Application and control of intravenous fluids in German intensive care units: A national survey among critical care physicians

Background: The administration of intravenous fluids includes various indications, e.g., fluid replacement, nutritional therapy or as a solvent for drugs and is a common routine in the intensive care unit (ICU); however, overuse of intravenous fluids can lead to fluid overload, which can be associated with a poorer outcome in critically ill patients. Objective: The aim of this survey was to find out the current status of the use and management of intravenous fluids as well as the interprofessional cooperation involving clinical pharmacists on German ICUs. Methods: An online survey with 33 questions was developed. The answers of 62 participants from the Scientific Working Group on Intensive Care Medicine of the German Society for Anesthesiology and Intensive Care Medicine were evaluated. Results: Fluid overload occurs "frequently" in 62.9% (39/62) and "very frequently" in 9.7% (6/62) of the ICUs of respondents. An established standard for an infusion management system is unknown to 71.0% (44/62) of participants and 45.2% of the respondents stated that they did not have a patient data management system. In addition, the participants indicated how they define fluid overload. This was defined by the presence of edema by 50.9% (28/55) and by positive fluid balance by 30.9% (17/55). According to the participants septic patients (38/60; 63.3%) and cardiological/cardiac surgical patients (26/60; 43.3%) are most susceptible to the occurrence of fluid overload. Interprofessional collaboration among intensive care physicians, critical care nurses, and clinical pharmacists to optimize fluid therapy was described as "relevant" by 38.7% (24/62) and "very relevant" by 45.2% (28/62). Participants with clinical pharmacists on the wards (24/62; 38.7%) answered this question more often as "very relevant" with 62.5% (15/24). Conclusion: Fluid overload is a frequent and relevant problem in German intensive care units. Yet there are few established standards in this area. There is also a lack of validated diagnostic parameters and a clear definition of fluid overload. These are required to ensure appropriate and effective treatment that is tailored to the patient and adapted to the respective situation. Intravenous fluids should be considered as drugs that may exert side effects or can be overdosed with severe adverse consequences for the patients. One approach to optimize fluid therapy could be achieved by a fluid stewardship corresponding to comparable established procedures of the antibiotic stewardship. In particular, fluid stewardship will contribute to drug safety of intravenous fluids profiting from joined expertise in a setting of interprofessional collaboration. An important principle of fluid stewardship is to consider intravenous fluids in the same way as medication in terms of their importance. Furthermore, more in-depth studies are needed to investigate the effects of interprofessional fluid stewardship in a prospective and controlled manner.