title: Iatrogenic salt water drowning and the hazards of a high central venous pressure.
abstract: Current teaching and guidelines suggest that aggressive fluid resuscitation is the best initial approach to the patient with hemodynamic instability. The source of this wisdom is difficult to discern, however, Early Goal Directed therapy (EGDT) as championed by Rivers et al. and the Surviving Sepsis Campaign Guidelines appears to have established this as the irrefutable truth. However, over the last decade it has become clear that aggressive fluid resuscitation leading to fluid overload is associated with increased morbidity and mortality across a diverse group of patients, including patients with severe sepsis as well as elective surgical and trauma patients and those with pancreatitis. Excessive fluid administration results in increased interstitial fluid in vital organs leading to impaired renal, hepatic and cardiac function. Increased extra-vascular lung water (EVLW) is particularly lethal, leading to iatrogenic salt water drowning. EGDT and the Surviving Sepsis Campaign Guidelines recommend targeting a central venous pressure (CVP) > 8 mmHg. A CVP > 8 mmHg has been demonstrated to decrease microcirculatory flow, as well as renal blood flow and is associated with an increased risk of renal failure and death. Normal saline (0.9% salt solution) as compared to balanced electrolyte solutions is associated with a greater risk of acute kidney injury and death. This paper reviews the adverse effects of large volume resuscitation, a high CVP and the excessive use of normal saline.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk 23507, VA, USA.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Marik
keywords: Acute respiratory distress syndrome; Central venous pressure; Extra-vascular lung water; Fluid; Fluid balance; Fluid overload; ICU; Lactate Ringers Solution; Lung water; Mean circulatory filling pressure; Normal saline; Sepsis
references.citation: J Intensive Care Med. 2009 Jan-Feb;24(1):35-46
references.pmid: 19103612
references.citation: J Intensive Care Med. 2007 Sep-Oct;22(5):294-9
references.pmid: 17895487
references.citation: Chest. 2009 Jul;136(1):102-109
references.pmid: 19318675
references.citation: JAMA. 2012 Oct 17;308(15):1566-72
references.pmid: 23073953
references.citation: Intensive Care Med. 2013 Jul;39(7):1299-305
references.pmid: 23653181
references.citation: Chest. 2000 Jun;117(6):1749-54
references.pmid: 10858412
references.citation: N Engl J Med. 2001 Nov 8;345(19):1368-77
references.pmid: 11794169
references.citation: Crit Care. 2012 Jan 25;16(1):302
references.pmid: 22277834
references.citation: Sci Transl Med. 2011 Jun 22;3(88):88ps25
references.pmid: 21697528
references.citation: Am J Physiol Heart Circ Physiol. 2005 Nov;289(5):H1993-9
references.pmid: 15964925
references.citation: Resuscitation. 2009 Jul;80(7):811-8
references.pmid: 19467755
references.citation: Chest. 2006 Oct;130(4):962-7
references.pmid: 17035425
references.citation: Crit Care Med. 2013 Feb;41(2):472-80
references.pmid: 23263578
references.citation: Emerg Med J. 2010 Feb;27(2):110-5
references.pmid: 20156862
references.citation: N Engl J Med. 2006 Jun 15;354(24):2564-75
references.pmid: 16714767
references.citation: Anesthesiology. 1999 May;90(5):1265-70
references.pmid: 10319771
references.citation: Am J Physiol. 1990 Jul;259(1 Pt 2):H42-7
references.pmid: 2142859
references.citation: N Engl J Med. 2011 Jun 30;364(26):2483-95
references.pmid: 21615299
