Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Hardcore ICU: Fluids: what, when and why?

481 views

Published on

Hardcore ICU: Fluids: what, when and why? by Manu Malbrain

Published in: Health & Medicine
  • Be the first to comment

Hardcore ICU: Fluids: what, when and why?

  1. 1. Disclosure: The speaker is member of the medical advisory board of Getinge (manu.malbrain@telenet.be) @Manu_Malbrain Co-chairman Fluid Academy @Fluid_Academy Fluids are DRUGS #dasSMACC HARDCORE ICU WORKSHOP Berlin – June 26th 2017
  2. 2. HYPOVOLEMIA IS BAD
  3. 3. “The application of what we already know will have a bigger impact than any drug or technology likely to be introduced in the next decade.” Sir Muir Gray Chief Knowledge Officer, National Health Service, UK
  4. 4. “The application of what we already know will have a bigger impact than any drug or fluid or technology likely to be introduced in the next decade.” Sir Muir Gray Chief Knowledge Officer, National Health Service, UK We need to make better DRUGS We need to make good DRUGS better We need to make good FLUIDS better
  5. 5. Longer than necessary (10%) No infection (10%) Colonizing organism (5%) 30%
  6. 6. IV Fluids on the contraindications and overdosing Arch Intern Med 2017; 177: 1-9 Manu LNG Malbrain, Flavia Machado, John Myburgh, Anders Perner, Rinaldo Bellomo, Peter Brindley, Karin Amrein, Rob McSweeney Longer than necessary (15%) No underfilling (15%) Wrong fluid (10%) Wrong dose (10%) 50%?
  7. 7. 1 When to start fluids When to stop fluids When to start fluid removal 2 3 When to stop removal 4
  8. 8. Fluid overload: Poor cosmetics or bad medecine? 9Fluid overload: Poor cosmetics or bad medecine? Drug Dose De-escalation Duration HOW MUCH HOW LONG WHAT WHEN
  9. 9. www.fluidacademy.com IFAD Faculty Dinner 18/11/2011
  10. 10. AntibioticsDRUG
  11. 11. AntibioticsDRUG
  12. 12. DRUG Colloids vs CrystalloidsVISEP study CRYSTMAS study 6S study CHEST study
  13. 13. CRISTAL study
  14. 14. 18
  15. 15. ALBIOS study
  16. 16. High Quality Research ???
  17. 17. VOMIT Victims of Medical Investigational Treatments
  18. 18. Fluid overload: Poor cosmetics or bad medecine? 22Fluid overload: Poor cosmetics or bad medecine?
  19. 19. R E S U S C I T A T I O N M A I N T E N A N C E R E P L A C E M E N T
  20. 20. Resuscitation FluidsDRUG Malbrain ML et al. Anaesthesiol Intensive Ther. 2014 Nov-Dec;46(5):313-8. To CORRECT IV Volume Deficit RECEIVED most attention Large part = other category Maintenance Fluids To COVER daily needs WATER 25 ml/kg NA + K 1 mEq/kg GLUCOSE 1.5 g/kg
  21. 21. Maintenance FluidsDRUG 1L NS= 3 chips 1L saline Na 154 mEq NaCl: 9000mg Elementary salt: 3.6g Na 1 chips = 8 oz = 1.36g Na
  22. 22. MihMoSa - TRIAL Metabolism of Isotonic vs Hypotonic Maintenance Solutions in Fasting Healthy Adults
  23. 23. MihMoSa Trial: Urine outputDRUG Van Regenmortel N, Malbrain ML et al. British J Anaesthesiol 2017; 118 (6): 892-900 HYPOTONIC FLUIDISOTONIC FLUID Hypotonic = More UO
  24. 24. MihMoSa Trial: Fluid balanceDRUG Van Regenmortel N, Malbrain ML et al. British J Anaesthesiol 2017; 118 (6): 892-900 HYPOTONICISOTONIC FLUID Hypotonic = Less + FB
  25. 25. MihMoSa Trial: ElectrolytesDRUG Van Regenmortel N, Malbrain ML et al. British J Anaesthesiol 2017; 118 (6): 892-900 Sodium difference Chloride difference Hypotonic = nl Na Hypotonic = nl Cl
  26. 26. DRUGBeer + peanuts
  27. 27. Fluid overload: Poor cosmetics or bad medecine? 32Fluid overload: Poor cosmetics or bad medecine? STOP1. Resuscitation o HES in sepsis o Albumin in TBI o Saline > 2L 2. Maintenance o Isotonic fluids o Unbalanced o Uncover daily needs 3. Replacement o Unmatched to losses
  28. 28. Fluid overload: Poor cosmetics or bad medecine? 33Fluid overload: Poor cosmetics or bad medecine? Fluids are drugs Type Indication Contra- indication Adverse effect
