dose, and timing, there are four main indications for IV fluid use: resuscitation, replacement, maintenance, and nutrition. This chapter discusses these indications and fluid management strategies, including early adequate goal-directed fluid management (EAFM), late conservative fluid management (LCFM), and late goal-directed fluid removal (LGFR). It introduces the six D’s of fluid therapy: diagnosis, drug, dosing, duration, de-escalation, and discharge, providing a comprehensive understanding of IV fluid therapy.

Introduction

IV fluid administration in critically ill patients poses a therapeutic challenge. Key aspects include fluid type, speed, dose, and timing. There are four major indications for IV fluids: resuscitation, replacement, maintenance, and nutrition. Fluid management strategies like EAFM, LCFM, and LGFR are discussed. The chapter also explores the concept of the six D’s of fluid therapy, providing clinicians with a systematic approach.

The Four Indications

1. Resuscitation Fluids:
2. Maintenance Fluids:
3. Replacement Fluids:
4. Nutrition Fluids:

Fluid Management Strategies

1. Early Adequate Fluid Management (EAFM):
2. Late Conservative Fluid Management (LCFM):
3. Late Goal-Directed Fluid Removal (LGFR):

The Six D’s of Fluid Therapy

1. Diagnosis: Correct diagnosis of shock, hypovolemia, and fluid responsiveness.
2. Drug: Type of fluid, considering clinical factors and patient conditions.
3. Dose: Appropriate dosing based on patient condition and pharmacokinetics of fluids.
4. Duration: Fluid administration should be as short as possible.
5. De-escalation: Taper fluids when no longer needed.
6. Discharge: Ensure adequate fluid and electrolyte intake post-discharge.

The Four Phases (ROSE Concept)

1. Resuscitation: Early fluid therapy to rescue the patient and save lives.
2. Optimization: Monitor and support organ function.
3. Stabilization: Achieve two consecutive negative daily fluid balances within the first week of ICU stay.
4. Evacuation: Late goal-directed fluid removal through diuretics or ultrafiltration.

The Four Hits Model

1. Initial Insult: The first phase of severe circulatory shock.
2. Ischemia-Reperfusion: Reflects the severity of illness.
3. Global Increased Permeability Syndrome (GIPS): Persistent fluid accumulation and capillary leak.
4. Hypoperfusion: Result of hypovolemia, needing accurate fluid status assessment.

Conclusions

IV fluid therapy in critically ill patients involves understanding the four major indications: resuscitation, maintenance, replacement, and nutrition. The six D’s and the ROSE concept offer a structured approach to fluid therapy. Fluid stewardship, akin to antibiotic stewardship, ensures optimal patient outcomes and minimizes risks associated with fluid therapy.

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Watch the following video on "Assessing Fluid Responsiveness in 2023" by SCCM

Discussion Questions

1. What are the main indications for IV fluid therapy, and how do they differ in terms of clinical application?
2. How can the six D’s framework be used to optimize fluid therapy in critically ill patients?
3. What are the potential risks of improper fluid management, and how can they be mitigated through the ROSE concept?

Javier Amador-Casta?eda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

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