references.citation: Physiol Rev. 1955 Jan;35(1):123-9
references.pmid: 14356924
references.citation: Anesth Analg. 2001 Oct;93(4):817-22
references.pmid: 11574339
references.citation: Am J Physiol Heart Circ Physiol. 2012 Nov 15;303(10):H1245-54
references.pmid: 22961865
references.citation: Ann Intensive Care. 2011 Jun 07;1(1):17
references.pmid: 21906348
references.citation: J Physiol. 1894 Apr 17;16(3-4):159-318.7
references.pmid: 16992163
references.citation: Intensive Care Med. 2008 Apr;34(4):707-13
references.pmid: 18157662
references.citation: Clin Gastroenterol Hepatol. 2011 Aug;9(8):710-717.e1
references.pmid: 21645639
references.citation: Basic Res Cardiol. 2011 Nov;106(6):1111-21
references.pmid: 21769675
references.citation: Ann Surg. 2012 Jul;256(1):18-24
references.pmid: 22580944
references.citation: Chest. 1988 May;93(5):903-10
references.pmid: 3359845
references.citation: Crit Care Med. 2013 Jan;41(1):255-62
references.pmid: 23269130
references.citation: J Trauma. 1992 Aug;33(2):279-82; discussion 282-3
references.pmid: 1507294
references.citation: J Cereb Blood Flow Metab. 2009 Jun;29(6):1121-9
references.pmid: 19337275
references.citation: Crit Care. 2009;13(6):R186
references.pmid: 19930656
references.citation: J Neurosci. 2011 May 18;31(20):7477-85
references.pmid: 21593331
references.citation: Pflugers Arch. 1996 Feb;431(4):618-24
references.pmid: 8596707
references.citation: Crit Care Med. 2005 Feb;33(2):315-22
references.pmid: 15699833
references.citation: Crit Care. 2011;15(3):164
references.pmid: 21672278
references.citation: J Physiol. 1931 Jun 6;72(1):49-61
references.pmid: 16994199
references.citation: Sci Transl Med. 2010 Mar 17;2(23):23ra19
references.pmid: 20375003
references.citation: JAMA Intern Med. 2013 Jul 22;173(14):1369-72
references.pmid: 23752755
references.citation: Crit Care Med. 2011 Feb;39(2):259-65
references.pmid: 20975548
references.citation: J Crit Care. 2011 Apr;26(2):175-9
references.pmid: 20619601
references.citation: Am J Gastroenterol. 2011 Oct;106(10):1843-50
references.pmid: 21876561
references.citation: Intensive Care Med. 2013 Jul;39(7):1190-206
references.pmid: 23673399
references.citation: Crit Care Med. 2006 Feb;34(2):344-53
references.pmid: 16424713
references.citation: Best Pract Res Clin Anaesthesiol. 2009 Jun;23(2):145-57
references.pmid: 19653435
references.citation: Anaesthesia. 1997 May;52(5):422-7
references.pmid: 9165959
references.citation: Ann Intensive Care. 2011 Mar 21;1(1):1
references.pmid: 21906322
references.citation: Crit Care Med. 2014 Apr;42(4):954-61
references.pmid: 24335443
references.citation: BMC Med. 2013 Mar 14;11:68
references.pmid: 23496872
references.citation: Nat Rev Nephrol. 2014 Jan;10(1):37-47
references.pmid: 24217464
references.citation: Crit Care Med. 2004 Sep;32(9):1928-48
references.pmid: 15343024
references.citation: BMJ. 2012 Sep 11;345:e5752
references.pmid: 22968721
references.citation: J Am Coll Cardiol. 2008 Apr 1;51(13):1268-74
references.pmid: 18371557
references.citation: BMC Anesthesiol. 2013 Aug 07;13:17
references.pmid: 23919272
references.citation: Crit Care Med. 2013 Feb;41(2):580-637
references.pmid: 23353941
references.citation: FASEB J. 2008 Oct;22(10):3443-9
references.pmid: 18653766
references.citation: Physiol Rev. 2010 Jan;90(1):207-58
references.pmid: 20086077
references.citation: Crit Care Med. 2013 Jul;41(7):1774-81
references.pmid: 23774337
references.citation: Shock. 1998 May;9(5):364-8
references.pmid: 9617887
