Fluid optimization in selected ICU situations

Emad  Zarief Kamel
Emad Zarief KamelAssociate professor of Anesthesia , Critical care medicine , and Pain
Flu d
In Some ICU situations
Optimization
i
Emad Z. Kamel
a Professor of Anesthesia and Surgical IC.
Assiut faculty of Medicine
1
AGENDA
• Introduction
• Fluids available
• Fluids in ARDS
• Fluids in Hepatic
• Fluids in Renal
Fluids
Emad Zarief 2023 2
Fluids &
ICU Outcomes
• Type of fluid
• Volume of fluid
• Rate of infusion
Emad Zarief 2023 3
The fluid challenge is a fluid bolus given at a defined
quantity and rate to assess fluid responsiveness.
Emad Zarief 2023 7
Emad Zarief 2023 8
Ideal Fluid
• In shock, it should have a composition like plasma to
support cellular metabolism and avoid organ dysfunction
• Should be able to achieve a sustained ↑ in intravascular
volume to optimize CO.
• Unfortunately, no ideal fluid exists.
• The available fluids : crystalloids, colloids, and blood
products.
Emad Zarief 2023 11
Colloids
• Of large molecules →remain intravascular for
several hours, ↑plasma osmotic pressure .
• In sepsis → alterations in glycocalyx and ↑
endothelial permeability → extravasation of
colloids molecules → ↑ the risk of global ↑
permeability syndrome and abolishes the primary
advantage.
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
Emad Zarief 2023 14
• The molecular leakage has demonstrated either
no effect or detrimental consequences in
critically ill patients, ↑ AKI.
• Thus, the use of semisynthetic colloids in shock
patients should be abandoned.
Colloids
Intensive Care Medicine Experimental. 2022;10(1):46.
acute kidney injury (AKI).
Emad Zarief 2023 15
• Its role in shock is still debated.
• Although theoretically promising for its anti-
inflammatory and anti-oxidant proprieties, and for
its supposedly longer intravascular confinement,
clinical data have been conflicting.
Albumin
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
Emad Zarief 2023 16
Albumin
• Intravascular albumin leaks / hour into the
extravascular space [transcapillary escape rate (TER)] →
half-time of about 15 h.
• Distributed in intravascular and extravascular fluid (In
health, up to 5% of) and increase up to 20% or more in
septic shock.
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
Emad Zarief 2023 17
• (SAFE) study : albumin should be avoided in patients
with TBI.
• It is recommended for patients with chronic liver
disease and in combination with terlipressin for
patients with hepatorenal syndrome.
• The most recent Surviving Sepsis Guidelines also
suggest using albumin in patients with sepsis who
have received large volume crystalloid resuscitation.
Albumin
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
Emad Zarief 2023 18
Emad Zarief 2023 19
• Non anion gap metabolic acidosis
• Renal arteriolar VC
• May impair cardio contractility
• Neutrophil activation and pulmonary
inflammation
Emad Zarief 2023 20
• Ringer’s lactate, Ringer’s acetate and Plasmalyte.
• Lower chloride concentration and lower osmolarity
…….(280 - 294mosm/l)
• buffered with lactate or acetate to maintain
…electroneutrality.
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
Balanced Solutions
Emad Zarief 2023 21
Intensive Care Medicine Experimental. 2022;10(1):46.
Balanced Solutions
• In sepsis may be associated with improved
outcomes compared with chloride-rich solutions and
the lack of cost effectiveness
• balanced crystalloids are recommended (weak
recommendation) as first-line fluid type in patients
with septic shock.
Emad Zarief 2023 22
Emad Zarief 2023 23
Emad Zarief 2023 24
Fluid Handling in
Selected Situations
Emad Zarief 2023 26
Intensive Care Med. 2020 Dec;46(12):2252-2264.
Emad Zarief 2023 27
• Optimal fluid management in ARDS
remains challenging and
controversial.
• It should provide adequate DO2 to
the body & avoiding inadvertent ↑
in lung edema
Intensive Care Med. 2020 Dec;46(12):2252-2264.
In ARDS
Emad Zarief 2023 28
In ARDS
• Net positive fluid balance occurs in most patients
at the onset of ARDS even when closely monitored.
• It predicts prolonged mechanical ventilation, longer
ICU and hospital stay, and higher mortality
Intensive Care Med. 2020 Dec;46(12):2252-2264.
Emad Zarief 2023 29
Emad Zarief 2023 30
Emad Zarief 2023 31
J Hepatol. 2023 Jul;79(1):240-246.
• →Require larger volumes of fluids to expand central blood
volume and improve sepsis-induced organ hypoperfusion
• Fluid overload should be avoided, as it can worsen portal
hypertension, ascites, and pulmonary edema
• Monitoring tools →echocardiography for bedside
assessment of fluid status and responsiveness.
