Fluids in septic shock too much of a good thing.docVIP

Groeneveld Critical Care 2010,14:101 /content/14/1/101 COMMENTA RY Fluids in septic shock: too much of a good thing? AB Johan Groeneveld* See related research by Brandt et al., /content/13/6/R186 cardiac output responses assessed by esophageal Doppler - Abstract the doses used for ? uid loading were relatively ? xed In a recent issue of Critical Care, Brandt and colleagues report the e?ects of a‘liberal’?uid loading protocol compared to a more‘restrictive’protocol on rather than completely based on cardiac ? uid responses (? uid responsivene e latter is preferable at the bedside, even if we do not formally know whether such therapy causes less morbidity and mortality in septic shock than using ? xed volumes or guiding infusion according to relatively crude hemodynamics, such as the central venous pressure, as currently recommended [5]. It is likely, however, that tailored ‘liberal’ therapy decreases the risk for iatrogenic and detrimental ? uid hemodynamics and mortality in pigs in which septic shock had been induced. It appears that the former protocol was associated with higher mortality in spite of improved hemodynamics compared to the latter. The results of the paper are discussed here in view of the scope and mechanisms of these ?ndings. With regard to ?uid resuscitation, they indicate that too much of an otherwise good thing is harmful, even if overhydration and edema formation seem to have been prevented. They also do not exclude a speci?c toxic e?ect of the larger volumes of hydroxyethyl starch in the‘liberal’ strategy. The precise nature of a toxic e?ect remains obscure, however, but may involve the kidneys. overload compared to ? xed ‘liberal’ thera e debate about ? xed ‘restrictive’ versus ‘liberal’ versus ‘goal- directed’ therapy in the case of major surgery is also unresolved [2,3,9]. Di? ering results among studies, which may relate to di? ering case mi