Pulling the Break Triggers to stop Fluid Loading Jan J. De Waele MD PhD Surgical ICU Ghent...
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Transcript of Pulling the Break Triggers to stop Fluid Loading Jan J. De Waele MD PhD Surgical ICU Ghent...
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