Emad Zarief 2023 32
• Balanced crystalloids preferred over normal saline,
because normal saline can exacerbate acidosis and
hyperkalemia
• Experimental data suggest albumin is superior to
crystalloids at controlling systemic inflammation and
preventing acute kidney injury.
J Hepatol. 2023 Jul;79(1):240-246.
Emad Zarief 2023 33
Renal patient
• In patients with CKD or heart failure, slower and smaller
fluid boluses (e.g., 250 mL over 1 to 2 hours) may be safer
to avoid fluid overload and pulmonary edema.
• The end point → based on clinical and hemodynamic
parameters, such as blood pressure, heart rate, urine
output, central venous pressure, lactate, and oxygen
saturation
Nephron (2019) 143 (3): 170–173.
Emad Zarief 2023 34
Hyperchloremia may be encountered because of chloride-liberal fluid replacement strategy
→hyperchloremic metabolic acidosis and renal vasoconstriction that may ↓↓ eGFR and
UOP in major surgeries, and prolong the time to first micturition
Emad Zarief 2023 35
• Results: A total of 5037 patients were recruited from 53 ICUs .
• 2515 patients were randomly assigned to the BMES group and 2522 to the saline group.
• 90-Day Death in 21.8% in the BMES group and in 22.0% in the saline group, (P = 0.90).
• New RRT in 12.7% BMES group and in 12.9% the saline group
• The number of adverse and serious adverse events did not differ meaningfully between the groups.
• Conclusions:→ no evidence that the risk of death or acute kidney injury among critically ill adults in the
ICU was lower with the use of BMES than with saline.
• (Australia and the Health Research Council of New Zealand; NCT02721654.).
Emad Zarief 2023 36
Metanalysis 10 489 patients with sepsis concluded that risk for AKI
was significantly lower in patients receiving balanced crystalloids
(11.3%) compared with normal saline (12.7%) without differences
in the need for renal replacement therapy or duration of ICU stay
J Clin Med. 2022 Apr 1;11(7):1971
Therefore, the type and amount of fluid should be
individualized based on the patient’s clinical condition and
laboratory results.
Am Fam Physician. 2019;100(11):687-694
Emad Zarief 2023 37
Emad Zarief 2023 38
• The ideal fluid for critically ill patients does not
exist; however, crystalloids should be used as first
choice.
• Balanced crystalloid solutions may be associated
with better outcomes, but the evidence is still low.
• Albumin infusion may have a role in already fluid
resuscitated patients at risk of fluid overload.
Final Notes
Emad Zarief 2023 39
• Ideal fluid
• Volume of fluid
• Rate of infusion
Matters
Final Notes
Emad Zarief 2023 40
emadzarief@aun.edu.eg
Emad Zarief 2023 41
Emad Zarief 2023 42
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Fluid optimization in selected ICU situations

  • 1. Flu d In Some ICU situations Optimization i Emad Z. Kamel a Professor of Anesthesia and Surgical IC. Assiut faculty of Medicine 1
  • 2. AGENDA • Introduction • Fluids available • Fluids in ARDS • Fluids in Hepatic • Fluids in Renal Fluids Emad Zarief 2023 2
  • 3. Fluids & ICU Outcomes • Type of fluid • Volume of fluid • Rate of infusion Emad Zarief 2023 3
  • 4. The fluid challenge is a fluid bolus given at a defined quantity and rate to assess fluid responsiveness. Emad Zarief 2023 7
  • 6. Ideal Fluid • In shock, it should have a composition like plasma to support cellular metabolism and avoid organ dysfunction • Should be able to achieve a sustained ↑ in intravascular volume to optimize CO. • Unfortunately, no ideal fluid exists. • The available fluids : crystalloids, colloids, and blood products. Emad Zarief 2023 11
  • 7. Colloids • Of large molecules →remain intravascular for several hours, ↑plasma osmotic pressure . • In sepsis → alterations in glycocalyx and ↑ endothelial permeability → extravasation of colloids molecules → ↑ the risk of global ↑ permeability syndrome and abolishes the primary advantage. Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46. Emad Zarief 2023 14
  • 8. • The molecular leakage has demonstrated either no effect or detrimental consequences in critically ill patients, ↑ AKI. • Thus, the use of semisynthetic colloids in shock patients should be abandoned. Colloids Intensive Care Medicine Experimental. 2022;10(1):46. acute kidney injury (AKI). Emad Zarief 2023 15
  • 9. • Its role in shock is still debated. • Although theoretically promising for its anti- inflammatory and anti-oxidant proprieties, and for its supposedly longer intravascular confinement, clinical data have been conflicting. Albumin Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46. Emad Zarief 2023 16
  • 10. Albumin • Intravascular albumin leaks / hour into the extravascular space [transcapillary escape rate (TER)] → half-time of about 15 h. • Distributed in intravascular and extravascular fluid (In health, up to 5% of) and increase up to 20% or more in septic shock. Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46. Emad Zarief 2023 17
