CRITICAL CARE MEDICINE SECTION
The Future of Fluid Resuscitation in Critically Ill Patients is Here. Or is It? Shadman Kabir, OMS-III, Elias Wan, MD, and David H. Gordon, MD
F
luid balance is a critical aspect in the management of critically ill patients. Maintaining the right balance of fluids in the body is essential for the proper organ and system function. However, critically ill patients often have fluid imbalances due to a variety of factors, such as injury, surgery, infection, or underlying medical conditions. Fluid overload in critically ill patients has been associated with increased mortality, longer length of stay in the intensive care unit (ICU), and a higher incidence of organ failure. Therefore, determining the most effective fluid balance control is essential for the management of critically ill patients. The POINCARE-2 study is a recent stepped wedge cluster-randomized trial that evaluated the effectiveness of a protocol-based approach to fluid balance control in critically ill patients.1 Over the course of three years, from May 2016 to May 2019, the study enrolled critically ill patients in 12 intensive care units from nine hospitals in France. The inclusion criteria for patients included at least 18 years old, under mechanical ventilation, admitted to one of the 12 recruiting units for more than 48 and up to 72 hours, and expected to have a length of stay greater than 24 hours after inclusion. Out of 10,272 patients screened, 1361 met the inclusion criteria and 1353 completed follow-up. The POINCARE-2 intervention involved daily weight-based restriction of fluid intake, diuretic administration, and ultrafiltration in case of renal replacement therapy from day 2 to day 14 after admission. The primary outcome was all-cause mortality at 60 days. Intention-to-treat analyses were used for both cluster-randomized analyses (CRA) and randomized before-and-after analyses (RBAA). The results indicate that there was a total of 905 patients included in the study, with 433 patients in the strategy group and 472 patients in the control group for the cluster-randomized analysis (CRA), and 643 patients in the strategy group and 718 patients in the control group for the randomized before-and-after analysis (RBAA). The mean age and weight at admission were similar between the two groups in the CRA. In the strategy group, 129 patients died compared to 160 in the control group, and the difference in 60-day mortality rates between the two groups was not statistically significant. The safety outcomes showed that hypernatremia was more frequent in the strategy group compared to the control
group. Similar results were obtained from the RBAA analysis. These findings suggest that the POINCARE-2 strategy did not result in a significant reduction in mortality compared to standard care. However, the use of the POINCARE-2 strategy was associated with a higher risk of severe hypernatremia, which has also been observed in an ARDS network trial and a protocoled diuresis trial for de-resuscitation in the ICU.2,3 Growing evidence suggests that iatrogenic hypernatremia leads to an increased risk of mortality, highlighting the importance of addressing this issue.4 In conclusion, effective fluid balance control in critically ill patients requires a multidisciplinary approach that includes nurses, physicians, and other health care personnel. Regular monitoring of fluid intake, output, and balance is essential for detecting and managing fluid imbalances. The POINCARE-2 strategy did not yield a statistically significant reduction in mortality; however, it did demonstrate an observational reduction in both 60 and 28 day mortality rates. Due to differences in current global clinical practice, reduced compliance, or contamination of data, it is imperative to conduct large, sufficiently powered trials to evaluate the clinical efficacy of the POINCARE-2 strategy in critically ill patients while monitoring & treating for hypernatremia. References 1. Bollaert PE, Monnier A, Schneider F, et al. Fluid balance control in critically ill patients: results from POINCARE-2 stepped wedge clusterrandomized trial. Crit Care. Feb 21 2023;27(1):66. doi:10.1186/s13054023-04357-1 2. Bissell BD, Laine ME, Thompson Bastin ML, et al. Impact of protocolized diuresis for de-resuscitation in the intensive care unit. Crit Care. Feb 28 2020;24(1):70. doi:10.1186/s13054-020-2795-9 3. National Heart L, Blood Institute Acute Respiratory Distress Syndrome Clinical Trials N, Wiedemann HP, et al. Comparison of two fluidmanagement strategies in acute lung injury. N Engl J Med. Jun 15 2006;354(24):2564-75. doi:10.1056/NEJMoa062200 4. Lindner G, Funk GC, Schwarz C, et al. Hypernatremia in the critically ill is an independent risk factor for mortality. Am J Kidney Dis. Dec 2007;50(6):952-7. doi:10.1053/j.ajkd.2007.08.016
COMMON SENSE MAY/JUNE 2023
45