What is the recommended approach for replenishment under Vanderbilt guidelines?

Vanderbilt Fluid Replenishment Guidelines

The Vanderbilt fluid replenishment guidelines recommend an individualized fluid management approach with careful monitoring of fluid balance, guided by urine output and other end-point measurements, with daily adjustments based on the patient's clinical status. 1

Initial Fluid Resuscitation

• Establish adequate intravenous fluid replacement initially, with fluid requirements guided by urine output and other end-point measurements 1
• Site venous lines through non-lesional skin whenever possible, and change peripheral venous cannulas every 48 hours 1
• Monitor fluid balance carefully; catheterize if appropriate or necessary 1
• For severe cases requiring more precise monitoring, use continuous invasive hemodynamic monitoring through central or arterial lines 1

Ongoing Fluid Management

• Individualize fluid management and adjust on a daily basis according to patient needs 1
• Use markers of end organ function (urine output, serum lactate, base deficit, serum urea and electrolytes) to detect tissue hypoperfusion 1
• Be cautious of overhydration and resultant hyponatremia, especially in patients with limited access to vasopressors and mechanical ventilation 1
• Progressively increase oral administration of fluids as the patient's condition improves 1

Fluid Volume Guidelines

• For patients with sepsis or shock, initial resuscitation may require 20-30 ml/kg of crystalloid solution 1
• For patients with extensive skin involvement (as in Stevens-Johnson syndrome/toxic epidermal necrolysis), fluid requirements should be calculated based on body surface area affected 1
• Central lines should be changed if signs of sepsis or local infection are present, ideally every 5-7 days through non-lesional skin 1

Choice of Fluids

• Crystalloid solutions are the preferred first-line fluid choice due to lower costs and fewer side effects compared to colloids 1
• Consider human albumin solution as a second-line fluid choice in patients with refractory shock or requiring large volumes of crystalloid solutions 1
• For post-exercise rehydration, replace 100-150% of body mass losses, including electrolytes to maintain total body water 1

Monitoring Response to Fluid Therapy

• Use clinical measures of adequate tissue perfusion (capillary refill, skin temperature, degree of mottling, pulse, blood pressure, and conscious level) 1
• Lactate measurements can be used to assess adequate response, with a goal of 20% reduction in serum lactate over the first hour or absolute values ≤1.5 mmol/L 1
• For competitions or activities lasting several days, monitor hydration status using daily morning body mass and urine specific gravity 1

Nutrition Considerations During Fluid Replenishment

• Provide continuous enteral nutrition throughout acute phases of illness 1
• Deliver 20-25 kcal/kg daily during early, catabolic phases, and 25-30 kcal/kg daily during anabolic, recovery phases 1
• For athletes, ensure not only water and sodium losses are replenished but also carbohydrate stores 1

Special Considerations

• For patients with refractory volume overload and acute kidney injury, consider renal replacement therapy 1
• Immobile patients should receive low molecular weight heparin for thromboembolism prophylaxis 1
• Patients in whom enteral nutrition cannot be established should receive a proton pump inhibitor to reduce the risk of stress-related gastrointestinal ulceration 1

Criteria for Termination of Fluid Resuscitation

• Stop or interrupt fluid resuscitation when no improvement of tissue perfusion occurs in response to volume loading 1
• Be vigilant for signs of fluid overload or pulmonary edema, particularly in resource-limited settings 1
• Titrate fluid management carefully even in fluid-responsive patients 1