Aiming for zero fluid accumulation: First, do no harm.

Area of Science:

• Critical Care Medicine
• Nephrology
• Pharmacology

Background:

• Critically ill patients are frequently presumed to require continuous intravenous (IV) fluids, often leading to overhydration.
• Excessive fluid administration and subsequent fluid overload are linked to adverse patient outcomes, increased morbidity, and mortality.
• Current fluid prescription practices often involve outdated paradigms and potential malpractice, such as inappropriate fluid selection or administration for maintenance.

Purpose of the Study:

• To provide a pragmatic overview of novel concepts regarding intravenous fluid use in critically ill patients.
• To emphasize individualized fluid therapy needs, moving away from routine maintenance infusions.
• To discuss the importance of active deresuscitation and achieving a zero cumulative fluid balance.

Main Methods:

• Review of existing evidence supporting a restrictive fluid approach.
• Analysis of common clinical scenarios and indications for IV fluid therapy.
• Discussion of the definition and implications of fluid overload.

Main Results:

• Fluid overload, defined as a 10% increase in cumulative fluid balance from baseline weight, is an independent predictor of morbidity, mortality, and increased hospital costs.
• A restrictive fluid strategy is increasingly supported by evidence.
• Overzealous fluid administration in patients already receiving oral intake can lead to "fluid creep" and overload.

Conclusions:

• Intravenous fluids should be prescribed judiciously, considering patient-specific factors and the risks versus benefits of therapy.
• Routine maintenance IV fluids are not indicated unless clinically necessary.
• Active deresuscitation and a focus on achieving a zero cumulative fluid balance are crucial for optimizing outcomes in critically ill patients.