In this episode, I’ll discuss recent guidelines about fluid removal in critically ill patients.
The European Society of Intensive Care Medicine Clinical has published part 3 of its Practice Guideline on fluid therapy in adult critically ill patients, which addresses fluid removal during the de-escalation phase.
The title chosen is a bit unfortunate since de-escalation is often used to mean a reduction of treatment intensity or the cessation of treatment. Fluid removal in critically ill patients is more accurately referred to as deresuscitation as it is the active removal of excess fluid, not simply de-escalating the intensity of fluids administered. Two of the three recommendations issued refer to deresuscitation by removal of excess fluid, not de-escalation.
Semantics aside, the guideline authors conducted a meta-analysis of 13 randomized controlled trials, which they used to base the certainty of evidence for their 3 conditional recommendations.
The panel suggested de-escalation of fluid therapy over no de-escalation in critically ill adults after the acute phase of fluid resuscitation (low certainty evidence).
They suggested protocolized fluid removal by diuretics over usual care in critically ill patients after the acute phase of fluid resuscitation (moderate certainty evidence).
A conditional recommendation was issued against the routine use of ultrafiltration or extracorporeal fluid removal in critically ill adults after the acute phase of fluid resuscitation, without other indication for RRT (low certainty evidence).
A different way to think about the phases of care of a critically ill patient is to use the ROSE acronym, which stands for:
R – Resuscitation, which focuses on patient rescue (lasts for minutes)
O – Optimization, which focuses on organ rescue (lasts for hours)
S – Stabilization, which focuses on organ support (lasts for hours to days)
E – Evacuation, which focuses on organ recovery (lasts for multiple days)
Deresuscitation or active fluid removal typically occurs during the S or E phase, depending on patient needs.
The topic in this episode is inspired by an in-depth training available to members of my Hospital Pharmacy Academy. The Hospital Pharmacy Academy is my online membership site that will teach you practical critical care and hospital pharmacy skills you can apply at the bedside so that you can become confident in your ability to save lives and improve patient outcomes. To get immediate access to this and many other resources to help in your practice, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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