Stop Drowning Your Patients! Safe Fluid Resuscitation with Nicole Kupchik

When fluid resuscitating a hypotensive patients, how do you know when to continue with IV fluids and when to initiate vasopressors? In this episode, critical care teaching legend Nicole Kupchik, RN MSN CNS, shares evidence-based practices for determining the best course of action. Explore the significance of noninvasive measurements in assessing fluid responsiveness and learn how incorrect decisions can lead to adverse patient outcomes. 

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Effects of IV fluid overload

  • Increased intra abdominal pressures: kidney injury, compression of inferior vena cava causes hemodynamic instability
  • Pulmonary edema: impaired oxygen exhange, ARDS
  • Decreased mobilization

How to assess for fluid responsiveness

If a patient is fluid responsive, it means that if more IV fluids are given, their stroke volume will increase.

The passive leg raise test (PLR) is a noninvasive technique for assessing stroke volume and, thus, fluid responsiveness.

Passive Leg Raise (PLR) Technique

  • Sit patient at a 45 degree angle, assess stroke volume
  • Lower patient HOB down and passively raise their legs 45 degrees, re-assess stroke volume in 2-3 minutes
  • A 10% or more increase in stroke volume indicates positive fluid responsiveness

Examples of noninvasive devices used to assess for fluid responsiveness

Edwards ClearSight
Baxter’s Starling Device

Which IV fluid is best?

Balanced crystalloid solutions (i.e. lactated ringer, Plasma-Lyte, Normosol) are recommended for sepsis, DKA, and pancreatitis fluid resuscitation.

Many studies, such as the following, have demonstrated that balanced crystalloids are associated with better patient outcomes, as they don’t cause secondary acidosis and hyperchloremia associated with large amounts of normal saline.