Fluid in ICU, Friend or Foe? Facts Revealed

Husain A Alawadhi MDChief of MICU.

Consultant Intensivist & pulmonologistMafarq Hospital ,Abudhabi, UAE

Mafraq Hospital

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What you will hear today :

• Swan Ganz Catheter, & Central venous pressure catheter• EGD: The land mark study • Fluid overload in post-operative• Fluid overload in AKI • Fluid overload and ARDS• Fluid overload and sepsis• Causes of Fluid overload• If its is foe , why ?• Best fluid management option• Take home message

Old Equipment( PA catheter, Swan Ganz )

• Right heart catheterization was once the gold standard of haemodynamic assessment in the field of intensive care.

• With time, numerous clinical studies questioned the utility of PAC.

.

30 % vs. 46 %; p=0.009

Central venous andarterial catheterization

CVP8 -12 mm Hg

MAP65 and 90 mm Hg

ScvO2

70%

Goals achieved

Hospital admission

Protocol for Early Goal-Directed Therapy

CrystalloidColloid

Vasoactive agents

Transf. of RBCuntil Hct 30%Inotropic agents

He relied on CVP only for 6 hours, and used other parameters : lactic acid and Svo2

Crit Care Med 2013; 41:580–637

International Guidelines 2013

International Guidelines 2013

The results of this study suggest that at any CVP the likelihood that CVP can accurately CVP can accurately predict fluidpredict fluid responsiveness is only 56%responsiveness is only 56%

(no better than flipping a coin).

CHEST

Furthermore, an AUC of 0.56 suggests that there is no clear cutoff no clear cutoff point that helps the physician to determine if the patientpoint that helps the physician to determine if the patient is “wet” or “dry.” is “wet” or “dry.”

When you inform the family that you are using CVP to monitor their beloved person, they will

go and read about it in the internet.

More Weight (Fat) >>>More FatalMore Fluid >>>?More Fatal

Lets go back 25 years

Anesth Analg. 2012 Mar;114(3):640-51. Perioperative fluid management strategies in major surgery: a

stratified meta-analysis.

Goal Directed :3860 liberal Fluid :1160

RR Pneumonia 0.7 3

Hospital stay < 2 days > 4 days

CONCLUSION: Perioperative outcomes favored a GD therapy rather than liberal fluid therapy without hemodynamic goals. Whether GD therapy is superior to a restrictive fluid strategy remains uncertain.

But you may say patient with renal failure are exception , and will benefit from more fluid therapy

• 198 ICUs, 24 European countries , 1-15 may 2002• N=3147• AKI ARF was defined according to the renal SOFA score as

a serum creatinine of greater than 3.5 mg/dL (310 μmol/L) or a urine output of less than 500 mL/day. Separate analyses were made in patients with early- and late-onset ARF, oliguric and non-oliguric patients, and patients treated with or without RRT.

Critical Care 2008, 12:R74

SOAP :Critical Care 2008, 12:R74

AKI NO AKI

Groups N=112036%

N=202764%

60 days mortality

36% 16%

P value < 0.01

SUVIVAL NON SUVIVAL

Mean fluid balance over 24hour

150m l± 1L 1000ml ± 1.5L

P value < 0.001

Fluid Overload :>10% increase in body weight

Fluid and kidney

In conclusion, fluid overload is an important prognostic factor for survival in critically ill AKI patients. Further

studies are needed to elicit mechanisms and develop

appropriate interventions.

• Observational study in 17 Finnish ICUs over 5 months.

• 229 (283) patients with renal failure on RRT

• Fluid overload =>10 % body weight

• 90 days mortality

FINNAKN=286

• In logistic regression analysis fluid overload was associated with 90 days mortality ,Odds ratio 2.6 after adjusting other variable.

• 20% of survival at 90 days still remained RRT dependant

Fluid status Fluid overload n=27 27%

No fluid overload n=207 73%

90 days mortality p=0.01

60% 30%

To be Wet is Not good.

Fluid is Foe in ARDS

What about the kids?, of course they need more fluid !!!!

Fluid Overload is BAD

• What about sepsis?

Fluid Expansion as Supportive Therapy (FEAST study)

• Conclusion: These results suggest that at least 1 day of negative fluid balance (< 2500 mL) achieved by the third day of treatment may be a good independent predictor of survival in patients with septic shock. These findings suggest the hypothesis “that negative fluid balance achieved in any of the first 3 days of septic shock portends a good prognosis,” for a larger prospective cohort study.

Fluid and sepsis

• Observational study in 2 ICUs of 123 mechanically ventilated patients .PICCO plus

• Capillary leak index :CRP/Albumin• Conservative Late Fluid Management “even to negative fliud

balance in the first week of ICU”• Cumulative Fluid Balance • 28 days mortality

Wet First –Dry later

• Approach that combines both adequate initial fluid resuscitation followed by conservative late-fluid management was associated with improved survival

CHEST 2009; 136:102–109

The importance of fluid management in ALI secondary to

septic shock Murphy CV, et al Chest 2009,136

• Observational study in 212 patients.

• Multivariate regression analysis showed inability to achieve a Late Conservative Fluid management was independent mortality factors (odds ration 6.13, P<0.001)

When the family complain, they are right .!!!!listen to the nurse also.

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Why patients Gain Fluid??

• 1-Once fluid order is written, it will continue on and on.

Why patients gain fluid??

• 2- using CVP to guide the fluid therapy.

• The EGDT used CVP only for the first 6 hours.

Why patients gain fluid??

• 3- Not checking the weight of the patient on daily basis.

Why patients gain fluid??

• 4- Fall in Love with potassium, and Mg, Phosphate replacement .

Why patients gain fluid??

• 5- Flooding the Kidney to pee.

Why patients gain fluid??

• 6- Any Tachycardiac patient , we think that he is DRY, although by default majorities of patients GAIN weight in ICU.

• So we give our tachycardiac patient a fluid boluses , and if he did not respond , then we give another boluses.

Why patients gain fluid??

• 7- I cannot understand that once a patients is kept NPO for a procedure next day, he gets immediately “ flooded or hydrated “ with so called “ Mainatence fluid”.

• Do we need to have IV fluid when we sleep at night in our home, because we are NPO???

Fluid in ICU, Friend or Foe?Facts Revealed

“Iatrogenic Drowning”

• Each time you give more fluid to save your patient , you are actually making him to drown.

“Fluid overload is a Biomarker”

Critical Care 2008, 12:169

HIT

Monitor

Fluids

GOAL

FB

Why FO is FOE?

Jean-Louis Téboul, Brussle 2013 meeting

• The abdominal compartment syndrome is the ARDS of the lung .

• Increase permeability leading to more bacteria translocation.

Or measure the water in the lung.

YOU WANT TO KNOW MORE ?You want to know more

Read this…

Read this

Or if you have some money , Buy this book

But if you have more money travel to Belgium.

www.fluid-academy.org

If you were sleepy during my lecture!!!!

• Following CVP is not proven to be helpful to determine perfusion.

• Fluid excess is associated with increased mortality and morbidity.

• Flooding the kidney , will not make it urinate more.

• Follow up the patient hand foot edema.

Fluid is Fatal later .