Pitfalls in fluid management for critically Ill patients in Thailand

Abstract

Fluid management is one of the most important treatments for critically ill patients. It has an influence in patients outcomes and is considered one of the most common pitfalls encountered in the management of the critically ill patient. In Thailand, fluid overload (>10% of fluid accumulation), mismanagement of fluid restrictions and the "bolusing" of colloid solutions are the main pitfalls that may lead to serious complications. These complications can compromise the patient in areas such as decreasing the oxygen index, putting the patient in cardiac failure and possible acute kidney injury (AKI). They can also increase resource utilization and the mortality of critically ill patients. More than 80% of critically ill patients, who are admitted to the intensive care units, are reimbursed from the "universal coverage". Universal coverage does not support the use of albumin solution, which has been reported to improve the function of the endothelial glycocalyx layer, vascular permeability and improved outcomes in the hypoalbuminemic patient (serum albumin <2.5 mg/dL) with severe sepsis, in septic shock or undergoing major abdominal surgery. Therefore, primary colloids used for resuscitation the patients are 6% hydroxyethyl starch (HES), 4% gelatin and fresh frozen plasma. AKI and renal replacement therapy (RRT) continue to be a major problem when using these synthetic colloids especially in the high-risk patients who receive large amounts of fluids. Evaluation of the fluid responsiveness for goal directed therapy is another problem in Thailand. This has been predominant in critically ill surgical patients both intra-operatively and postoperatively. To obtain optimal benefits of fluid therapy and for the prevention of complications associated with this treatment, physician need to acquire more knowledge, choose the right strategy, choose the proper type and amount of colloid and assure the correct mode of evaluation.