Fluid and electrolyte overload in critically ill patients: An overview.
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as "maintenance" fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.
Bruno Adler Maccagnan Pinheiro Besen, André Luiz Nunes Gobatto, Lívia Maria Garcia Melro, Alexandre Toledo Maciel, Marcelo Park, Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo 05403000, Brazil.
Bruno Adler Maccagnan Pinheiro
BA
Besen
Bruno Adler Maccagnan Pinheiro Besen, André Luiz Nunes Gobatto, Lívia Maria Garcia Melro, Alexandre Toledo Maciel, Marcelo Park, Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo 05403000, Brazil.
André Luiz Nunes
AL
Gobatto
Bruno Adler Maccagnan Pinheiro Besen, André Luiz Nunes Gobatto, Lívia Maria Garcia Melro, Alexandre Toledo Maciel, Marcelo Park, Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo 05403000, Brazil.
Lívia Maria Garcia
LM
Melro
Bruno Adler Maccagnan Pinheiro Besen, André Luiz Nunes Gobatto, Lívia Maria Garcia Melro, Alexandre Toledo Maciel, Marcelo Park, Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo 05403000, Brazil.
Alexandre Toledo
AT
Maciel
Bruno Adler Maccagnan Pinheiro Besen, André Luiz Nunes Gobatto, Lívia Maria Garcia Melro, Alexandre Toledo Maciel, Marcelo Park, Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo 05403000, Brazil.
Marcelo
M
Park
Acute kidney injury; Central venous pressure; Critically Ill; Diuretics; Fluid therapy; Multiple organ dysfunction syndrome; Oliguria; Resuscitation; Systemic inflammatory response syndrome; Water-electrolyte balance