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Abstract Title: Making Sense of Insensible Losses: A Case Study on Post-Operative Fluid Management
Background: Fluid management in post-operative patients remains a critical yet complex aspect of care. Balancing volume overload with adequate resuscitation is a delicate practice, with shifts contributing to electrolyte abnormalities, delayed wound healing, and organ dysfunction. This case study examines a sentinel event involving fluid overload, performed to investigate systemic shortcomings and potential solutions for optimizing fluid monitoring in the ICU.
Methods: We conducted a retrospective case analysis of a 53-year-old female who presented on postoperative day eight following a laparoscopic appendectomy, complicated by necrotizing fasciitis. Her clinical course was reviewed in detail including surgical and medical interventions, imaging findings, and sequence of ICU care. A root cause analysis was performed to identify factors contributing to the harm event. A process map was created to review current hospital fluid monitoring practices. A literature review was completed, and a revised process map was created to highlight targeted strategies for improvement.
Results: Despite current fluid monitoring protocols, the patient developed progressive respiratory failure in the setting of net positive fluid balance to 91-liters and worsening pulmonary edema on imaging. A root cause analysis revealed notable contributing factors as unquantified insensible losses, non-protocolized measurement of wound losses, and communication gaps between teams. A literature review supported interventions for future implementation including insensible loss calculators, protocols for weighing wound dressings, automated output monitoring systems, daily POCUS rounds, and structured communication tools such as rounding checklists and EMR-integrated fluid alerts.
Conclusion: This case exemplifies the complexities of fluid management in the ICU and the need for continuous assessment and revision of current protocols. Fluid overload is a preventable, iatrogenic cause of patient harm events. Through exploration of the various systems involved, preventable harm events can be reduced using strategies focusing on accurate fluid monitoring/documentation, knowledge of assessment methods, and open communication between treatment teams.