  29. 29. Not a good idea • Start with whisky in the morning • Continue with wine at lunch • Some soup at 16 o clock • Some milk at dinner • Some coffee before sleeping DRUG Malbrain ML et al. Anaesthesiol Intensive Ther. 2015; 47 (Spec Issue): s1-s5.
  30. 30. Likewise not a good idea IN HEMORHAGIC SHOCK • Start with glucose 5% in 1st hour • Continue with albumin 20% afterwards • Add some litres of NS + balanced solutions • Top it with HES • Finish with Packed cells • Conclude with FFP + fibrinogen DRUG Malbrain ML et al. Anaesthesiol Intensive Ther. 2015; 47 (Spec Issue): s1-s5.
  31. 31. Appropriate Timing (AB) Kumar A. et al. Crit Care Med 2006; 34(6): 1589-96
  32. 32. Appropriate Timing (IV Fluids) Murphy CV et al. CHEST 2009; 136:102–109) 19%
  33. 33. Description Antibiotics Fluids DR UG Inappropriate therapy More organ failure, longer ICU LOS, longer hospital LOS, longer MV Hyperchloremic metabolic acidosis, more AKI, more RRT, increased mortality
  34. 34. Description Antibiotics Fluids DR UG Inappropriate therapy More organ failure, longer ICU LOS, longer hospital LOS, longer MV Hyperchloremic metabolic acidosis, more AKI, more RRT, increased mortality Appropriate therapy Key factor in empiric AB selection is consideration of patient risk factors (prior AB, duration MV, corticosteroids, recent hospitalisation, residence in nursing home, …) Key factor in empiric fluid therapy is consideration of patient risk factors (fluid balance, fluid overload, capillary leak, source control, kidney function, organ function). Don’t use glucose as resuscitation fluid
  35. 35. Description Antibiotics Fluids DR UG Inappropriate therapy More organ failure, longer ICU LOS, longer hospital LOS, longer MV Hyperchloremic metabolic acidosis, more AKI, more RRT, increased mortality Appropriate therapy Key factor in empiric AB selection is consideration of patient risk factors (prior AB, duration MV, corticosteroids, recent hospitalisation, residence in nursing home, …) Key factor in empiric fluid therapy is consideration of patient risk factors (fluid balance, fluid overload, capillary leak, source control, kidney function, organ function). Don’t use glucose as resuscitation fluid Combination therapy Possible benefits: broader spectrum, synergy, avoidance of emergency of resistance, less toxicity,… Possible benefits: specific fluids for different indications (replacement vs maintenance vs resuscitation), less toxicity
  36. 36. Description Antibiotics Fluids DR UG Inappropriate therapy More organ failure, longer ICU LOS, longer hospital LOS, longer MV Hyperchloremic metabolic acidosis, more AKI, more RRT, increased mortality Appropriate therapy Key factor in empiric AB selection is consideration of patient risk factors (prior AB, duration MV, corticosteroids, recent hospitalisation, residence in nursing home, …) Key factor in empiric fluid therapy is consideration of patient risk factors (fluid balance, fluid overload, capillary leak, source control, kidney function, organ function). Don’t use glucose as resuscitation fluid Combination therapy Possible benefits: broader spectrum, synergy, avoidance of emergency of resistance, less toxicity,… Possible benefits: specific fluids for different indications (replacement vs maintenance vs resuscitation), less toxicity Appropriate timing Survival decreases with 7% per hour delay. Needs discipline and practical In refractory shock EGDT has proven beneficial. The longer the delay the more
  37. 37. "All things are poison, and nothing is without poison; only the dose permits something not to be poisonous.“ Paracelsus Philippus Aureolus Theophrastus Bombastus von Hohenheim, 1493 – 1541 Alle Ding' sind Gift, und nichts ohn' Gift; allein die Dosis macht, daß ein Ding kein Gift ist T IS THE DOSE AT MAKES THE POISON
