Lung Ultrasound-Guided Fluid Management versus Standard Care in Surgical ICU Patients: A Randomised Controlled Trial.

Daniel-Mihai Rusu,Ianis Siriopol,Adrian Constantin Covic,Mihai Onofriescu,Ioana Grigoraș,Adi-Ionut Ciumanghel,Gigel Sandu,Mihaela Blaj,Olguta Lungu

doi:10.3390/diagnostics11081444

Abstract

The value of lung ultrasound (LU) in assessing extravascular lung water (EVLW) was demonstrated by comparing LU with gold-standard methods for EVLW assessment. However, few studies have analysed the value of B-Line score (BLS) in guiding fluid management during critical illness. The purpose of this trial was to evaluate if a BLS-guided fluid management strategy could improve fluid balance and short-term mortality in surgical intensive care unit (ICU) patients. We conducted a randomised, controlled trial within the ICUs of two university hospitals. Critically ill patients were randomised upon ICU admission in a 1:1 ratio to BLS-guided fluid management (active group) or standard care (control group). In the active group, BLS was monitored daily until ICU discharge or day 28 (whichever came first). On the basis of BLS, different targets for daily fluid balance were set with the aim of avoiding or correcting moderate/severe EVLW increase. The primary outcome was 28-day mortality. Over 24 months, 166 ICU patients were enrolled in the trial and included in the final analysis. Trial results showed that daily BLS monitoring did not lead to a different cumulative fluid balance in surgical ICU patients as compared to standard care. Consecutively, no difference in 28-day mortality between groups was found (10.5% vs. 15.6%, p = 0.34). However, at least 400 patients would have been necessary for conclusive results.

Highlights

Despite increasing awareness of the deleterious effects of fluid overload (FO) [1] and the advances made in guiding fluid therapy [2,3,4,5], avoiding FO in intensive care unit (ICU) patients remains challenging
We found that the B-Line score (BLS)-guided fluid management effect on the primary outcome was significantly different across subgroups of patients with emergency surgery and sepsis/septic shock
A possible explanation for the lack of significant difference in cumulative FB (CFB) and short-term mortality between groups is that we examined BLS-guided fluid management within the context of ERAS pathways

Summary

Introduction

Despite increasing awareness of the deleterious effects of fluid overload (FO) [1] and the advances made in guiding fluid therapy [2,3,4,5], avoiding FO in intensive care unit (ICU) patients remains challenging. FO is multifactorial [13], but the challenge of finding the right moment to start fluid de-escalation is a major contributor; for instance, clinical examination, FB, chest X-ray, and patients’ oxygen requirements are often used by clinicians to trigger fluid de-escalation over more reliable (but more invasive) volume assessment methods [14]. In this context, the possible value of monitoring extravascular lung water (EVLW) with lung ultrasound (LU) in order to individualise fluid management and improve outcome has recently come into question [15]

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Discussion

Conclusion