What is the ideal IV fluid? (#iFADmini #IFAD2018)

Take Home message on the ideal fluid (lecture by @Manu_Malbrain #14ECCC #iFADmini Dubai):

• The ideal IV fluid does not exist
  • Different fluids have different (contra)indication during the different phases
• Resuscitation fluids should save lives: give them in appropriate dose and timing
  • 4ml/kg/10 minutes and repeat
  • Set your targets appropriately to reach your goals
  • Targets and goals are dynamic and can change during different phases
• Maintenance fluids should cover daily needs
  • for water: 1ml/kg/hr
  • for glucose: 1 – 1.5 g/kg
  • for Sodium (Na): 1 – 1.5 mEq/kg
  • for Potassium (K): 0.5 – 1 mEq/kg
• Replacement fluids should the fluids that were lost
  • Give saline or NH4Cl (multion gastrique) in case of GI losses
  • Give blood when bleeding
• Fluids in sepsis and in general ICU patients
  • Never use starches (little evidence for gelatins)
  • Don’t use (abnormal) saline (NaCl 0.9%) or glucose 5% for resuscitation
  • You can use saline to dilute drugs (max 1ml/kg/first week)
  • Use (balanced) crystalloids for resuscitation
  • Consider albumin 20%, esp. in very sick septic patients at later stage and during de-resuscitation
  • Cover daily needs with…? Hypotonic solutions probably better than isotonic
• Fluids in perioperative setting (+ trauma)
  • We can’t extrapolate from the big fluid trials and need dedicated studies, beyond fluid choice alone
  • Starches still could have their place, but… we are awaiting final EMEA decision on PRAC recommendation
    • In their dedicated setting: acute and proven hypovolemia
    • With great care (maximum dose 30ml/kg, not in AKI or CKI, not in sepsis or burns)
  • Gaps best to be filled by balanced crystalloids (not saline), little evidence for gelatins
  • More emphasis on fluid strategy than on the fluid itself
• Implement Fluid Stewardship in your hospital and ICU
  • Start with snapshot
    • Check what you use (pharmacy)
    • Perform survey on knowledge (doctors and nurses)
    • Clinical audit (medical records and patient files)
  • PDCA cycle
    • Set-up guidance
    • Start teaching
    • Re-evaluation after 6 months
      
      
• Link to Video on Vimeo: https://vimeo.com/263125026