The Surgical Critically Ill Patients: A Focus on Deresuscitation Strategy

During more than one century, fluid management of critically ill trauma and surgery patients emphasized prevention and management of shock, notably hemorrhagic shock. This was conducted by replenishment of fluids, both crystalloids and blood-related. Volume reduction is a much more recent concept and a markedly counterintuitive one. Yet the diffuse interstitial edema created and the excess of body sodium content acquired in many circumstances probably mediate a large amount of the fluid overload-attributed complications. Indeed, they could increase the local pressure and thus participate in a perfusion decrease as observed in the abdominal compartment syndrome. The same phenomenon may be observed at the organ level in the encapsulated ones, such as the kidneys or the liver. Furthermore, interstitial edema distorts local architecture of the extracellular matrix, impairs local exchange (oxygen and metabolite diffusion, cell-cell interactions) and lymphatic drainage, decreasing its resorption. As recommended in acute heart failure, the use of a multifactorial approach associating clinical examination, ultrasound evaluation (and/or chest X-ray), and biological markers was recently proposed in critically ill patients, as a score to estimate clinical efficiency of “decongestion.”