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Organ SUpport

4.1 Prescribes drugs and therapies safely 

4.2 Manages antimicrobial drug therapy

4.3 Administers blood and blood products safely

4.4 uses fluids and vasoactive / inotropic drugs

4.5 Describes the use of mechanical assist devices to support the circulation

4.6 Initiates, manages, and weans patients from invasive and non-invasive ventilatory support

4.7 Initiates, manages, and weans patients from renal replacement therapy 

4.8 Recognises and manages electrolyte, glucose and acid-base disturbances

4.9 Co-ordinates and provides nutritional assessment and support 

Organ Support

How I manage Fluids. John Myburgh describes his approach to managing Fluids at the Critical Care Reviews Conference 2017 Belfast

January 01, 2020

'The How I Manage' section of the critical care reviews conference 2017 had the who's whos of ICM describing how they manage patients. These are shorter than some of the other lectures and useful insights into real practice.

This post was John Myburgh describing how he approaches fluids on his ITU.


Key points 

  • Fluid is the most common intervention in our patients- still a relatively evidence free area

  • Fluids should be given with as much caution as any toxic IV drugs

  • Consider type, dose, indication, contraindication, potential for toxicity and cost

  • Only give resuscitation fluids for patients with symptomatic hypovolaemia

  • He challenges the concept of a fluid challenge in patients who are not symptomatically hypovolaemic

  • Describes the purpose of a fluid challenge is to partly restore the venous capacitance system of the blood in a complex physiological system

  • Replace known losses e.g. GI, sweating, dehydration, bleeding

  • Fluid won’t necessarily fix the problem of hypotension in the absence of fluid loss

  • Serum sodium/osmolality and acid base are important determinants of the fluid to give

  • Remember each fluid bolus is adding to the cumulative fluid balance that is associated with pathological oedema and adverse outcomes

  • Use early patient specific catecholamines in symptomatic hypotension  

  • Remember fluid requirements change over time in the patients journey- few indications for a fluid challenge after 48 hrs in a patient

  • Avoid maintenance fluids

  • Oliguria should not be used as a sole indication for fluid administration- he challenges the concept of fluid challenges for oliguria

  • Measurements of fluid responsiveness have limited application- need to weigh up the whole picture

  • Give bleeding patients blood products

  • Isotonic crystalloid is appropriate in critically ill patients

  • Normal saline is appropriate in alkalaemic or hypochloraemic patients or brain injury

  • Albumin may be appropriate in early sepsis but avoid in brain injury.

  • Avoid starches in all patients, avoid synthetic colloids

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