I'm sorry. I must have missed something. I didn't mean to suggest you were wrong or to debate you, just the idea of primary "outcomes" (i.e. mortality)-based care.
Yes, one can always argue that association doesn't mean causation, but that's for mortality purposes. I don't need statistics to "prove" that fluid overload will cause pulmonary edema, increased oxygen requirements, hence intubation, VAP etc., or abdominal organ congestion and decreased tissue perfusion, hence AKI, hence bowel ischemia, or hemodilution hence unnecessary transfusions, or cardiac strain hence ischemia and heart failure, hence more hypotension and organ ischemia, hence central lines with more of their complications etc. etc. etc. And this is just the tip of the hypervolemia iceberg.
It's known pathophysiology (i.e. it's been proven before). And it's much easier to prevent than to treat. Even Hippocrates knew this. First do no harm.
Of course I am not talking about the super sick patient on 3 pressors, where the physiology is already a big mess. That ship has probably sailed. I am talking about the patient who is still salvageable, who still has time for therapeutic trials that don't involve fluids. Why fluid overload him, instead of trying pressors first? Just because it's more convenient? Why chase numbers that have been proven to mean nothing, e.g. urine output? Why not try to understand the physiology, instead of jumping on some knee-jerk protocol?
It drives me nuts when people who don't KNOW critical care and/or physiology are allowed to play fluid resuscitation. Fluid responsive does not mean hypovolemic, it only means that a fluid bolus will increase the stroke volume. So what? It does the same in healthy individuals and we don't drown them in fluids because of that. It's STUPID to treat vasodilation with fluids. If a shock is secondary to low SVR (as in OP's example), there is no reason to give fluids. IV fluids should be given only to replace loss of intravascular fluid, not for basically any hypotension (that's just PGY-1 level, no offense). People should learn how to use simple things such as a peripheral phenylephrine infusion or bolus (both SAFE peripherally), fix the MAP faster than it takes to bolus salted or lactated crap, which can't be always diuresed as easily as people think; and not wait till the patient is fluid overloaded, still hypotensive, and still needing pressors. People should learn to use a bedside echo and calculate a VTI or cardiac output, and derive a SVR (or drop a Swan for CO/SVR monitoring if TTE is too much to ask), or just use some imprecise fancy bioimpedance or waveform monitoring or whatever toy (anything is better than guessing). People should stop guesstimating fluid overload based on archaic jokes such as a chest X-ray, and learn to do a lung ultrasound, and see the increase in lung water before it's obvious clinically. And some people should start by reading Marik's EB Critical Care book (since all those great and free CCM blogs are too much for the "busy professional" anyway), and would probably become 3 times better intensivists overnight, because critical care has changed tremendously in those 10 years since they last read current literature. And some people should definitely stop TEACHING others. End of rant.
