The decision-making behind a fluid resuscitation prescription and the evidence-based assessment tools that are available to support it: A mixed-methods study

Seccombe, Adam W. ORCID: 0000-0002-9789-4332 (2022). The decision-making behind a fluid resuscitation prescription and the evidence-based assessment tools that are available to support it: A mixed-methods study. University of Birmingham. M.Sc.

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Abstract

Fluid resuscitation is a commonly used treatment that has the potential to be life-saving when used correctly but harmful in excess. This is particularly true in sepsis where harm has been described in the absence of clinical features of hypervolaemia. Despite this, it is unclear how patients with sepsis should be assessed for fluid resuscitation in an acute medical setting. Furthermore, clinicians frequently fail to perform a fluid assessment, raising questions about the underlying decision-making process.

A systematic review of diagnostic test accuracy studies was completed to assess diagnostic tests that identify a need for fluid resuscitation as defined by the presence of fluid responsiveness. It identified 14 studies in adults with sepsis who would be appropriate for admission to an acute medical unit. Five categories of index test were studied (haemodynamic change following passive leg raise, haemodynamic change with respiration, haemodynamic change following fluid bolus, inferior vena cava collapsibility index and static assessment tools), however a high level of heterogeneity and a high risk of bias prevented meaningful comparisons.

A qualitative study was then undertaken to explore the decision-making process used by acute physicians to determine when fluid resuscitation was required. 18 clinicians of varying grades consented to a semi-structured interview. Transcripts were coded and analysed using thematic analysis. The decision-making process was heavily influenced by the identification of a patient as sick, which was informed by a limited fluid assessment, as well as a ‘pro-fluid’ culture that limited the impact of features of fluid overload. More experienced clinicians valued a flexible approach to decision-making in contrast to junior clinicians who preferred a standardised approach. Both decision-making approaches were informed by information from the limited assessment. Clinicians of all grades also highlighted a ‘proper’ assessment, based on learning at medical school, which was felt to be important yet simultaneously ineffective.

Because of the dearth of evidence identified by the systematic review, the guideline development group of NICE CG174 has had to rely on consensus opinion to develop recommendations on how the decision to give fluid resuscitation should be made. Of note, their recommendations matched the findings of the qualitative study. To address this evidence gap, the effectiveness of commonly used diagnostic tests, such as fluid responsiveness, should be evaluated. In addition, the decision-making process that clinicians use to determine when fluid responsiveness is required should be explored so that future iterations of guidelines can reflect current clinical practice.

Type of Work:

Thesis (Masters by Research > M.Sc.)

Award Type:

Masters by Research > M.Sc.

Supervisor(s):