While fluid responsiveness is directly relevant to emergency
care, a systematic review has found very little evidence (489 patients in
total) on which to base best practice. High quality, adequately powered outcome
studies are still lacking, so the place of fluid responsiveness in the
emergency department (ED) remains undefined, according to the review team.
Fluid therapy is a key part of resuscitation of the shocked
patient in ED. The immediate goal of fluid resuscitation is improving cardiac
output (CO) and ultimately improving tissue perfusion. If a fluid bolus does
not increase CO, it will not improve tissue perfusion and may be harmful. The
haemodynamic response to fluid loading, "fluid responsiveness" has
been suggested as a dynamic guide for fluid therapy and a controlled method of
resuscitation. Testing fluid responsiveness involves both a fluid challenge,
and subsequent monitoring of change in a haemodynamic parameter.
This review aimed to synthesise the existing literature
investigating fluid responsiveness in in-hospital emergency care. MEDLINE,
Embase and the Cochrane library were searched for relevant peer-reviewed
studies published from 1946 to present. A total of 249 publications were
retrieved of which 22 studies underwent full-text review and eight relevant
studies were identified.
Only three studies addressed clinical outcomes, including
two randomised controlled trials and one feasibility study, the review team
said. Five articles evaluated the diagnostic accuracy of fluid responsiveness
techniques in ED. Due to marked heterogeneity, the reviewers said, it was not
possible to combine results in a meta-analysis.
According to the review team, future studies should have
standardisation of patient groups, the target response and the underpinning
theoretic concept of fluid responsiveness. The value of a fluid responsiveness
based fluid resuscitation protocol needs to be established in a clinical trial,
the team added.
"As the benefit of fluid administration is often
related to early administration, we think that, despite the practical
difficulties, studying fluid resuscitation in the ED is fundamental for
improving patient outcomes," the authors write. "Fluid responsiveness
based resuscitation strategies have not been adequately tested in the ED to
know whether or not they influence outcome, but fluid responsiveness remains an
attractive concept."
Source: Scandinavian Journal of Trauma, Resuscitation andEmergency Medicine
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