Intravenous Fluid Administration in the Intensive Care Unit

Educational Objectives

The goal of this program is to improve use of intravenous (IV) fluids in the intensive care unit (ICU). After hearing and assimilating this program, the clinician will be better able to:

1. Select appropriate IV fluids for patient resuscitation in the ICU.

Summary

Hemodynamic monitoring: the goal is to optimize cardiac preload to deliver the best stroke volume (SV) during the cardiac cycle; accomplished through, eg, arterial line, central venous pressure, pulmonary artery catheterization, pulmonary capillary wedge pressure, echocardiography, pulse index continuous cardiac output (CO), lithium dilution CO, extravascular lung water (through, eg, plethysmography, laser Doppler imaging); CO, end-diastolic volume, and SV variation may inform about preload

Negative fluid balance: data show that maintaining a negative fluid balance ≤72 hr following admission to the intensive care unit (ICU) delivers the best outcome

When to administer intravenous (IV) fluids: change in hemodynamic parameters on passive leg raise is one of the best indicators for need for IV fluids; lack of change in hemodynamic parameters indicates when to discontinue IV fluids

Crystalloids: normal saline (NS) is an acidic, unbalanced solution that may be harmful to most people; buffered saline solutions are preferable for resuscitation; the SMART trial (Semler et al, 2018) concluded that patients who received IV NS had a 3-fold higher risk of requiring renal-replacement therapy (RRT) and a 2-fold higher risk of other complications, compared with patients who received a balanced crystalloid solution; the SALT-ED trial (Self et al, 2018) found that infusion of 1 L NS has significant impact on the requirement for RRT; in a study involving healthy volunteers, serum renin and aldosterone concentrations were elevated for 2 days after infusion of NS, and renal perfusion decreased ≤1 hr after infusion

Colloids: Lewis et al (2018) determined no difference in outcomes following administration of colloids vs crystalloids in the ICU; identifying patients requiring fluid volume reduction may be easier with colloid administration; the ALBIOS trial (Caironi et al, 2014) revealed no difference in 90-day mortality rate in patients who received colloids, compared with those who received crystalloids; some physiologic benefits (eg, lower heart rates, higher blood pressure) were observed in the colloid group

Readings

Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370(15):1412-1421. doi:10.1056/NEJMoa1305727; Self WH, Semler MW, Wanderer JP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819-828. doi:10.1056/NEJMoa1711586; Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839. doi:10.1056/NEJMoa1711584.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Smith was recorded at Trauma, Critical Care and Acute Care Surgery 2022, held March 28-30, 2022, in Las Vegas, NV, and presented by the Trauma and Critical Care Foundation. For more information about upcoming CME activities from this presenter, please visit https://www.trauma-criticalcare.com/. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS700503

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.