references.citation: Crit Care. 2008;12(3):R74
references.pmid: 18533029
references.citation: Chest. 2002 Dec;122(6):2080-6
references.pmid: 12475851
references.citation: N Engl J Med. 2001 Aug 23;345(8):588-95
references.pmid: 11529214
references.citation: Crit Care Med. 2013 Mar;41(3):857-66
references.pmid: 23318490
references.citation: Med Sci Sports Exerc. 1991 Aug;23(8):920-4
references.pmid: 1956265
references.citation: Crit Care Med. 2012 Mar;40(3):1004-6
references.pmid: 22343856
references.citation: Anesth Analg. 2013 Aug;117(2):412-21
references.pmid: 23757473
references.citation: Crit Care Med. 2012 Mar;40(3):847-54
references.pmid: 22036857
references.citation: Crit Care Med. 2013 Sep;41(9):2144-50
references.pmid: 23760152
references.citation: Nat Rev Nephrol. 2010 Feb;6(2):107-15
references.pmid: 20027192
references.citation: J Am Coll Cardiol. 2009 Feb 17;53(7):589-596
references.pmid: 19215833
references.citation: Crit Care. 2013 Mar 05;17(2):209
references.pmid: 23672779
references.citation: Crit Care Med. 2009 Dec;37(12):3114-9
references.pmid: 19789447
references.citation: Br J Anaesth. 2014 Apr;112(4):648-59
references.pmid: 24413429
references.citation: Crit Care Med. 2004 Mar;32(3):858-73
references.pmid: 15090974
references.citation: Shock. 2000 Aug;14(2):215-21
references.pmid: 10947169
references.citation: Crit Care Med. 2007 Feb;35(2):477-82
references.pmid: 17204996
references.citation: Acta Anaesthesiol Scand. 2002 Feb;46(2):166-72
references.pmid: 11942864
references.citation: Crit Care. 2013 Nov 29;17(6):R278
references.pmid: 24289206
references.citation: Crit Care Med. 2005 Oct;33(10):2235-40
references.pmid: 16215376
references.citation: Intensive Care Med. 2001 Sep;27(9):1446-58
references.pmid: 11685337
references.citation: Anesthesiology. 2008 Apr;108(4):735-48
references.pmid: 18362606
references.citation: Anesth Analg. 2012 Mar;114(3):640-51
references.pmid: 22253274
references.citation: Lymphology. 1996 Jun;29(2):67-75
references.pmid: 8823729
references.citation: J Trauma. 2011 Feb;70(2):398-400
references.pmid: 21307740
references.citation: Br J Anaesth. 2014 Apr;112(4):617-20
references.pmid: 24535603
references.citation: Lancet Diabetes Endocrinol. 2014 Apr;2(4):339-347
references.pmid: 24703052
references.citation: Am J Physiol. 1991 Mar;260(3 Pt 2):R610-4
references.pmid: 1825749
references.citation: N Engl J Med. 2014 May 1;370(18):1683-93
references.pmid: 24635773
references.citation: Respir Med. 2008 Jul;102(7):956-61
references.pmid: 18397821
references.citation: Ann Intensive Care. 2012 Dec 20;2 Suppl 1:S19
references.pmid: 23282242
references.citation: Am J Surg. 1998 Apr;175(4):308-10
references.pmid: 9568658
references.citation: Crit Care. 2013 Oct 20;17(5):R246
references.pmid: 24138869
references.citation: Intensive Care Med. 2012 Mar;38(3):422-8
references.pmid: 22278593
references.citation: Ann Surg. 2012 May;255(5):821-9
references.pmid: 22470070
references.citation: Crit Care Med. 2014 Jul;42(7):1585-91
references.pmid: 24674927
references.citation: Clin Sci (Lond). 2003 Jan;104(1):17-24
references.pmid: 12519083
references.citation: Kidney Int. 2009 Aug;76(4):422-7
references.pmid: 19436332
references.citation: Ann Intensive Care. 2012 Jul 05;2(Suppl 1 Diagnosis and management of intra-abdominal hyperten):S1
references.pmid: 22873410
references.citation: J Clin Invest. 1983 Mar;71(3):726-35
references.pmid: 6826732
references.citation: J Nephrol. 2005 Jan-Feb;18(1):54-60
references.pmid: 15772923