Higher versus lower volumes of fluids in critically ill patients

Simon Oczkowski, MD, MHSc, MSc, is an assistant professor in the Department of Medicine and Department of Health Research Methods, Evidence, and Impact at McMaster University and coauthor of Surviving Sepsis Campaign guidelines.

Recently there has been a lot of debate about higher versus lower volumes of fluids to be used in critically ill patients. What are your own principles in this regard?

When it comes to giving fluids in critical care, there’s been a lot of debate over giving more fluids or less fluids. In my time in practice, we’ve changed from very, very liberal fluid administration in the early goal-directed therapy days to... now the pendulum seems to be swinging more towards giving conservative fluids.

My perspective on this is that actually the door has not shut on any of these strategies and that we really do need more research. But for the time being what I do in my everyday practice is until I know that more fluids are going to be helpful and I’ve given a fluid test or a fluid challenge, I do not continue to prescribe fluid.

So, if I see a patient, I see signs of hypoperfusion, altered mentation, low blood pressure, high heart rate, low urine output that I think might be amenable to fluid, my approach is [to] treat the patient in front of me, give a fluid test, and follow up very quickly to see if that fluid was helpful or not.

I don't think that targeting a specific amount of fluid is necessarily as helpful. And I think a really tailored patient-centered approach for the person right in front of you is the way to go until we have more evidence on what to do.