Kidney Week 2025 Annual Meeting-Fluid Therapy in Critical Care: Innovations, Controversies, and Future Directions

Video Transcription

Video Summary

This critical care session on fluid therapy covered when to give fluids, when to stop, and how to safely remove excess fluid.<br /><br />Marlies Ostermann focused on “de-resuscitation” and fluid removal. While fluids are essential early in shock, excess fluid leaks into interstitial spaces, worsening organ function, including kidney injury due to venous congestion and increased intrarenal pressure. Safe fluid removal requires matching removal rate to the (unmeasurable) capillary refill rate to avoid hypotension and organ ischemia. New European guidelines (based on 13 heterogeneous RCTs) suggest fluid removal can shorten ICU and ventilator days, recommend diuretics conditionally after resuscitation when overload causes harm, and recommend against routine first-line ultrafiltration unless another indication for renal replacement therapy exists. Ostermann reviewed causes of furosemide resistance and strategies such as dose escalation, combination diuretics, and possible albumin co-administration; albumin may also reduce hypotension during ultrafiltration.<br /><br />Leonard Yesayan reviewed shock phenotypes and resuscitation endpoints, emphasizing multimodal assessment (clinical signs, lactate trends, capillary refill time, ScvO2/SvO2, veno-arterial CO2 gap, and dynamic fluid responsiveness tests). Lactate-guided resuscitation improves outcomes; capillary refill–guided strategies are non-inferior and may reduce fluid administration. Dynamic tests (especially passive leg raise with stroke volume/cardiac output change) outperform CVP, and PLR-guided strategies reduce fluid balance and organ support needs. Blood pressure targets vary: MAP ≥65 in sepsis, permissive hypotension in uncontrolled hemorrhage, and avoiding MAP <65 in cardiogenic shock. Early vasopressors with restricted fluids are supported by recent trials.<br /><br />Amanda Zeidman described tools to assess volume status and congestion, highlighting ultrasound-based VExUS (IVC plus hepatic/portal/renal venous Doppler), bioimpedance methods, and invasive monitors (PAC, transpulmonary thermodilution, pulse contour analysis). She stressed avoiding single-data-point “anchoring,” and noted CVP is a poor standalone volume marker.<br /><br />Hsu reviewed crystalloid composition and acid-base effects. Large trials comparing balanced crystalloids vs saline show mixed individual results, but Bayesian meta-analysis suggests a modest probability of mortality benefit with balanced fluids (except possible harm in traumatic brain injury). Bicarbonate therapy trials in severe acidosis did not improve mortality but may reduce/delay need for kidney replacement therapy in severe AKI.

Asset Subtitle

Moderator(s): Jorge Cerda, J. Pedro Teixeira

Presentation(s):

De-Resuscitation and Fluid Overload: Managing the Tipping Point - Marlies Ostermann
Resuscitation in Shock: Timing, Strategies, and End Points - Lenar Yessayan
Precision Fluid Therapy: Tools and Techniques for Tailored Care - Amanda Zeidman
Fluid Composition and Acid-Base Balance: Unraveling the Evidence - Edward Siew

Meta Tag

Date 11/7/2025

Pathway 1 AKI and Critical Care

Session ID 506832

Keywords

critical care

fluid therapy

shock resuscitation

de-resuscitation

fluid overload

fluid removal

diuretics

furosemide resistance

ultrafiltration

renal replacement therapy

venous congestion

VExUS ultrasound

passive leg raise test

lactate-guided resuscitation

balanced crystalloids vs saline