  38. 38. Key Concept: Dose (IV Fluids)DOSE • Maintenance: – 25ml/kg/day – 1 ml/kg/hour • Resuscitation: – EGDT: 30ml/kg in the first 3 hours (SSCG) – Fluid bolus: 4ml/kg/15min (SVR) • 200ml colloid/15min • 1000ml crystalloid/20-30 min • Replacement: – Depends on type and amount lost Timing: Early Speed: Fast
  39. 39. Gluc 5% 10% remains IV 25% remains IV 100% remains IV Crystalloid Colloid
  40. 40. Resuscitation Goals?DOSE CVP 8-12 mmHg MAP 65 mmHg UO 0.5 ml/kg Other Endpoints? GEDVI RVEDVI LVEDAI PPV SVV PLR EEO
  41. 41. Description Antibiotics Fluids DO SE Pharmaco- kinetics Depends on distribution volume, clearance (kidney and liver function), albumin level, tissue penetration Depends on type of fluid: glucose 10% IV, crystalloids 25%, vs colloids 100% IV after 1 hour and on factors osmolality, oncoticity, distribution volume, kidney function. Clearance increased: capillary leak, eclampsia, inflammation. Clearance decreased: low MAP, surgery, anaesthesia
  42. 42. Description Antibiotics Fluids DO SE Pharmaco- kinetics Depends on distribution volume, clearance (kidney and liver function), albumin level, tissue penetration Depends on type of fluid: glucose 10% IV, crystalloids 25%, vs colloids 100% IV after 1 hour and on osmolality, oncoticity, kidney function. Clearance increased: capillary leak, eclampsia, inflammation. Clearance decreased: low MAP, surgery, anaesthesia Pharmaco- dynamics Reflected by the minimal inhibitory concentration. Reflected by “kill” charac- teristics, time (T>MIC) vs concentration (Cmax/MIC) dependent (AUIC) Depends on type of fluid and where you want them to go: intravascular (resuscitation), interstitial vs intracellular (cellular dehydration)
  43. 43. Description Antibiotics Fluids DO SE Pharmaco- kinetics Depends on distribution volume, clearance (kidney and liver function), albumin level, tissue penetration Depends on type of fluid: glucose 10% IV, crystalloids 25%, vs colloids 100% IV after 1 hour and on osmolality, oncoticity, kidney function. Clearance increased: capillary leak, eclampsia, inflammation. Clearance decreased: low MAP, surgery, anaesthesia Pharmaco- dynamics Reflected by the minimal inhibitory concentration. Reflected by “kill” characteristics, time (T>MIC) vs concentration (Cmax/MIC) dependent Depends on type of fluid and where you want them to go: intravascular (resuscitation), interstitial vs intracellular (cellular dehydration) Toxicity Some AB are toxic for kidneys, advice on dose adjustment needed. However not getting infection under control isn’t helping kidney Some fluids (HES) are toxic for the kidneys. However not getting shock under control is not helping kidney either HES Max dose: 30ml/kg/day
  44. 44. What I really need to know is… When do I start giving fluids? When do I stop giving fluids? SEE MORE THAN OTHERS benefit of fluid administration? risk of fluid administration? DURATION
  45. 45. RIVERS study FEAST study ProCess study SEPSISPAM study
  46. 46. ARISE study ProMise trial
  47. 47. CALM WATERS?
  48. 48. Federal Law High Court 30ml/kg Malpractice First 3 hours
  49. 49. Description Antibiotics Fluids DU RAT ION Appropriate duration No strong evidence but trend towards shorter duration. Don’t use AB to treat fever, CRP, infiltrates,… but use AB to treat infections No strong evidence but trend towards shorter duration. Don’t use fluids to treat the numbers: low CVP, MAP, UO,… but use fluids to treat shock
  50. 50. Description Antibiotics Fluids DU RAT ION Appropriate duration No strong evidence but trend towards shorter duration. Don’t use AB to treat fever, CRP, infiltrates,… but use AB to treat infections No strong evidence but trend towards shorter duration. Don’t use fluids to treat the numbers: low CVP, MAP, UO,… but use fluids to treat shock Treat to response Stop AB when signs and symptoms of active infection resolves. Future role for biomarkers (PCT) Fluids can be stopped when shock is resolved (normal lactate). Future role for biomarkers (NGAL, cystatin C, citrullin, L-FABP)
