7. #ifad2019 how to assess volemic status (langer)
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects. Many questions remain to be answered indeed: Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost? Does HES still have a place in the OR? Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin? Is it really impossible to avoid fluid overload by using only crystalloids? Is there still a definitive place for human albumin? How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others? How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy? What with the fluids beyond resuscitation? And what do the authors of the big fluid trials do in real life themselves? The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill. Date: October 26th 2019, 8:00 - 18:00
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7. #ifad2019 how to assess volemic status (langer)
- 1. How to assess volemic status? Overload vs. Underload. Department of Pathophysiology and Transplantation, University of Milan; Pediatric Intensive Care Unit "De Marchi", Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy Valencia, 26th October 2019 Thomas Langer, MD Thomas.Langer@unimi.it @Thom_Langer
- 2. Agenda Basics — Fluid compartments Fluid assessment — Examination & Physiology Fluid administration — Indications & Prevalence Conclusions — Wrap it up!
- 3. Agenda Basics — Fluid compartments Fluid assessment — Examination & Physiology Fluid administration — Indications & Prevalence Conclusions — Wrap it up!
- 4. On the importance of body water Aurelia Aurita Lowndes AG Nature 1942;150:234–5.Thomas.Langer@unimi.it TBW = 95.5%
- 5. Body Fluid Compartments Tortora G et al. Principles of Anatomy and Physiology.Thomas.Langer@unimi.it
- 6. Fluid compartments and their composition LangerT Anesth IntTher 2017Thomas.Langer@unimi.it
- 7. Intracellular Extracellular 280 mOsm/kg 280 mOsm/kg H2O H2O K+ = 140 mEq/L Na+ = 140 mEq/L 25 litres 17 litres Volume Water, osmolarity and osmolar equilibrium
- 8. Agenda Basics — Fluid compartments Fluid assessment — Examination & Physiology Fluid administration — Indications & Prevalence Conclusions — Wrap it up!
- 10. BLOOD FLOW Return functionCardiac function • Heart rate • Preload • Afterload • Contractility of ventricles • Vascular volume • Venous compliance • Venous resistance • Downstream CVP THE BASICS
- 11. Pra Q Pra Q Cardiac function Return functionCardiacOutput VenousReturn
- 12. QCardiac Output Venous Return Crys. 500 ml Pra
- 13. Agenda Basics — Fluid compartments Fluid assessment — Examination & Physiology Fluid administration — Indications & Prevalence Conclusions — Wrap it up!
- 14. Indications for parenteral fluid FLUID RESUSCITATION: AIM: Correct an acute intravascular or extracellular fluid volume deficit FLUID REPLACEMENT: AIM: Replace past or ongoing losses of extracellular fluid, which cannot be compensated by oral fluid intake alone FLUID MAINTENANCE: AIM: Provide water and electrolytes in haemodynamically stable patients that are not able/allowed to drink water Thomas.Langer@unimi.it
- 15. Cumulative mean daily fluid rate: 114 ml/h ~2.5 L 14654 pts 103098 ICU days Van Regenmortel N Intensive Care Med 2018 32.5% 25% 6.5% 3% 33%
- 17. Sodium and water balance in health Rose BD Textbook 5th edition
- 18. Time [hours] Time [hours] Fluidbalance[ml] 4190 ml 3120 ml Van Regenmortel N Intensive Care Med 2019 [Na+] = 154 (n=34) [Na+] = 54 (n=33)
- 19. H2O Na+ 14 mEq/kg/day150 ml/kg/day Critically ill children < 3 years, ventialted ≥ 48 hours LangerT under review Suggested Na intake 1-2 mEq/kg/day
- 20. Total Sodium intake [mEq] Cumulativefluidbalance[ml] Total sodium intake and WB in critical children LangerT under review
- 21. Agenda Basics — Fluid compartments Fluid assessment — Examination & Physiology Fluid administration — Indications & Prevalence Conclusions — Wrap it up!
- 22. • We are made of water and salt • Fluid assessment is fundamental • Resuscitation vs. Maintenance/creep [6.5% vs. 57%] • Water and salt overload Conclusions
- 23. Fluid assessment
Editor's Notes
- We evaluate the patients
- We evaluate the patients
- We evaluate the patients
- Sottolineare che in un caso un aumento del preload migliora la funzione cardiaca, mentre sull’altro versante un aumento della CVP riduce il ritorno venoso.
- We evaluate the patients
- We evaluate the patients