Fluid administration and monitoring in ARDS: which management?

• Type of Material: Article
• Authors: Philippe Vignon, Dupuytren Teaching Hospital; Bruno Evrard, Dupuytren Teaching Hospital; Pierre Asfar, CHU Angers; Mattia Busana, University of Gottingen; Carolyn S. Calfee, University of California San Francisco; Silvia Coppola, Polo Universitario; Julien Demiselle, CHU Angers; Guillaume Geri, Ambroise Pare University Hospital; Mathieu Jozwiak, Cochin Hospital; Gregory Martin, Emory University; Luciano Gattinoni, University of Gottingen; Davide Chiumello, Polo Universitario
• Language: English
• Date: 2020-11-09
• Publisher: SPRINGER
• Publication Version: Final Published Version
• Copyright Statement: © 2020, Springer-Verlag GmbH Germany, part of Springer Nature.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1007/s00134-020-06310-0
• Title of Journal or Parent Work: INTENSIVE CARE MEDICINE
• Volume: 46
• Issue: 12
• Start Page: 2252
• End Page: 2264
• Grant/Funding Information: None
• Keywords: electrolyte balance; SEPTIC SHOCK; Pulmonary edema; Prognosis; Critical Care Medicine; Fluid therapies; 100 ML; RESPONSIVENESS; Science & Technology; Acute respiratory distress syndrome; END-EXPIRATORY PRESSURE; Life Sciences & Biomedicine; MECHANICAL VENTILATION; RESPIRATORY-DISTRESS-SYNDROME; PULSE PRESSURE VARIATION; Water– ACUTE LUNG INJURY; General & Internal Medicine; TIDAL VOLUME; HYPOPROTEINEMIC PATIENTS
• Research Categories: Biology, Virology; Health Sciences, Health Care Management

Abstract

Modalities of fluid management in patients sustaining the acute respiratory distress syndrome (ARDS) are challenging and controversial. Optimal fluid management should provide adequate oxygen delivery to the body, while avoiding inadvertent increase in lung edema which further impairs gas exchange. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer ICU and hospital stay, and higher mortality. Accordingly, a restrictive strategy has been compared to a more liberal approach in randomized controlled trials conducted in various clinical settings. Restrictive strategies included fluid restriction guided by the monitoring of extravascular lung water, pulmonary capillary wedge or central venous pressure, and furosemide targeted to diuresis and/or albumin replacement in hypoproteinemic patients. Overall, restrictive strategies improved oxygenation significantly and reduced duration of mechanical ventilation, but had no significant effect on mortality. Fluid management may require different approaches depending on the time course of ARDS (i.e., early vs. late period). The effects of fluid strategy management according to ARDS phenotypes remain to be evaluated. Since ARDS is frequently associated with sepsis-induced acute circulatory failure, the prediction of fluid responsiveness is crucial in these patients to avoid hemodynamically inefficient—hence respiratory detrimental—fluid administration. Specific hemodynamic indices of fluid responsiveness or mini-fluid challenges should be preferably used. Since the positive airway pressure contributes to positive fluid balance in ventilated ARDS patients, it should be kept as low as possible. As soon as the hemodynamic status is stabilized, correction of cumulated fluid retention may rely on diuretics administration or renal replacement therapy.