Pulling the Break Triggers to stop Fluid Loading Jan J. De Waele MD PhD Surgical ICU Ghent University Hospital Ghent, Belgium. @CriticCareDoc [email protected]

Pulling the BreakTriggers to stop Fluid Loading

Jan J. De Waele MD PhDSurgical ICU

Ghent University HospitalGhent, Belgium.

@CriticCareDoc

[email protected]

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



Triggers to stop fluid loading

Pulling the break – mostly useful, sometimes a necessity


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


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


Fluid resuscitation and outcome

• FEAST study

Maitland, K. N Engl J Med 2011 26:2483-2495


Fluid resuscitation and outcome

Maitland, K. N Engl J Med 2011 26:2483-2495


Fluid balance and outcome

Micek, ST. Crit Care 2013 5:R246


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


SSC guidelines

Dellinger, RP. Intensive Care Med 2013 2:165-228


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


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


A new perspective on fluids

Fluid therapy = drug therapy



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)



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?


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



1. Identify where your patient is



2. Recognize the need

Hypoper-fusion

Fluid responsive

-ness

Fluid administra-

tion



Hypoperfusion - how to measure?• Mean arterial pressure• CVP• (Cardiac output)• Clinical parameters• Lactate• ScvO2

• Urinary output



Hypoperfusion – Problems with lactate• Marker of tissue oxygenation• Clearance vs. production• Local ischemia e.g. GI tract• B2-stimulation



Hypoperfusion – Urinary output caveats• Acute kidney injury• Other causes e.g. intra-abdominal

hypertension• Fluid loading may aggravate kidney injury



Hypoperfusion – CVP Affected by right ventricular function, intrathoracic pressure, venous compliance, …



Fluid responsiveness• Passive leg raising• SVV/PPV• End-expiratory occlusion test• IVC collapsibility

Fluid responsiveness ≠ in need of fluids


Fluid responsiveness

6a00d8341c658953ef0133ed785daa970b.jpg



Fluid responsiveness caveatsSVV and PVV in intra-abdominal hypertension is higher

Duperret S, Intensive Care Med 2007 33: 163-171.

NormovolemiaHypovolemia



2. Recognize the need

Hypoper-fusion

Fluid responsive

ness

Fluid administrat

ion



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!



4. Limit doses• Avoid rules of thumb e.g. ‘minimum of

30ml/kg’• Individualize therapy• Fluid bolus 250-500mL aliquots• Maximum 1000-1500mL ?



5. Frequent re-evaluation• Need for fluids

• Tissue hypoperfusion• Fluid responsiveness

• Endpoints and targets• Don’t necessarily aim for normalization of

parameters


How to reduce fluid administration

6. Avoid ‘fluid creep’• Reconsider “maintenance fluid”• Keep track of other routes/drugs that

contribute to fluid overload


6a00d8341c658953ef0133ed785daa970b.jpg


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


Thank you for your attention

Email: [email protected] @CriticCareDoc

mailto:[email protected]

Documents

Pulling the Break Triggers to stop Fluid Loading Jan J. De Waele MD PhD Surgical ICU Ghent University Hospital Ghent, Belgium. @CriticCareDoc [email protected]