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Pulling the BreakTriggers to stop Fluid Loading
Jan J. De Waele MD PhDSurgical ICU
Ghent University HospitalGhent, Belgium.
@CriticCareDoc
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Disclosures
Consultancy/speaker/advisory board/research grantAstraZeneca, Astellas, Bard, Bayer Healthcare, Cubist, KCI, Medicon, MSD, Pfizer, Smith&Nephew, Sumitomo, WolfeTory, WyethSocietiesESICM, SIS-E, WSACSResearchResearch Foundation Flanders
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Triggers to stop fluid loading
Pulling the break – mostly useful, sometimes a necessity
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Triggers to stop fluid loading
• Anybody interested?• Discussion
• Type of fluid• Technology for monitoring• Resuscitation endpoints
• Stop when you reach the endpoint??• Often not possible
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Large volume resuscitation
• Cornerstone of therapy for many diseases • Severe sepsis, acute pancreatitis, trauma, …
• Paradigm change in recent years in trauma resuscitation
• Risk of adding to the damage• Endothelial damage resulting in increased
permeability and tissue edema
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Fluid resuscitation and outcome
• FEAST study
Maitland, K. N Engl J Med 2011 26:2483-2495
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Fluid resuscitation and outcome
Maitland, K. N Engl J Med 2011 26:2483-2495
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Fluid balance and outcome
Micek, ST. Crit Care 2013 5:R246
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Fluid balance and outcome
Micek, ST. Crit Care 2013 5:R246
Adjusted odds ratio
95% CI p
APACHE II score 1.05 1.03 – 1.07 0.035
Age 1.02 1.01 – 1.03 0.028
Left ventricle ejection fraction
1.04 1.02 – 1.06 0.025
Greatest quartile of positive net fluid balance at D8
1.66 1.39 – 1.98 0.004
Pulling the brake – when to stop fluid loading – Jan J. De Waele
SSC guidelines
Dellinger, RP. Intensive Care Med 2013 2:165-228
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Current practice
• Few detailed data available• FENICE study: large variability and little use
of functional fluid responsiveness evaluation
• Large volumes in most sepsis studies • EGDT 4.9 (±2.9) L at 6h
• Fluid overload common• Little awareness of total fluid load
Pulling the brake – when to stop fluid loading – Jan J. De Waele
A new perspective on fluids
Side effects of fluids are multiple• Fluid overload• Organ damage or failure (lungs, brain,
kidneys)• Hyponatraemia and hypernatraemia• Hyperchloraemic metabolic acidosis • Coagulation effects
Hoste, EA. Br J Anaesth 2014
Pulling the brake – when to stop fluid loading – Jan J. De Waele
A new perspective on fluids
Fluid therapy = drug therapy
Hoste, EA. Br J Anaesth 2014
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Terminology
Fluid bolus: a rapid infusion to correct hypotensive shock and typically includes the infusion of at least 500 ml over a maximum of 15 minFluid challenge: 100–200 ml over 5–10 min with reassessment to optimize tissue perfusionFluid infusion: continuous delivery of i.v. fluids to maintain homeostasis, replace losses, or prevent organ injury (e.g. prehydration before operation or for contrast nephropathy)
Hoste, EA. Br J Anaesth 2014
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Stopping fluid is part of a process
Starting the fluids
Choosing the right endpoint
Judicious monitoring
Recognizing unnecessary
fluid administration
How to avoid fluid overload?
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
0. Consider the cause of shockSevere sepsis / septic shock• Fluid depletion common
Trauma • Hemostatic resuscitation• Fluid restriction until bleeding control
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
1. Identify where your patient is
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
2. Recognize the need
Hypoper-fusion
Fluid responsive
-ness
Fluid administra-
tion
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
Hypoperfusion - how to measure?• Mean arterial pressure• CVP• (Cardiac output)• Clinical parameters• Lactate• ScvO2
• Urinary output
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
Hypoperfusion – Problems with lactate• Marker of tissue oxygenation• Clearance vs. production• Local ischemia e.g. GI tract• B2-stimulation
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
Hypoperfusion – Urinary output caveats• Acute kidney injury• Other causes e.g. intra-abdominal
hypertension• Fluid loading may aggravate kidney injury
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
Hypoperfusion – CVP Affected by right ventricular function, intrathoracic pressure, venous compliance, …
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
Fluid responsiveness• Passive leg raising• SVV/PPV• End-expiratory occlusion test• IVC collapsibility
Fluid responsiveness ≠ in need of fluids
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Fluid responsiveness
6a00d8341c658953ef0133ed785daa970b.jpg
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
Fluid responsiveness caveatsSVV and PVV in intra-abdominal hypertension is higher
Duperret S, Intensive Care Med 2007 33: 163-171.
NormovolemiaHypovolemia
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
2. Recognize the need
Hypoper-fusion
Fluid responsive
ness
Fluid administrat
ion
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
3. Identify an endpoint and a target when you start fluid therapye.g. MAP – 65mmHg, urinary output 40mL/h, lactate – decrease 20%, …
Communication to the whole team!
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
4. Limit doses• Avoid rules of thumb e.g. ‘minimum of
30ml/kg’• Individualize therapy• Fluid bolus 250-500mL aliquots• Maximum 1000-1500mL ?
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to avoid fluid overload
5. Frequent re-evaluation• Need for fluids
• Tissue hypoperfusion• Fluid responsiveness
• Endpoints and targets• Don’t necessarily aim for normalization of
parameters
Pulling the brake – when to stop fluid loading – Jan J. De Waele
How to reduce fluid administration
6. Avoid ‘fluid creep’• Reconsider “maintenance fluid”• Keep track of other routes/drugs that
contribute to fluid overload
Pulling the brake – when to stop fluid loading – Jan J. De Waele
6a00d8341c658953ef0133ed785daa970b.jpg
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Conclusions
• Fluids may have adverse effects• Pulling the brake – essential part of fluid
therapy• Underappreciated and poorly investigated• More restrictive strategy with careful
evaluation of fluid needs probably advisable
• Fluid responsiveness important requirement
Pulling the brake – when to stop fluid loading – Jan J. De Waele
Thank you for your attention
Email: [email protected] @CriticCareDoc