  • 11. • (SAFE) study : albumin should be avoided in patients with TBI. • It is recommended for patients with chronic liver disease and in combination with terlipressin for patients with hepatorenal syndrome. • The most recent Surviving Sepsis Guidelines also suggest using albumin in patients with sepsis who have received large volume crystalloid resuscitation. Albumin Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46. Emad Zarief 2023 18
  • 13. • Non anion gap metabolic acidosis • Renal arteriolar VC • May impair cardio contractility • Neutrophil activation and pulmonary inflammation Emad Zarief 2023 20
  • 14. • Ringer’s lactate, Ringer’s acetate and Plasmalyte. • Lower chloride concentration and lower osmolarity …….(280 - 294mosm/l) • buffered with lactate or acetate to maintain …electroneutrality. Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46. Balanced Solutions Emad Zarief 2023 21
  • 15. Intensive Care Medicine Experimental. 2022;10(1):46. Balanced Solutions • In sepsis may be associated with improved outcomes compared with chloride-rich solutions and the lack of cost effectiveness • balanced crystalloids are recommended (weak recommendation) as first-line fluid type in patients with septic shock. Emad Zarief 2023 22
  • 18. Fluid Handling in Selected Situations Emad Zarief 2023 26
  • 19. Intensive Care Med. 2020 Dec;46(12):2252-2264. Emad Zarief 2023 27
  • 20. • Optimal fluid management in ARDS remains challenging and controversial. • It should provide adequate DO2 to the body & avoiding inadvertent ↑ in lung edema Intensive Care Med. 2020 Dec;46(12):2252-2264. In ARDS Emad Zarief 2023 28
  • 21. In ARDS • Net positive fluid balance occurs in most patients at the onset of ARDS even when closely monitored. • It predicts prolonged mechanical ventilation, longer ICU and hospital stay, and higher mortality Intensive Care Med. 2020 Dec;46(12):2252-2264. Emad Zarief 2023 29
  • 24. J Hepatol. 2023 Jul;79(1):240-246. • →Require larger volumes of fluids to expand central blood volume and improve sepsis-induced organ hypoperfusion • Fluid overload should be avoided, as it can worsen portal hypertension, ascites, and pulmonary edema • Monitoring tools →echocardiography for bedside assessment of fluid status and responsiveness. Emad Zarief 2023 32
  • 25. • Balanced crystalloids preferred over normal saline, because normal saline can exacerbate acidosis and hyperkalemia • Experimental data suggest albumin is superior to crystalloids at controlling systemic inflammation and preventing acute kidney injury. J Hepatol. 2023 Jul;79(1):240-246. Emad Zarief 2023 33
  • 26. Renal patient • In patients with CKD or heart failure, slower and smaller fluid boluses (e.g., 250 mL over 1 to 2 hours) may be safer to avoid fluid overload and pulmonary edema. • The end point → based on clinical and hemodynamic parameters, such as blood pressure, heart rate, urine output, central venous pressure, lactate, and oxygen saturation Nephron (2019) 143 (3): 170–173. Emad Zarief 2023 34
  • 27. Hyperchloremia may be encountered because of chloride-liberal fluid replacement strategy →hyperchloremic metabolic acidosis and renal vasoconstriction that may ↓↓ eGFR and UOP in major surgeries, and prolong the time to first micturition Emad Zarief 2023 35
  • 28. • Results: A total of 5037 patients were recruited from 53 ICUs . • 2515 patients were randomly assigned to the BMES group and 2522 to the saline group. • 90-Day Death in 21.8% in the BMES group and in 22.0% in the saline group, (P = 0.90). • New RRT in 12.7% BMES group and in 12.9% the saline group • The number of adverse and serious adverse events did not differ meaningfully between the groups. • Conclusions:→ no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline. • (Australia and the Health Research Council of New Zealand; NCT02721654.). Emad Zarief 2023 36
  • 29. Metanalysis 10 489 patients with sepsis concluded that risk for AKI was significantly lower in patients receiving balanced crystalloids (11.3%) compared with normal saline (12.7%) without differences in the need for renal replacement therapy or duration of ICU stay J Clin Med. 2022 Apr 1;11(7):1971 Therefore, the type and amount of fluid should be individualized based on the patient’s clinical condition and laboratory results. Am Fam Physician. 2019;100(11):687-694 Emad Zarief 2023 37
  • 31. • The ideal fluid for critically ill patients does not exist; however, crystalloids should be used as first choice. • Balanced crystalloid solutions may be associated with better outcomes, but the evidence is still low. • Albumin infusion may have a role in already fluid resuscitated patients at risk of fluid overload. Final Notes Emad Zarief 2023 39
  • 32. • Ideal fluid • Volume of fluid • Rate of infusion Matters Final Notes Emad Zarief 2023 40