IFAD 2013

1. WRAP IT UP
3rd IFAD
Manu Malbrain
3rd IFAD – International Fluid Academy Day

2. Today’s Agenda
• Introduction
• What you should know about Fluids
• What you should know about Monitoring
• What you should know about Antwerp
• What you should know about next year

3. WRAP IT UP
Introduction
3rd IFAD – International Fluid Academy Day

4. 250 Doctors
25 Faculty members
25 Industry representatives
X
300

5. 3rd iFAD—29-30 November 2013
Belgium
56.0%
Netherlands
12%
Italy
2.7%
Poland
2.4%
France
2.1%
United Kingdom
2.1%
Austria
1.5%
Libyan Arab Jamahiriya
1.5%
Lithuania
1.2%
Spain
1.2%
Nigeria
0.9%
South Africa
0.9%
Germany
0.9%
Sweden
0.9% United States
0.9%
Australia
0.6%
Chile
0.6%
Finland
0.6% Ireland
0.6%
Peru
0.6%
Slovenia
0.6% Switzerland
0.6%
Denmark
0.6%
Other
6.5%
Country of Origin of 3rd IFAD participants
355 Doctors
45 countries
110 nurses
65 industry
550

6. Beyond our Wildest Dreams…

7. 249
104
25 30
408
340
99
28 33
500
355
110
38
65
568
0
100
200
300
400
500
600
Doctors Nurses Faculty Industry Total
2011 2012 2013

8. WRAP IT UP
What you should
know about fluids
3rd IFAD – International Fluid Academy Day

9. DAY1
Remember
SID!
Saline
Sucks!
Crystalloids
are not equal
Colloids are
not equal
No starches
in sepsis
Albumin may
have a place
GIVE THE RIGHT FLUIDS RIGHT
PUSH THE BOUNDARIES

10. DAY2
TBI
Hemorrhagic
shock
Sepsis
Heart Failure
Trauma
Perioperative
USE THE RIGHT FLUID RIGHT
PUSH THE BOUNDARIES
DONT FORGET MICROCIRCULATION

11. November
2012 Germany
Re-examination
request by industry

12. 3rd iFAD 29/11/2013 Warm Welcome to 3rd iFAD 12
PRO vs CON – Colloid vs Crystalloid

13. 3rd iFAD 29/11/2013 Warm Welcome to 3rd iFAD 13

14. 3rd iFAD 29/11/2013 Warm Welcome to 3rd iFAD 14
Fluids are drugs
Type Dose
Timing Speed

15. Conclusions (Dr Niels Van Regenmortel)
• Sepsis
– Don’t use HES anymore!
– Replace them by (balanced!) crystalloids,
– Consider albumin 20%, esp. in very sick pts but at
LATE stage (DE-resuscitation)
• General ICU “Critically Ill Patient”
– Don’t use HES anymore
• The evidence against it is somewhat flawed
• We used HES too lightly in the past
• There is no good proof pro HES either

16. Conclusions
• Perioperative (+ trauma)
– We can’t extrapolate from the big fluid trials and
need dedicated studies, beyond fluid choice alone
– HES still have their place, but…
• In dedicated setting: acute and proven hypovolemia
• With great care
• Gaps best to be filled by balanced crystalloids,
little evidence for gelatins
• More emphasis on fluid strategy than on the fluid
itself

17. Septic shock

18. The results of clinical research, pathophysiologic reasoning, and clinical
experience represent different kinds of medical knowledge crucial for
effective clinical decision making…
No single source of medical knowledge is sufficient to guide clinical
decisions… No kind of medical knowledge always takes precedence over
the others
Each kind of medical knowledge has various strengths and weaknesses
when utilized in the care of individual patients…
It reflects the swing of the pendulum away from rigidly adhering to EBM
principles and expresses the growing disappointment from RCT’s as a
guide to clinical decisions.

19. WRAP IT UP
What you should know
about monitoring
3rd IFAD – International Fluid Academy Day

20. Conclusions (Prof Azriel Perel):
 Hemodynamic monitoring is essential for
proper decision-making in critically ill and high-
risk surgical patients.
 The fact that this statement is not supported
by EBM tells us more about the shortcomings of
EBM than those of hemodynamic monitoring.
perelao@shani.net

21. MONITORING
Overload =
BAD
Goals =
dynamic
Each job has
a right tool
BIA,EVLWI,CO
FR >< Preload
Lactate =
Key/Clue
USE THE RIGHT MONITOR RIGHT
PUSH THE BOUNDARIES
DONT FORGET MICROCIRCULATION

22. • PAC
• Transpulmonary thermodilution monitors
• Lithium dilution monitor
→ PiCCO2
→ FloTrac/Vigileo
→ VolumeView
→ MostCare
→ Nexfin
• Doppler methods
→ esophageal Doppler
→ echocardiography
→ USCOM
→ LiDCOrapid
→ PulsioFlex
• Bioimpedance
→ Thoracic Electrical Bioimpedance
→ Endotracheal Bioimpedance
• Bioreactance
• CO2 rebreathing
Available hemodynamic monitoring tools
• Uncalibrated Pulse Contour methods
→ LiDCOplus
non invasive
invasive
less invasive
less invasive
less invasive
non invasive
non invasive
non invasive
non invasive

