Mariks' Deadly Trio! - Critical Care Practitioner

Mariks’ Deadly Trio!

 November 10

by Jonathan Downham

Iatrogenic salt water drowning and the hazards of a high central venous pressure.

Marik Annals of Intensive Care 2014, 4:21


Paul Marik has been investigating the effects of fluid on the septic patient over the years, publishing several important papers in the process.

Does Central Venous Pressure Predict Fluid Responsiveness? CHEST 2008

Heamodynamic parameters to guide fluid therapy. Annals of Intensive Care 2011

Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Crit Care Med. 2013

He opens his paper by first of all discussing some of the dangers of large volume fluid resuscitation. These seem to be many;

Marik concludes here by saying that the only piece of research which seems to support aggressive fluid resuscitation is that by Rivers (Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. NEJM 2001) which proposed early goal directed therapy. He goes on to present some evidence which highlights some of the flaws in this study.

He then goes on to highlight some of the dangers of a high CVP:

The dangers of normal saline are the next point of discussion.


“A liberal fluid resuscitation strategy, a CVP less than eight and the use of normal saline as the predominant resuscitation fluid are all associated with an increased risk of renal failure, respiratory failure, gastrointestinal dysfunction and death across a broad spectrum of clinical disorders. These three treatment strategies probably act synergistically to harm patients, forming the “Deadly Trio“.

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