Stacey Wyrick

Emergency Medicine Physician, EMS Medical Director

[Stacey Wyrick @jwyrick]

@nickmmark I go to the reading room all of the time. Fortunately it is just 20 feet from the ED.

[Stacey Wyrick @jwyrick]

@IM_Crit_ Agree

[Stacey Wyrick @jwyrick]

@TheEMNerd I saw that when it was presented at CCR26. I think some of the noise comes from the heterogenous “sepsis” population.

[Stacey Wyrick @jwyrick]

@IM_Crit_ EM not ICU, completely true.

[Stacey Wyrick @jwyrick]

@Turningthe_Tide I disagree a bit. Take the patient in CHF who suddenly has a massive GI bleed. They can be both edematous and hypovolemic at the same time. I know it’s splitting hairs but it can occur.

[Stacey Wyrick @jwyrick]

@AriReddy @nickmmark @IM_Crit_ Well said!!

[Ken Milne MD @TheSGEM]

@rob_leeper

[Stacey Wyrick @jwyrick]

@AriReddy Very well said!

[Dr. Chacón-Lozsán F .'. @franciscojlk]

💧 Fluid Responsiveness ≠ Fluid Tolerance

For years, critical care clinicians have focused on a fundamental question:

Will this patient increase cardiac output if I give fluids?

A new multicentre study from France and China suggests we may need to ask a second question:

What price will the patient pay for that fluid?

In this observational study of 64 critically ill patients receiving a standardized 500 mL fluid challenge, investigators evaluated not only cardiac index (CI), but also venous congestion using VExUS and pulmonary congestion using extravascular lung water (EVLWI).

The findings are striking.

Before fluid administration, venous congestion could coexist with fluid responsiveness. In fact, many patients remained preload responsive despite already demonstrating evidence of systemic venous congestion.

However, what happened after fluid administration was even more important.

Among fluid responders:

✅ Cardiac index increased significantly

✅ Venous congestion remained largely stable

✅ Only 5% experienced worsening VExUS grade

✅ Lung water remained relatively unchanged

Among fluid non-responders:

❌ Cardiac output barely changed
❌ Venous congestion worsened dramatically
❌ VExUS deterioration occurred in 73%
❌ EVLWI increased significantly
❌ Congestion became evident across hepatic, portal, and renal venous territories

Perhaps the most important physiological message is this:

When the heart cannot convert preload into flow, the fluid has to go somewhere.

And where it goes is congestion.

The study also found a strong correlation between CVP and VExUS, suggesting that while advanced ultrasound provides valuable organ-level information, a carefully interpreted CVP may still remain a useful bedside marker of right-sided congestion.

The ARDS subgroup provides another important lesson.

Even fluid-responsive ARDS patients accumulated more extravascular lung water after fluid administration than non-ARDS patients, highlighting the role of pulmonary permeability in determining fluid tolerance.

This study reinforces a concept that is increasingly central to modern hemodynamic management:

The goal is not simply to identify fluid responsiveness.

The goal is to identify patients who are both:

✔ Fluid responsive

✔ Fluid tolerant

A fluid challenge that increases congestion without increasing flow is not resuscitation.

It is fluid accumulation.

The future of hemodynamic management may lie at the intersection of:

• Fluid responsiveness

• Venous congestion assessment

• Pulmonary permeability

• Organ-specific fluid tolerance

Because the best fluid is not the one that can be given.

It is the one that provides benefit without causing harm.

Reference , 📚
Si X, Critical Care. 2026;30:35.

[Rafael Melo @intensivaev]

New publication out!
For decades, hemodynamic management has centered on preload and fluid responsiveness. But as evidence linking fluid accumulation to worse outcomes grows, the conversation is shifting.
Our latest article explores the need for a more dynamic assessment of venous congestion and where critical care physiology may be heading next.
Special thanks to @azevedo_lcp and @edu_kattan for the partnership and contribution!

https://t.co/L0KZ6y0K39

[Stacey Wyrick @jwyrick]

@CritCareReviews What I can’t figure out for reading this trial is how much of the fluid administered was LR versus Hartman’s versus Plasma-Lyte.

[Stacey Wyrick @jwyrick]

@NEJM I read through this trial twice, and I still can’t figure out how much of each of the various types of balanced crystalloids was administered.

[Stacey Wyrick @jwyrick]

@IM_Crit_ Agreed!

[the EMCrit Crew @emcrit]

EMCrit 422 - SSC 2026 Guidelines: The good, the Bad, and the UGLY - a discussion with lead author, Hallie Prescott
A fantastic interview on how the SSC guideline sausage was made and the areas I found contentious
[#FOAMed for now]
https://t.co/6fXnmRSzYI

[Josh Farkas MD 💊 @PulmCrit]

breaking news from @TheOnion:

due to irreconcilable differences between SCCM & ACEP, SCCM now recommends that *all* sepsis resuscitation be done in the back of an ambulance, followed by direct admit to ICU.

“this frees us up from following evidence we don't like” said the SCCM

[Turning the Tide @Turningthe_Tide]

30 ml/kg for sepsis is a recipe, not a treatment.
Patients aren’t bundles — they’re physiology.
And when it comes to fluids, that difference can be life-saving
This thread by @icmteaching shows why fluid therapy needs to be individualised, not recipe-based

[NephroPOCUS @NephroP]

AKI ≠ indication for IV fluid 💧 by reflex. #POCUS first!
In congestive nephropathy (AKI from high CVP/fluid overload), adding more fluid can actually make things worse.
#FOAMed #Nephpearls

[Stacey Wyrick @jwyrick]

@UNMHospital I remember about 28 years ago when the Air Force tried to land an CH-53 at UMN. It did not go so well. That let to much improved communication and planning.

[Lai Christopher @LaiChristopher2]

🚨 "Early norepinephrine in #septic shock: SRMA" @Crit_Care
✅↓D28 mortality ✅↓fluids ✅Faster MAP stabilization 🛡️Safe & effective 🔍Trial sequential analysis : more RCTs still needed to confirm
Big thanks to my co-authors! @shiruimaya @Prof_XMonnet
🔗https://t.co/aG2FlIN8ao