23. Low Preload ≠ Give Fluids
Preload
High
Nor
mal
Low
Fluids
+
=
-
So, I also need to know if my patient is Fluid Responsive

24. • impossible to interpret in pts with spontaneous breathing activity
• difficult to interpret if tidal volume is too low
• impossible to interpret in patients with arrhythmias
Limitations of respiratory variability indices
• difficult to interpret if lung compliance is too low
• difficult to interpret in case of high frequency ventilation
• difficult to interpret under open-chest conditions
• difficult to interpret in case of severe RV failure
In all these situations and in case of any doubt about
interpretation
other reliable dynamic tests are required
… and are now available
• difficult to interpret in case of abdominal hypertension

25. Two Questions (Lobo)
Does my patient need
parenteral fluid?
Why does my patient need
parenteral fluid?

26. Why?
 To correct an intravascular or
extracellular volume deficit –
Resuscitation
 To replace ongoing losses –
Replacement
 To supply the daily needs -
Maintenance

27. 3rd iFAD 29/11/2013 What’s New in Bio-Electrical Impedance Analysis? 34
What I really need to know
When do I start giving fluids?
When do I stop giving fluids?
When do I start unloading?
When do I stop unloading?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?
risk of fluid administration?
benefit of fluid removal?
risk of fluid removal?
GEF/GEDVi↓ PPV↑ PLR+
GEF/GEDVi↑ PPV↓ PLR-
EVLW↑/PVPI↑ IAP↑/APP↓ FB+
ICG-PDR↓ APP↓ ScvO2↓ FB--

28. Moving Targets…
1st HIT
MAP, SVV,
PPV, ScvO2
2nd HIT
P/F, EVLWi,
IAP
3rd HIT
PVPI, ICG-
PDR
Moving Goals…
EAGD LGFR
LCFM
Give the right fluid right
Use the right monitor right

30. 3rd iFAD 29/11/2013 What’s New in Bio-Electrical Impedance Analysis? 37

31. Complete compliance with
all applicable elements of
the sepsis resuscitation
bundle was 21.6% in the
USA and 18.4% in Europe.
Are you compliant?

32. WRAP IT UP
What you should
know about Antwerp
3rd IFAD – International Fluid Academy Day

33. Opening Reception Town Hall

34. 10 reasons to visit Antwerp Next year
1. Chocolate
2. Architecture
3. Diamonds
4. Fashion
5. Sea port
6. Rubens
7. Shopping
8. Nightlife
9. Fine Food, Beer
10. 4th IFAD
What more do you need…?
4th IFAD

35. WRAP IT UP
What you should
know about 4th IFAD
3rd IFAD – International Fluid Academy Day

36. 4th
MARK THE DATE!
FRIDAY AND SATURDAY NOV 20TH-22ND 2013 /
ANTWERP BELGIUM
A CONCISE BUT COMPLETE 2 DAY SYMPOSIUM ON FLUID MANAGEMENT AND MONITORING IN THE CRITICALLY ILL
INTERACTIVE VOTING SYSTEM / POSTER SESSIONS / WORKSHOPS / ACADEMY PRIZE AWARD /
NURSING SESSION / CASE DISCUSSIONS / STATE OF THE ART LECTURES / FLUID MANAGEMENT /
HEMODYNAMIC MONITORING / ORGAN SUPPORT AND MONITORING / ROUND TABLE DISCUSSIONS /
ANN.BOGAERTS@ZNA.BE WWW.FLUID-ACADEMY.ORG
FOLLOW US ON:ORGANIZED BY THE INTERNATIONAL FLUID ACADEMY
3 days

37. iFAD - iPAD
again

38. Fluids'
! !
!
! ! !
Resuscitation Fluids
Abstracts
Posters

40. There is
One More
Thing…
What you
should know
before going
home

46. Thanks to the Faculty

47. Thanks to… the people in the back
Thanks to the Staff

48. Thanks to… the people in the back
Thank You Ann

49. 4th
MARK THE DATE!
FRIDAY AND SATURDAY NOV 20TH-22ND 2013 /
ANTWERP BELGIUM
A CONCISE BUT COMPLETE 2 DAY SYMPOSIUM ON FLUID MANAGEMENT AND MONITORING IN THE CRITICALLY ILL
INTERACTIVE VOTING SYSTEM / POSTER SESSIONS / WORKSHOPS / ACADEMY PRIZE AWARD /
NURSING SESSION / CASE DISCUSSIONS / STATE OF THE ART LECTURES / FLUID MANAGEMENT /
HEMODYNAMIC MONITORING / ORGAN SUPPORT AND MONITORING / ROUND TABLE DISCUSSIONS /
ANN.BOGAERTS@ZNA.BE WWW.FLUID-ACADEMY.ORG
FOLLOW US ON:ORGANIZED BY THE INTERNATIONAL FLUID ACADEMY
Thank You
See you next year