A talk by Anders Perner at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All of the conference content can be found here: https://scanfoam.org/ssai2017/ Developed in collaboration between scanFOAM, SSAI and SFAI. All conference content listed here: https://scanfoam.org/ssai2017/

1. Is there evidence for any fluid
therapy in the critically ill?
University of
Copenhagen
Anders Perner

2. COIs
Research funds from Fresenius Kabi,
CSL Behring and Ferring
Pharmaceuticals

3. • Are drugs
• Effects
• Side-effects
– ++ fluid balance associated with mortality
– Dysnatremias associated with mortality
Intravenous fluids…

4. • How did IV fluid become a frequent
intervention?
• Why do we give IV fluid?
• Does it work?
• What should we do?
IV fluids in the critically ill…

5. O’Shaughnessy

6. Thomas Latta
Thomas Craigie
Robert Lewins

7. IV fluid therapy in WWII

8. IV fluid during major surgery

9. IV fluid during major surgery

10. IV fluid during major surgery

11. Prof. Bjørn Ibsen

12. Polio epidemic Blegdamshospitalet 1952

13. The first ICU - December 21st
1953

15. • Blood flow over blood pressure
• Fill the circulation with dextran and saline
guided by jugular filling and the temperature
of hand and feet

17. EGDT protocol
1.
2.
3.
Rivers et al. NEJM 2001

20. ‘Physiology’ of the side-effects

22. Higher fluid
volumes in
EDGT groups
in all 3 trials

23. 2016 Surviving Sepsis Campaign guidelines
Rhodes et al ICM, 2017
We recommend that … at least 30 ml/kg of IV crystalloid
fluid be given
(strong recommendation, low quality evidence)

24. We recommend that a fluid challenge technique be
applied
where fluid administration is continued as long as
hemodynamic factors continue to improve
(Best Practice Statement)
2016 Surviving Sepsis Campaign guidelines
Rhodes et al ICM, 2017
We recommend that … at least 30 ml/kg of IV crystalloid
fluid be given
(strong recommendation, low quality evidence)

25. No clean IV fluid RCTs in adults

27. FEAST trial
No bolus
vs.
NaCl bolus
vs.
albumin bolus
in 3000 febrile African kids with impaired circulation

28. Mortalityat48hours
Mortality

30. • Septic circulatory failure complex
• Overt loss of fluid?
• Builds on a simplified physiologic model
• No proven benefit in trials
• Indirect evidence of harm
Fluid resuscitation in septic patients

31. Effects of Restricting Resuscitation Fluid in Patients with
Septic Shock
SCCTG, Copenhagen Trial Unit
9 ICUs in Denmark and Finland
Funded by the Danish Medical Research Council
Supported by Rigshospitalets Research Council,
SSAI (the ACTA foundation) and
the Ehrenreich foundation

33. ICU patients with septic shock
Protocol restricting fluid
resuscitation
Multicentre, randomized feasibility trial
Protocol aiming at
standard care
Design
Had received at least 30 ml/kg of fluid

34. Noradrenaline to MAP ≥ 65 mmHg
Fluid Restriction
250-500 ml of isotonic crystalloid solution may be given if
•Lactate 4 mmol/l or above AND/OR
•Severe hypotension (MAP below 50 mmHg) AND/OR
•Mottling beyond edge of kneecap AND/OR
•Severe oliguria Only first 2 hours after randomisation
Standard Care
Isotonic crystalloids (Saline or Ringer’s) could be
given as long as hemodynamic variables improve
The choice of hemodynamic variable(s) were free
of choice
= SSC guideline
Randomized
• Replacement of overt fluid losses allowed in both groups
• No use of colloids for circulatory impairment

35. Primary outcome
Fluid Restriction
Group (N=75)
Standard Care Group
(N=76)
P-Value
Co-primary outcome measures
Volumes of resuscitation fluid (ml)
First 5 days after randomization
500 (0-2,500)
[1,687]
2,000 (1,000-4,100)
[2,928]
<0.001

36. Resuscitation fluid

37. Why was resus fluid given?
Lactate
NA-dose/MAP
Oliguria

38. AAS 2017

39. Estimated
differences
0.1 (-0.7-0.9)
mmol/l
0.01 (-0.02-0.05)
µg/kg/min
-0.1 (-0.3-0.2)
ml/kg/h
AAS 2017

40. Exploratory outcome measures

41. • Safe volume? Triggers? Targets?
• Increasing evidence of harm from higher volumes of
IV fluids
• Large trials on lower vs. higher volumes urgently
needed
Fluid resuscitation – lower vs higher?

42. Ongoing IV fluid therapy in the critically ill
• Obvious ongoing losses – bleeding, ascites
• Deficits – water and electrolytes
• IV contrast
• Rhabdomyolysis
• Maintenance

43. New SR

44. Mortality

45. Ventilator-free days

46. Ongoing IV fluid therapy in the critically ill
• Obvious ongoing losses – bleeding, ascites
• Deficits – water and electrolytes
• IV contrast
• Rhabdomyolysis
• Maintenance

47. Ongoing IV fluid therapy in the critically ill
• Obvious ongoing losses – bleeding, ascites
• Deficits – water and electrolytes
• IV contrast – AMAZING trial
• Rhabdomyolysis
• Maintenance

48. Ongoing IV fluid therapy in the critically ill
• Obvious ongoing losses – bleeding, ascites
• Deficits – water and electrolytes
• IV contrast
• Rhabdomyolysis??
• Maintenance

49. Variable N Median Lower Quartile Upper Quartile
Day1 151 978 415 1700
Day2 145 2272 1433 3245
Day3 124 2382 1690 3231
Day4 107 2545 1616 3169
Day5 86 2436 1676 3023
Day6 73 2336 1566 3096
Day7 63 2154 1502 2889
IV drugs + nutrition + oral fluid in mL

50. Ongoing IV fluid therapy in the critically ill
• Obvious ongoing losses – bleeding, ascites
• Deficits – water and electrolytes
• IV contrast
• Rhabdomyolysis??
• Maintenance??

51. • Consider IV fluids as drugs!!!
• Do trials on IV fluids for resuscitation, maintenance
and rhabdomyolysis ASAP!
• Obvious fluid loss – give what is lost
• Fluid bolus for ‘cold shock’, only repeat if the
hypoperfusion improves
• Considering IV fluids? Consider oxygenation and
fluid- and sodium balances
What should we do?

52. Effects of Restricting Intravenous Fluids in Patients
with Septic Shock on Patient-important Outcomes
The CLASSIC randomized trial
DK, S, FIN, N, NL, F, CH, UK
A large…

55. University of
Copenhagen
anders.perner@regionh.dk