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Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy

Manu L N G Malbrain, Niels Van Regenmortel, Bernd Saugel, Brecht De Tavernier, Pieter-Jan Van Gaal, Olivier Joannes-Boyau, Jean-Louis Teboul, Todd W Rice, Monty Mythen, Xavier Monnet
Annals of Intensive Care 2018 May 22, 8 (1): 66
29789983
In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose and timing of intravenous fluid administration. There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications and for parenteral nutrition. In this paradigm-shifting review, we discuss different fluid management strategies including early adequate goal-directed fluid management, late conservative fluid management and late goal-directed fluid removal. In addition, we expand on the concept of the "four D's" of fluid therapy, namely drug, dosing, duration and de-escalation. During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase and the evacuation phase. The four questions are "When to start intravenous fluids?", "When to stop intravenous fluids?", "When to start de-resuscitation or active fluid removal?" and finally "When to stop de-resuscitation?" In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.

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Abdul Ansari wrote:

12

Very well conceptualized and excellent review of the perils of fluid administration ( under resuscitation versus overzealous ) . Hope this creates awareness about 'Guarded' prolonged fluid therapy..!

Terren Trott wrote:

10

"Therefore, current treatment of septic shock should
include every efort to reduce the cumulative fuid balance.
We must always bear in mind that fuids are drugs and
oedema is akin to a drug overdose. "

Good read!

b starks wrote:

2

Amen! Time to stop drowning our patients.

Edwin Cantillano wrote:

0

Its most apply in countries whit less resources bacouse of we dont have RRT

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