Make your ICU fluid stewardship

As a hospital pharmacist, you can improve fluid safety in the ICU, since fluids are used inappropriately in up to 20% of patients. Fluid stewardship aims to reduce harm by promoting judicious use during the “ROSE” phases resuscitation or rescue, optimization, stabilization, and evacuation.

Review fluids as you do other medications, right fluid, patient, amount, etc. Consider focusing first on the stabilization, or “maintenance fluid,” phase, a majority of interventions seem to occur here. Try to stop fluids once patients are in this phase. Keep in mind, patients who are eating usually don’t need maintenance fluids. And a patient’s parenteral or enteral nutrition may meet fluid needs. If you’re continuing maintenance fluids, individualize goals and give IV or enterally. Think of 25 to 30 mL/kg/day as a starting point. But consider when needs may be lower, such as kidney disease or heart failure. Also identify patients with significant “hidden” fluid intake, especially infusions, or piggybacks with at least 250 mL or given frequently (Q8H, Q6H, etc).

NPS-adv

Add up hidden fluids and subtract them from maintenance needs. For instance, a patient on vancomycin 1500 mg every 8 hours may get 1500 mL/day from vancomycin alone. If their fluid needs are 2 L/day, ensure other sources don’t exceed 500 mL/day. If hidden fluids exceed the patient’s needs, stop IV fluids and enteral water and adjust medications. For example, try to change an amiodarone drip to oral, or IV heparin to subcutaneous enoxaparin. If appropriate, consider concentrating infusions (pressors, parenteral nutrition, etc) or switching from piggyback to IV push for certain antibiotics, such as cefazolin or meropenem.

Reassess needs often. Follow trends in daily weights and fluid balance to help guide when to adjust or stop fluids. When choosing a fluid, debate continues about whether balanced fluids (lactated Ringer’s, etc) reduce kidney injury compared to normal saline. Weigh patient factors into your choice. For example, if lactated Ringer’s is your default, consider using normal saline instead to replace chloride from GI losses or for its higher sodium content in traumatic brain injury.

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References

1. Hawkins WA, Butler SA, Poirier N, Wilson CS, Long MK, Smith SE. From theory to bedside: Implementation of fluid stewardship in a medical ICU pharmacy practice. Am J Health Syst Pharm. 2022 Jun 7;79(12):984-992.
2. Hawkins WA, Smith SE, et al. Fluid Stewardship During Critical Illness: A Call to Action. J Pharm Pract. 2020 Dec;33(6):863-873.
3. Gamble KC, Smith SE, Bland CM, Sikora Newsome A, Branan TN, Hawkins WA. Hidden Fluids in Plain Sight: Identifying Intravenous Medication Classes as Contributors to Intensive Care Unit Fluid Intake. Hosp Pharm. 2022 Apr;57(2):230-236.
4. Kopp BJ, Lenney M, Erstad BL. Balanced Salt Solutions for Critically Ill Patients: Nonplused and Back to Basics. Ann Pharmacother. 2022 Apr 7:10600280221084380.
5. College of Pharmacy UGA. Fluid Stewardship. [online] Available at: https://rx.uga.edu/departments/academic/clinical-administrative-pharmacy/critical-care-collaborative/fluid-stewardship.

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