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The four phases of intravenous fluid therapy: Manu Malbrain
This document discusses fluid management in intensive care patients. It notes that fluids are drugs that require appropriate dosing, timing, and de-escalation. Inappropriate fluid therapy can lead to hyperchloremic metabolic acidosis, acute kidney injury, and increased mortality. The key factors in empiric fluid therapy are considering patient risk factors for fluid overload and targeting fluids specifically for resuscitation, maintenance, or replacement needs rather than focusing solely on hemodynamic parameters. Fluid removal should begin when shock is resolved to avoid complications from fluid overload.
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The four phases of intravenous fluid therapy: Manu Malbrain
- 1. Disclosure: The speakeris 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
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- 4. “The application ofwhat 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
- 5. “The application ofwhat 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
- 6. Longer than necessary(10%) No infection (10%) Colonizing organism (5%) 30%
- 7. IV Fluids on thecontraindications 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%?
- 8. 1 When to start fluids When to stop fluids When tostart fluid removal 2 3 When to stop removal 4
- 9. Fluid overload: Poorcosmetics or bad medecine? 9Fluid overload: Poor cosmetics or bad medecine? Drug Dose De-escalation Duration HOW MUCH HOW LONG WHAT WHEN
- 12. www.fluidacademy.com IFAD Faculty Dinner18/11/2011
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- 15. DRUG Colloids vsCrystalloidsVISEP study CRYSTMAS study 6S study CHEST study
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- 22. Fluid overload: Poorcosmetics or bad medecine? 22Fluid overload: Poor cosmetics or bad medecine?
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- 25. Resuscitation FluidsDRUG Malbrain MLet 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
- 26. 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
- 27. MihMoSa - TRIAL Metabolismof Isotonic vs Hypotonic Maintenance Solutions in Fasting Healthy Adults
- 28. MihMoSa Trial: UrineoutputDRUG Van Regenmortel N, Malbrain ML et al. British J Anaesthesiol 2017; 118 (6): 892-900 HYPOTONIC FLUIDISOTONIC FLUID Hypotonic = More UO
- 29. MihMoSa Trial: FluidbalanceDRUG Van Regenmortel N, Malbrain ML et al. British J Anaesthesiol 2017; 118 (6): 892-900 HYPOTONICISOTONIC FLUID Hypotonic = Less + FB
- 30. MihMoSa Trial: ElectrolytesDRUG VanRegenmortel N, Malbrain ML et al. British J Anaesthesiol 2017; 118 (6): 892-900 Sodium difference Chloride difference Hypotonic = nl Na Hypotonic = nl Cl
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- 32. Fluid overload: Poorcosmetics 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
- 33. Fluid overload: Poorcosmetics or bad medecine? 33Fluid overload: Poor cosmetics or bad medecine? Fluids are drugs Type Indication Contra- indication Adverse effect
- 35. Not a goodidea • 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.
- 36. Likewise not agood 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.
- 37. Appropriate Timing (AB) KumarA. et al. Crit Care Med 2006; 34(6): 1589-96
- 38. Appropriate Timing (IVFluids) Murphy CV et al. CHEST 2009; 136:102–109) 19%
- 39. Description Antibiotics Fluids DR UG Inappropriate therapy Moreorgan failure, longer ICU LOS, longer hospital LOS, longer MV Hyperchloremic metabolic acidosis, more AKI, more RRT, increased mortality
- 40. Description Antibiotics Fluids DR UG Inappropriate therapy Moreorgan 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
- 41. Description Antibiotics Fluids DR UG Inappropriate therapy Moreorgan 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
- 42. Description Antibiotics Fluids DR UG Inappropriate therapy Moreorgan 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
- 44. "All things arepoison, 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
- 45. 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
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- 47. Resuscitation Goals?DOSE CVP 8-12 mmHg MAP 65mmHg UO 0.5 ml/kg Other Endpoints? GEDVI RVEDVI LVEDAI PPV SVV PLR EEO
- 48. Description Antibiotics Fluids DO SE Pharmaco- kinetics Dependson 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
- 49. Description Antibiotics Fluids DO SE Pharmaco- kinetics Dependson 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)
- 50. Description Antibiotics Fluids DO SE Pharmaco- kinetics Dependson 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
- 52. What I reallyneed 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
- 53. RIVERS study FEAST study ProCessstudy SEPSISPAM study
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- 57. Federal Law HighCourt 30ml/kg Malpractice First 3 hours
- 58. Description Antibiotics Fluids DU RAT ION Appropriate duration Nostrong 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
- 59. Description Antibiotics Fluids DU RAT ION Appropriate duration Nostrong 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)
- 61. medisch-financieel overleg WATER ISTHE PROBLEMDERESUSCITATION
- 62. Interstitial Edema •diffusion distance •Pulmonaryedema •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
- 64. What I reallyneed 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
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- 68. 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
- 69. 2nd HIT 3rd HIT 4th HIT R. O. S.E. Time VolumeStatus 1st HIT This is a DRY rose not a dead one
- 70. Anasarca = Cosmeticor not?
