Fluid trials: searching for a solution to an age-old problem
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EDITORIAL
Fluid trials: searching for a solution to an age‑old problem Tine Sylvest Meyhoff1* , Peter Buhl Hjortrup1 and Anthony Delaney2,3 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
For nearly two centuries, intravenous fluids have been used to treat the critically ill patient [1]. Despite this omnipresent practice, the task of choosing the right fluid solution and volume to infuse remains challenging for clinicians, researchers and policymakers [2, 3]. Although adequately powered randomized clinical trials (RCTs) have been published, the only strong recommendation, based on high quality of evidence, is to avoid the use of hydroxyethyl starch [2]. Patients cared for in intensive care units (ICUs) receive vast amounts of intravenous fluids, including carrier fluids, maintenance fluids, resuscitation fluids, and fluids to replace losses [4]. It has recently been suggested that administering excessive fluid volumes could potentially be harmful [5–7]. How, then, may clinicians safely reduce fluid administration, without exposing patients to the risk of harm associated with hypovolemia? Different approaches have been tested; trials have aimed to limit fluid input by different means, with some using hemodynamic triggers, some administering fluids only to those deemed “fluid responsive”, and others applying a lower threshold for the administration of vasopressors. In the HERACLES trial by Pfortmüller et al., published in this issue, [8] a further approach was attempted, namely to limit fluid input in post-cardiac surgery patients through infusion of hypertonic saline. Hypertonic saline expands the intravascular volume due to a shift of fluids from the extravascular to the intravascular space, a principle perhaps most commonly used in the treatment of acute brain injury [9]. This mechanism has the potential to improve hemodynamic status, *Correspondence: [email protected] 1 Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Full author information is available at the end of the article
while allowing administration of a lower volume of fluid [10]. It is an appealing physiological approach when dealing with the critically ill, including patients following cardiac surgery, a population in which there is a shortage of evidence that might help to identify patients requiring additional fluids. It is noteworthy that the rationale for the use of hypertonic saline in this population was based solely on the expected physiological benefits. This is analogous to the arguments used to support the use of hydroxyethyl starches; their volume-expanding properties were expected to benefit critically ill patients, but when subsequently tested in RCTs, they were found to be associated with harm [11]. This is a story that clearly underlines the importance of RCTs to evaluate the balance between benefits and potential harm. The HERACLES trial [8] was a randomized, doubleblinded, single-center trial investigating the effects of a single infusion of 5 ml/kg of
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