The administration of fluids is one of the most common interventions in the intensive care unit. The effects and side effects of intravenous fluids depend on the amount administered and their specific composition. Intravenous fluid solutions are either considered crystalloids (for example 0.9% saline, lactated Ringer's solution) or colloids (artificial colloids such as gelatins, and albumin). This narrative review summarizes the physiological principles of fluid therapy and reviews the most important studies on crystalloids, artificial colloids and albumin in the context of critically ill patients.

Summary: Background: Widely varying mortality rates of critically ill Coronavirus disease 19 (COVID-19) patients in the world highlighted the need for local surveillance of baseline characteristics, treatment strategies and outcome. We compared two periods of the COVID-19 pandemic to identify important differences in characteristics and therapeutic measures and their influence on the outcome of critically ill COVID-19 patients.Methods: This multicenter prospective register study included all patients with a SARS-CoV‑2 infection confirmed by polymerase chain reaction, who were treated in 1 of the 12 intensive care units (ICU) from 8 hospitals in Tyrol, Austria during 2 defined periods (1 February 2020 until 17 July: first wave and 18 July 2020 until 22 February 2021: second wave) of the COVID-19 pandemic.Results: Overall, 508 patients were analyzed. The majority (n = 401) presented during the second wave, where the median age was significantly higher (64 years, IQR 54–74 years vs. 72 years, IQR 62–78 years,p < 0.001). Invasive mechanical ventilation was less frequent during the second period (50.5% vs 67.3%,p = 0.003), as was the use of vasopressors (50.3% vs. 69.2%,p = 0.001) and renal replacement therapy (12.0% vs. 19.6%,p = 0.061), which resulted in shorter ICU length of stay (10 days, IQR 5–18 days vs. 18 days, IQR 5–31 days,p < 0.001). Nonetheless, ICU mortality did not change (28.9% vs. 21.5%,p = 0.159) and hospital mortality even increased (22.4% vs. 33.4%,p = 0.039) in the second period. Age, frailty and the number of comorbidities were significant predictors of hospital mortality in a multivariate logistic regression analysis of the overall cohort.Conclusion: Advanced treatment strategies and learning effects over time resulted in reduced rates of mechanical ventilation and vasopressor use in the second wave associated with shorter ICU length of stay. Despite these improvements, age appears to be a dominant factor for hospital mortality in critically ill COVID-19 patients.

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) raises concerns as to whether it contributes to an increased mortality. The incidence of CAPA varies widely within hospitals and countries, partly because of difficulties in obtaining a reliable diagnosis. We implemented a routine screening of respiratory specimens in COVID-19 ICU patients for Aspergillus species using culture and galactomannan (GM) detection from serum and/or bronchoalveolar lavages (BAL). Out of 329 ICU patients treated during March 2020 and April 2021, 23 (7%) suffered from CAPA, 13 of probable, and 10 of possible. In the majority of cases, culture, microscopy, and GM testing were in accordance with CAPA definition. However, we saw that the current definitions underscore to pay attention for fungal microscopy and GM detection in BALs, categorizing definitive CAPA diagnosis based on culture positive samples only. The spectrum of Aspergillus species involved Aspergillus fumigatus, followed by Aspergillus flavus, Aspergillus niger, and Aspergillus nidulans. We noticed changes in fungal epidemiology, but antifungal resistance was not an issue in our cohort. The study highlights that the diagnosis and incidence of CAPA is influenced by the application of laboratory-based diagnostic tests. Culture positivity as a single microbiological marker for probable definitions may overestimate CAPA cases and thus may trigger unnecessary antifungal treatment.

Zusammenfassung: Die Saline vs. Albumin Fluid Evaluation (SAFE) Studie hat gezeigt, dass der Einsatz von Albumin als Infusionslösung im Bereich der Volumentherapie fast überall sicher ist. Eine Ausnahme stellt hypoonkotisches Albumin beim Schädel-Hirn-Trauma dar. Während für Patientinnen und Patienten mit Leberzirrhose klare Indikationen existieren, fehlen für andere Einsatzgebiete noch große Studien, die einen klinisch relevanten Vorteil jenseits der hämodynamischen Wirksamkeit zweifelsfrei zeigen konnten und damit einen breiteren Einsatz rechtfertigen würden. Bei der „Large-volume“-Parazentese, der spontanen bakteriellen Peritonitis, aber auch beim hepatorenalen Syndrom ist der Einsatz von Albumin aufgrund eines klinischen Benefits in randomisierten kontrollierten Studien klar empfohlen und etabliert. Beim septischen Schock kann ein Einsatz von Albumin in Erwägung gezogen werden, wobei sich zwei große Studien zu dieser Fragestellung in Deutschland und Italien noch in der Rekrutierungsphase befinden. Für viele Einsatzgebiete in der Volumentherapie gilt, dass Albumin vor allem dann eingesetzt werden kann, wenn andere Maßnahmen zur hämodynamischen Stabilisierung bereits ausgeschöpft sind. Das gilt sowohl für die Volumengabe bei Hypovolämie als auch für das konservative Volumenmanagement einschließlich der sog. Deresuscitation-Phase. Inwieweit die Korrektur einer ausgeprägten Hypoalbuminämie durch Gabe von exogenem Albumin auch das schlechtere Outcome solcher Patientinnen und Patienten verbessert, ist ebenfalls Teil laufender Studien. Auf dem Weg zu einem Mehr an individualisierter Therapie kann in Zukunft die Hypoalbuminämie bei Entscheidungen für oder gegen einen Einsatz von intravenösen Albuminlösungen in der Volumentherapie eine wichtige Rolle einnehmen.

Background: We aimed at investigating the incidence, characteristics and outcome of ventilator‐associated pneumonia (VAP) in patients after cardiac arrest (CA) and its potential association with mild therapeutic hypothermia (MTH). We hypothesized, that MTH might increase the risk of VAP.Methods: Prospective observational study including comatose adult patients after successful resuscitation from out‐of‐hospital or in‐hospital CA with presumed cardiac cause admitted to ICU and treated with MTH at 33°C for 24 h or normothermia (NT) with treatment of fever ≥38°C by pharmacological means. The primary outcome measure was the development of VAP. VAP diagnosis included mechanical ventilation >48 h combined with clinical and radiologic criteria. For a microbiologically confirmed VAP (mcVAP), a positive respiratory culture was required.Results: About 23% of 171 patients developed VAP, 6% presented with mcVAP. VAP was associated with increased ICU‐LOS (9 (IQR 5–14) vs. 6 (IQR 3–9) days; p < .01), ventilator‐dependent days (6 (IQR 4–9) vs. 4 (IQR 2–7) days; p < .01) and duration of antibiotic treatment (9 (IQR 5–13) vs. 5 (IQR 2–9) days; p < .01), but not with mortality (OR 0.88 (95% CI: 0.43–1.81); p = .74). Patients treated with MTH (47%) presented higher VAP (30% vs. 17%; p = .04) and mcVAP rates (11% vs. 2%; p = .03). MTH was associated with VAP in multivariable logistic regression analysis with an OR of 2.67 (95% CI: 1.22–5.86); p = .01.Conclusions: VAP appears to be a common complication in patients after CA, accompanied by more ventilator‐dependent days, prolonged antibiotic treatment, and ICU‐LOS. Treatment with MTH is significantly associated with development of VAP.