Fluid management

Fluid therapy is often used as a means of maintaining adequate organ tissue perfusion and oxygenation. However, too much fluid given to a TBI patient may result in cerebral oedema and raised intracranial pressure.

The main goal of fluid management in TBI patients has undergone a number of paradigmatic shifts. We have moved away from a dehydration strategy which aimed to limit cerebral oedema. This was advocated by Shenkin et al²⁴ and was used throughout the 1990s. The Trauma Foundation Guidelines of the early 2000s recommended euvolaemia or hypervolaemia. However, the 2007 and 2016 editions of the BTF guidelines recommendations regarding fluid management were removed due to an absence of high-quality evidence¹⁸.

In 2018, the European Society of Intensive Care Medicine (ESICM) released consensus-based practice recommendations, suggesting normovolaemia (which was not rigorously defined), using arterial BP and fluid balance the main safety endpoints to which to titrate fluid to. This consensus statement came about after an extensive literature search based on Grading of Recommendations Assessment, Development and Evaluation system evaluation of the quality of evidence found high-quality evidence to be lacking²⁵.

One of the most common interventions in the ED is to give IV fluids in response to hypotension. Fluid therapy has been widely studied in various contexts relating to the critically ill patient in large studies such as the SPLIT and SMART trials comparing plasmalyte and 0.9% sodium chloride; the FENICE study looking at fluid bolus administration in ICU patients; and BaSICS which, through subgroup analysis, suggests that patients with TBI may benefit from receiving saline solution, rather than balanced solutions.

However, the amount of evidence directly applicable to the critically ill TBI patient is limited, resulting in variable clinical practice and controversial best practice guidelines. This months paper aims to answer this question.