  51. 51. medisch-financieel overleg WATER IS THE PROBLEMDERESUSCITATION
  52. 52. Interstitial Edema •diffusion distance •Pulmonary edema •IAP  •wound healing •recovery gut function  •Mortality  N O R M O V O L E M I A Hypovolemia is also bad Volume status Mortality HypervolemiaHypovolemia Diffusion problem Convective problem Bellamy MC. Br J Anaesth 2006;97:755–757
  53. 53. What I really need to know is… When do I start giving fluids? When do I stop giving fluids? When do I start fluid removal? When do I stop fluid removal? SEE MORE THAN OTHERS benefit of fluid administration? risk of fluid administration? benefit of fluid removal? risk of fluid removal? E-ESCALATION
  54. 54. De-escalation (AB)
  55. 55. The R.O.S.E.
  56. 56. 2nd HIT 3rd HIT 4th HIT R. O. S. E. TimeResuscitation Organ Support VolumeStatus Evacuation Removal Maintenance Homeostasis De-resuscitation Hypo- perfusion Stabilisation 1st HIT
  57. 57. 2nd HIT 3rd HIT 4th HIT R. O. S. E. Time VolumeStatus 1st HIT This is a DRY rose not a dead one
  58. 58. Anasarca = Cosmetic or not?
  59. 59. Anasarca = Cosmetic or not? • Pinsky M. Chest 2007;132;2020-2029 • Hemodynamic Evaluation and Monitoring in the ICU
  60. 60. Respiratory Pulmonary edema  Pleural effusion  Altered pulmonary and chest wall elastance (cfr IAP ) paO2  paCO2  PaO2/FiO2  Extra vascular lung water  Lung volumes  (cfr IAP ) Prolonged ventilation  Difficult weaning  Work of breathing Cerebral edema, impaired cognition, delirium ICP CPP IOP ICH, ICS, OCS Ascites formation  Gut edema  Malabsorption  Ileus  Bowel contractility  IAP  and APP (=MAP-IAP)  Success enteral feeding  Intestinal permeability  Bacterial translocation  Splanchnic microcirculatory flow  ICG-PDR , pHi  Tissue edema  Poor wound healing Wound infection Pressure ulcers  Abdominal compliance  Myocardial edema  Conduction disturbance Impaired contractility Diastolic dysfunction CVP  and PAOP  Venous return  SV  and CO  Myocardial depression Pericardial effusion  GEF  GEDVI  CARS  Hepatic congestion  Impaired synthetic function Cholestatis  Cytochrome P 450 activity  Hepatic CS Fluid Overload Hepatic Gastrointestinal/visceral Central NS Cardiovascular Renal Abdominal Wall Renal interstitial edema Renal venous pressure  Renal blood flow  Interstitial pressure  Salt + water retention Uremia  GFR  RVR  Renal CS Prowle J. Nat Rev 2010 Malbrain M. AIT 2014 GIPS
  61. 61. Description Antibiotics Fluids DE- ESCA LATI ON Monitoring Take cultures first and have the guts to change a winning team After stabilisation with EAFM, early adequate fluid management or EGDT (normal PPV, normal CO, normal lactate) stop ongoing resuscitation and move to LCFM, late conservative fluid management and LGFR, late goal directed fluid removal (=de- resuscitation)
  62. 62. Fluid overload: Poor cosmetics or bad medecine? 74Fluid overload: Poor cosmetics or bad medecine?
  63. 63. Fluid overload: Poor cosmetics or bad medecine? 75Fluid overload: Poor cosmetics or bad medecine?
  64. 64. Fluid overload: Poor cosmetics or bad medecine? 76Fluid overload: Poor cosmetics or bad medecine? Wrap it up
  65. 65. FOLLOW US ON:
  66. 66. Therefore… RELAX I only have 2 statements left…
  67. 67. Take Home Messages • Answer the 4 questions of fluid therapy • Consider the 4 D’s of fluid therapy • Don’t forget 4 phases of fluid therapy (ROSE)
  68. 68. The 4 D’s of Fluid Therapy • Treat Fluids as Drugs – (contra)indications – adverse effects • Fluid Dose – Timing, initial dose, speed, cumulative dose • Duration – Stop when no longer fluid responsive – Use dynamic indices, PLR, EEO • De-escalation whenever possible – Deresuscitation if fluid overload (FO) – FO causes increased morbidity/mortality

×