Not an intensivist, but a severe septic shock survivor x2 with enough medical background to follow much of this article. My first episode was prolonged, starting in a community hospital where typical patient LOS was 3-4 days; I was there 6 weeks before being transferred (still comatose) to a university hospital. Fluid overload was one strategy to maintain desired MAP. This resulted in massive interstitial fluid accumulation such that I gained about 25 lbs in fluid weight and my skin “wept fluid” (according to both family and a few nursing notes). Dialysis was finally started at my daughter’s request, with significant improvement in reduction of edema within a few days.
But my point here is to please also consider long-term sequelae of your medical practices.
In my case, (1) massive edema from fluid overload made me more unstable, so pposition changes were minimal - only supine and semi side-lying for 6 weeks. When finally turned prone for a hail-Mary procedure by interventional radiology, a large quantity of very foul drainage came from my lungs. This clearance was the turning point for my survival (hospice had been on notice), but having that in my lungs for weeks also worsened interstitial scarring from ARDS. My PFT’s are stable, but with moderate lung damage - thankfully not severe.
And (2), arthritis LOVES edema. PT was not considered to mobilize fluid, elevate UE’s for drainage, use compression garments or provide ROM. Global joint changes followed. A stable scoliosis worsened by 50%; I am now fused from C4 to my sacrum, and C1-C3 are kyphotic. My knees degraded and have both had surgical replacements. My hands were frozen in abnormal alignment and have never fully regained function - this is perhaps (personally) my greatest impairment.
Why do I include my story here? Perhaps in hopes of skilled and caring intensivists considering potential unintended sequelae of their interventions, and possible mitigations along the way. In no way minimizing the heroic efforts that saved my life, balancing the massive fluids given for my septic shock hypotension with earlier dialysis, proning, and early physical therapy (essential with prolonged coma patients to initiate ROM, therapeutic positioning and compression garments) could have dramatically improved my post-critical illness morbidity and function.
I thank you for sharing your experiences as a survivor. It is so important. I was once asked to prepare a presentation about post-critical care syndrome, and I decided to find and interview doctors who survived critical care. I found only two, but this was a mind-changing experience. I vividly remember a ~60-year-old gyn surgeon crying like a baby in front of me.
When I was a "protocol droid" in the early 2000s, I would easily infuse 5 - 7 liters of crystalloids to emulate our thought leaders in a series of misconceptions about fluid therapy, one being the idea that you have a goal or target. Our thought leaders pretend they didn't take physiology classes. I deeply disbelieve in the whole idea of infusing fluids on an otherwise well-hydrated septic patient, save for small amounts in the first 2 or 3 hours if cardiovascular collapse appears imminent. Every liter of fluid will have to be removed later.
This whole post is about it. We are easily lured by artifacts we call fluid responsiveness, and more recently, fluid tolerance. Both are minor propositions made after a major proposition, namely, the dogmatic idea that it could benefit the patient in distributive shock. The major proposition has been refuted, but people fail to refute the minors.
The net result of applying those techniques is fluid overload, as you experienced it.
Thank you for listening! My critical care pulmonologist and nurse manager of the first ICU were not interested in my sharing my experience with staff. My motive was always educational, never to cast blame. We can always think critically, learn from outcomes, and become better clinicians/providers; you obviously do that, and your patients/their families/colleagues/students will all benefit.
Not an intensivist, but a severe septic shock survivor x2 with enough medical background to follow much of this article. My first episode was prolonged, starting in a community hospital where typical patient LOS was 3-4 days; I was there 6 weeks before being transferred (still comatose) to a university hospital. Fluid overload was one strategy to maintain desired MAP. This resulted in massive interstitial fluid accumulation such that I gained about 25 lbs in fluid weight and my skin “wept fluid” (according to both family and a few nursing notes). Dialysis was finally started at my daughter’s request, with significant improvement in reduction of edema within a few days.
But my point here is to please also consider long-term sequelae of your medical practices.
In my case, (1) massive edema from fluid overload made me more unstable, so pposition changes were minimal - only supine and semi side-lying for 6 weeks. When finally turned prone for a hail-Mary procedure by interventional radiology, a large quantity of very foul drainage came from my lungs. This clearance was the turning point for my survival (hospice had been on notice), but having that in my lungs for weeks also worsened interstitial scarring from ARDS. My PFT’s are stable, but with moderate lung damage - thankfully not severe.
And (2), arthritis LOVES edema. PT was not considered to mobilize fluid, elevate UE’s for drainage, use compression garments or provide ROM. Global joint changes followed. A stable scoliosis worsened by 50%; I am now fused from C4 to my sacrum, and C1-C3 are kyphotic. My knees degraded and have both had surgical replacements. My hands were frozen in abnormal alignment and have never fully regained function - this is perhaps (personally) my greatest impairment.
Why do I include my story here? Perhaps in hopes of skilled and caring intensivists considering potential unintended sequelae of their interventions, and possible mitigations along the way. In no way minimizing the heroic efforts that saved my life, balancing the massive fluids given for my septic shock hypotension with earlier dialysis, proning, and early physical therapy (essential with prolonged coma patients to initiate ROM, therapeutic positioning and compression garments) could have dramatically improved my post-critical illness morbidity and function.
Thank you for all you do!
I thank you for sharing your experiences as a survivor. It is so important. I was once asked to prepare a presentation about post-critical care syndrome, and I decided to find and interview doctors who survived critical care. I found only two, but this was a mind-changing experience. I vividly remember a ~60-year-old gyn surgeon crying like a baby in front of me.
When I was a "protocol droid" in the early 2000s, I would easily infuse 5 - 7 liters of crystalloids to emulate our thought leaders in a series of misconceptions about fluid therapy, one being the idea that you have a goal or target. Our thought leaders pretend they didn't take physiology classes. I deeply disbelieve in the whole idea of infusing fluids on an otherwise well-hydrated septic patient, save for small amounts in the first 2 or 3 hours if cardiovascular collapse appears imminent. Every liter of fluid will have to be removed later.
This whole post is about it. We are easily lured by artifacts we call fluid responsiveness, and more recently, fluid tolerance. Both are minor propositions made after a major proposition, namely, the dogmatic idea that it could benefit the patient in distributive shock. The major proposition has been refuted, but people fail to refute the minors.
The net result of applying those techniques is fluid overload, as you experienced it.
Thank you again for sharing.
Rafael.
Thank you for listening! My critical care pulmonologist and nurse manager of the first ICU were not interested in my sharing my experience with staff. My motive was always educational, never to cast blame. We can always think critically, learn from outcomes, and become better clinicians/providers; you obviously do that, and your patients/their families/colleagues/students will all benefit.