- 71. Anasarca = Cosmeticor not? • Pinsky M. Chest 2007;132;2020-2029 • Hemodynamic Evaluation and Monitoring in the ICU
- 72. Respiratory Pulmonary edema Pleuraleffusion 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
- 73. Description Antibiotics Fluids DE- ESCA LATI ON MonitoringTake 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)
- 74. Fluid overload: Poorcosmetics or bad medecine? 74Fluid overload: Poor cosmetics or bad medecine?
- 75. Fluid overload: Poorcosmetics or bad medecine? 75Fluid overload: Poor cosmetics or bad medecine?
- 76. Fluid overload: Poorcosmetics or bad medecine? 76Fluid overload: Poor cosmetics or bad medecine? Wrap it up
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- 79. Therefore… RELAX I only have2 statements left…
- 80. 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)
- 81. The 4 D’sof 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
Editor's Notes
- #16 Medical fluids Different types of fluids Crystalloids vs colloids Synthetic vs blood derived Balanced vs unbalanced Route of administration: IV vs PO Indications Contra-indications Adverse effects
- #23 Colloids: Conclusion Starches (HES) should NOT be used in: Sepsis Burns Acute or chronic kidney injury Oliguria not responsive to fluids (6h) Starches (HES) can be used in: Postoperative hypovolemic patients (<24h) Trauma and hemorrhagic shock Respect maximum dose (30 ml/kg) Albumin 20% can be used in: Late sepsis Deresuscitation
- #24 Crystalloid: conclusion (Ab)normal saline as resuscitation fluid Not in large amounts Not above 2L/ 1 week Risk of hyperNa Risk of hyperchloremic metabolic acidosis Risk for AKI …/... Balanced solutions are good first choice Hartmann Ringer’s lactate PlasmlaLyte …/... Cover daily baseline electrolyte needs Glucion 5% …/...
- #26 RESUSCITATION To correct an intravascular volume deficit acute hypovolemia Received most scientific attention especially in the light of the recent colloid-crystalloid debate Large part of the total infused volume during a patient’s stay in the hospital does not fall into this category… MAINTENANCE: To cover the patient’s daily basal needs + requirements of water and electrolytes These basic daily needs are: Water: 25-30 mL/kg of body weight Sodium: 1 mEq/kg Potassium: 1 mEq/kg Glucose or dextrose 5 or 10%: 1.4-1.6 g/kg Some specific maintenance solutions are commercially available, but far from ideal REPLACEMENT To correct existing or developing deficits that cannot be compensated by oral intake when fluids are lost via drains or stomata, fistulas, fever, open wounds (including evaporation during surgery), polyuria (salt wasting nephropathy or diabetes insipidus) Data on replacement fluids are scarse Several recent guidelines advise to match the amount of fluid and electrolytes as closely as possible to the fluid that is being or has been lost
- #27 Potassium 50—100 mEq/day Sodium 80—120 mEq/day 1L fysiologisch = 9g NaCl = salt = 3.6gr elementary Na 1 zakje chips = 8 oz en per oz = 170mg => 1 zakje = 1360mg Dus 1 L fysiologisch = 3 zakjes chips
- #28 Metabolism of Isotonic vs Hypotonic Maintenance Solutions in Fasting Healthy Adults
- #48 RESUSCITATION To correct an intravascular volume deficit acute hypovolemia Received most scientific attention especially in the light of the recent colloid-crystalloid debate Large part of the total infused volume during a patient’s stay in the hospital does not fall into this category… MAINTENANCE: To cover the patient’s daily basal needs + requirements of water and electrolytes These basic daily needs are: Water: 25-30 mL/kg of body weight Sodium: 1 mEq/kg Potassium: 1 mEq/kg Glucose or dextrose 5 or 10%: 1.4-1.6 g/kg Some specific maintenance solutions are commercially available, but far from ideal REPLACEMENT To correct existing or developing deficits that cannot be compensated by oral intake when fluids are lost via drains or stomata, fistulas, fever, open wounds (including evaporation during surgery), polyuria (salt wasting nephropathy or diabetes insipidus) Data on replacement fluids are scarse Several recent guidelines advise to match the amount of fluid and electrolytes as closely as possible to the fluid that is being or has been lost The requirements for and response to fluid resuscitation: Vary greatly during the course of any critical illness Therefore: No single physiological or biochemical measurement adequately reflects Complexity of fluid depletion Response to fluid
- #54 https://nycaamn.files.wordpress.com/2014/10/sepsis3.jpg
- #75 It is important that we use the right targets
- #76 To reach our goals