title: Evidence-based fluid management in the ICU.
abstract: OBJECTIVE
  Evidence-based fluid therapy is complicated by blurred boundaries toward other fields of therapy and the majority of trials not focusing on patient-relevant outcomes. Additionally, recent trials unsettled the faith in traditional concepts on fluid therapy. The article reviews the evidence on diagnosis and treatment of hypovolemia and discusses the use of balanced solutions and early goal-directed therapy (EGDT) in septic shock resuscitation.
  
  
  RESULTS
  Hypovolemia should be diagnosed and its treatment guided by a multifaceted approach, including medical history, physical examination, volume responsiveness, and technical parameters - dynamic indicators, volumetric indicators, sonography, and metabolic indicators. Central venous pressure and pulmonary artery occlusion pressure should be avoided. In ICU patients, balanced crystalloids should primarily be used, because unbalanced infusions (especially saline) cause hyperchloremic acidosis which is associated with renal impairment and infections. Colloids are beneficial to restore blood volume rapidly. Hydroxyethyl starch may be harmful although the validity of the respective recent studies is limited by methodological flaws. Early aggressive fluid therapy is still beneficial in septic shock resuscitation, despite recent trials challenging the EGDT concept. Today, 10 years after Rivers, 'usual care' includes aggressive fluid resuscitation that is as effective as formal EGDT.
  
  
  CONCLUSIONS
  Evidence-based fluid therapy includes a multifaceted diagnostic approach, the primary use of balanced crystalloids and early aggressive (septic) shock resuscitation.
authors.affiliation: Department of Intensive Care Medicine University Hospital, Aachen, Germany.
authors.forename: Achim W
authors.initials: AW
authors.lastname: Schindler
authors.forename: Gernot
authors.initials: G
authors.lastname: Marx
mesh_terms: D000138:Acidosis / Q000209:etiology; D002302:Cardiac Output; D003102:Colloids / Q000009:adverse effects / Q000627:therapeutic use; D003422:Critical Care / Q000379:methods*; D000077324:Crystalloid Solutions; D055416:Evidence-Based Emergency Medicine / Q000379:methods*; D005440:Fluid Therapy / Q000009:adverse effects / Q000379:methods*; D006321:Heart / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D020896:Hypovolemia / Q000175:diagnosis / Q000628:therapy*; D007362:Intensive Care Units; D007552:Isotonic Solutions / Q000009:adverse effects / Q000627:therapeutic use; D012151:Resuscitation / Q000379:methods; D012772:Shock, Septic / Q000628:therapy; D013318:Stroke Volume
chemical_list: D003102:Colloids; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions