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Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy

Malbrain, MLNG; Van Regenmortel, N; Saugel, B; De Tavernier, B; Van Gaal, P-J; Joannes-Boyau, O; Teboul, J-L; ... Monnet, X; + view all (2018) Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Annals of Intensive Care , 8 , Article 66. 10.1186/s13613-018-0402-x. Green open access

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Abstract

In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose and timing of intravenous fluid administration. There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications and for parenteral nutrition. In this paradigm-shifting review, we discuss different fluid management strategies including early adequate goal-directed fluid management, late conservative fluid management and late goal-directed fluid removal. In addition, we expand on the concept of the "four D's" of fluid therapy, namely drug, dosing, duration and de-escalation. During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase and the evacuation phase. The four questions are "When to start intravenous fluids?", "When to stop intravenous fluids?", "When to start de-resuscitation or active fluid removal?" and finally "When to stop de-resuscitation?" In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.

Type: Article
Title: Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy
Location: Germany
Open access status: An open access version is available from UCL Discovery
DOI: 10.1186/s13613-018-0402-x
Publisher version: https://doi.org/10.1186/s13613-018-0402-x
Language: English
Additional information: Copyright © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Keywords: Antibiotics, De-escalation, De-resuscitation, Dose, Drug, Duration, Fluid management, Fluid responsiveness, Fluid stewardship, Fluid therapy, Fluids, Four D’s, Four hits, Four indications, Four phases, Four questions, Goal-directed therapy, Maintenance, Monitoring, Passive leg raising, Replacement, Resuscitation
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > UCL GOS Institute of Child Health
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > UCL GOS Institute of Child Health > Infection, Immunity and Inflammation Dept
URI: https://discovery.ucl.ac.uk/id/eprint/10050839
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