In 2017 it was my pleasure to meet with many enthusiastic young Starlingists from all over the world who are committed to research through the lens of the Starling Principle. But it was also depressing to find that many of the “Hollywood Experts” who are critical care’s strongest Opinion Leaders have still never heard of steady state Starling as confirmed in 2004. They continue to peddle fake science in their latest textbooks. Just look up Starling in the Index! It is therefore the next generation of clinical scientists armed with understanding of the new (?) physiology that give me hope that, as I wind down my education commitments, there are enquiring younger minds out there who will continue my mission to bring reason to truly Rational fluid prescribing. For those of you recently discovering the steady state Starling Principle, here are just two important concepts that you won’t find in the best-selling textbooks;
- When you infuse fluid into a vein it dilutes the circulating blood and increases its volume. The Starling Principle and the physiologic reflexes to sudden intravascular volume expansion explain where the new equilibrium will be.
- The oft-taught notion that Infused Fluid A travels to Compartment B, or that Infused Fluid C stays in Compartment D is just obviously misleading.
- In early ‘sepsis’ or any other systemic vasodilation leading to arterial hypotension remember that the capillary pressure will be RISING, thus increasing Jv. Fluid bolus will further increase capillary pressure and Jv, aggravating the pathophysiology. An early low-dose infusion of norepinephrine (or similar alpha agonist) will REDUCE the raised capillary pressure, bringing Jv down and opposing the creation of oedema (raised interstitial fluid volume). Give just enough norepinephrine to stabilise the diastolic pressure, or raise diastolic pressure if it has fallen. To emphasise, use your preferred arteriolar constrictor BEFORE mean arterial hypotension has occurred if you possibly can. Arterial hypotension is Harmful and should be prevented. Simultaneous Capillary Hypertension is also and can also be prevented.
And of course to those heroes who are at the bedside delivering the care while most of us are enjoying home, family and friends an extra big Thankyou.