Dawei Liu

F Michard

Huaiwu He

JA Myburgh

NJ Glassford

RL Parke

RP Dellinger

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He and Liu Critical Care  (2015) 19:360 DOI 10.1186/s13054-015-1078-3LETTER Open AccessFluid bolus therapy is a medical therapy ora diagnostic method?Huaiwu He and Dawei Liu*See related research by Glassford et al., http://www.ccforum.com/content/18/6/696We read with interest the recently published articleabout the physiological changes after fluid bolus therapy(FBT) in Critical Care by Glassford et al. [1]. We areconcerned about the concept of FBT in this study.The authors claim that alternative interventions toFBT may include a diagnostic low-volume FBT, classicfluid challenge, low-volume FBT and low dose vasopres-sor therapy, or cardiac output-guided therapy. So, FBTcould be interpreted as a treatment and a diagnosticmethod for hypovolemia. We thought this interpretationwould cause misunderstanding about FBT. FBT is com-monly used to assess fluid responsiveness in hemodynamicmanagement, which is also called ‘fluid challenge’ [2]. FBTAuthors’ responseNeil J Glassford, Glenn M Eastwood and Rinaldo Bellomo* Correspondence: tjmuhhw@163.comDepartment of Critical Care Medicine, Peking Union Medical CollegeHospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, DongchengDistrict, Beijing, China© 2015 He and Liu. Open Access This articleInternational License (http://creativecommonsreproduction in any medium, provided you gthe Creative Commons license, and indicate if(http://creativecommons.org/publicdomain/zeessentially helps physicians to quickly make decisions re-garding fluid management. So, when hypovolemia has beenpreviously definitively diagnosed, it might be improper todefine a bolus of fluid such as FBT. We believe that FBT ismainly a diagnostic method and not a method of therapy.We acknowledge that FBT could also be interpreted as aspecial mode of fluid infusion, but this point is unclear inthe study by Glassford et al.FBT resulted in a positive outcome in only about 50 %of cases in the ICU [3]. In other words, FBT should beavoided in half of critically ill patients. So, we think inves-tigations should focus on how to reduce unnecessary FBTbut not the physiological effects of FBT over 2 to 4 h.Liu and He ask if FBT is a medical therapy or diagnosticmodality; the answer is, of course, context sensitive. Inthe context of the immediate management of the septic,critically ill patient, the administration of, often large,volumes of fluid in the form of FBT are an internationaltherapeutic standard of care [4, 5]. FBT is also respon-sible for large proportions of therapeutic fluid adminis-tration in the critically ill [6] and other populations,including cardiac surgery patients [7]. In the context ofthis review, a fluid bolus was a defined volume of a de-fined fluid over a defined period of time [1].We wonder if the confusion arises from one of thefundamental problems with research into fluid adminis-tration, fluid resuscitation and fluid responsiveness - thelack of fixed terminology. Moreover, fluid responsivenessis a complex topic, and not what we sought to investi-gate. We note that, in general, fluid responsiveness isidentified retrospectively, and therefore tautologically.Indeed, from the evidence we were able to identify, thereis very limited evidence for persistent physiological im-provement even in patients identified as ‘fluid respon-sive’ [1].We feel the question is not one of individual pa-tient fluid responsiveness, but a larger one regardingthe need to demonstrate the independent efficacy ofFBT in improving patient outcomes. Such evidence islacking in critically ill patients, whether fluid respon-sive or not.is distributed under the terms of the Creative Commons Attribution 4.0.org/licenses/by/4.0/), which permits unrestricted use, distribution, andive appropriate credit to the original author(s) and the source, provide a link tochanges were made. The Creative Commons Public Domain Dedication waiverro/1.0/) applies to the data made available in this article, unless otherwise stated.He and Liu Critical Care  (2015) 19:360 Page 2 of 2AbbreviationFBT: Fluid bolus therapy.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsHH and DL drafted the manuscript. Both authors read and approved thefinal manuscript.Authors’ informationHWH is an attending doctor and DWL is the Chief Director in the CriticalCare Medicine Department of the Peking Union Medical College Hospital.References1. Glassford NJ, Eastwood GM, Bellomo R. Physiological changes after fluidbolus therapy in sepsis: a systematic review of contemporary data. Crit Care.2014;18:696.2. Cecconi M, Hofer C, Teboul JL, Pettila V, Wilkman E, Molnar Z, et al. Fluidchallenges in intensive care: the FENICE study: a global inception cohortstudy. Intensive Care Med. 2015. [Epub ahead of print].3. Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: acritical analysis of the evidence. Chest. 2002;121:2000–8.4. Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, et al. Asystematic review and meta-analysis of early goal-directed therapy forseptic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive CareMed. 2015. [Epub ahead of print].5. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al.Surviving sepsis campaign: International guidelines for management ofsevere sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637.6. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al.Hydroxyethyl starch or saline for fluid resuscitation in intensive care.N Engl J Med. 2012;367:1901–11.7. Parke RL, McGuinness SP, Gilder E, McCarthy LW. Intravenous fluid use aftercardiac surgery: a multicentre, prospective, observational study. Crit CareResusc. 2014;16:164–9.

Critical Care

Fluid bolus therapy is a medical therapy or a diagnostic method?

https://ccforum.biomedcentral.com/track/pdf/10.1186/s13054-015-1078-3?site=ccforum.biomedcentral.com

Fluid bolus therapy is a medical therapy or a diagnostic method?

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