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

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.

Shown for reading. Its publisher allows quoting it, not republishing it.

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    Not in our library10.5603/ait.a2015.0064

Cited by papers we hold 7

• Biological impact of restrictive and liberal fluid strategies at low and high PEEP levels on lung and distal organs in experimental acute respiratory distress syndrome · 2022
  Not checked
• Effective hemodynamic monitoring · 2022
  No notice
• Prediction of fluid responsiveness. What’s new? · 2022
  No notice
• Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations · 2021
  Not checked
• Expiratory flow limitation developed in ICU patients: relationship of fluid overload, respiratory mechanics, and outcome · 2020
  Not checked
• Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA) · 2020
  No notice
• Cytokine removal in human septic shock: Where are we and where are we going? · 2019
  No notice

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