In this episode, I’ll discuss deresuscitation of patients in the ICU.
Since the first Surviving Sepsis Campaign, guidelines have contained a strong emphasis on early and aggressive fluid resuscitation for patients in septic shock. While this focus on fluid resuscitation is widely regarded as a cornerstone of the treatment of severe sepsis and septic shock, it presents its own set of clinical problems when it continues longer than necessary or is taken to the extreme.
An excessively positive fluid balance can lead to edema (both peripheral and pulmonary) as well as renal congestion. Such effects have been linked with increased mortality. This has led to research on 2 main strategies to combat the effects of over-resuscitation: Restrictive fluid strategies and de-resuscitation strategies.
Deresuscitation involves the active removing of excess fluid, usually by diuretic therapy or dialysis.
The term deresuscitation was first published in 2012 in a review article of fluid strategies in surgical ICU patients.
On social media, the term was used as early as 2013 by @fluid_academy:
DERESUSCITATION at ISICEM in Brussels: http://t.co/TSO79sNMek
— Fluid Academy (@Fluid_Academy) March 23, 2013
…and the late Dr. John Hinds:
— John Hinds (@DocJohnHinds) November 16, 2013
Dr. Hinds described his aggressive deresuscitation strategies in an interview published posthumously on the EmCrit podcast episode 154.
In the few years since the first apparent uses of the term deresuscitation, evidence has mounted to suggest that not only is a positive fluid balance detrimental to patient survival, but the act of deresuscitation is associated with lower mortality.
The most convincing article to date is a retrospective cohort study that took place in 10 ICUs in the UK and Canada. 400 patients were analyzed, and 87% of these patients had a positive fluid balance. A positive fluid balance on day 3 of ICU stay was associated with increased mortality with an odds ratio of 1.26. Patients who had deresuscitation measures applied in the form of furosemide administration or dialysis had a statistically significantly lower odds of mortality with a odds ratio of 0.29. In addition, about half of the patients who later achieved a negative fluid balance did so spontaneously, and this was associated with a mortality odds ratio of 0.21.
This study also points to the cause of positive fluid balance being more likely from maintenance IV fluid and medication diluent administration than from initial fluid bolus and resuscitation measures.
This suggests that positive fluid balances in ICU patients may be easily avoidable by paying close attention to the daily dose of IV fluids given in the form of maintenance fluids and diluents from medications.
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