F luid in ICU, F riend or F oe? F acts Revealed

1. Fluid in ICU, Friend or Foe? Facts Revealed Husain A Alawadhi MD Chief of MICU. Consultant Intensivist & pulmonologist Mafarq Hospital ,Abudhabi, UAE

2. Mafraq Hospital

4. 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

5. 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. .

6. 30 % vs. 46 %; p=0.009

7. Protocol for Early Goal-Directed Therapy Central venous and arterial catheterization He relied on CVP only for 6 hours, and used other parameters : lactic acid and Svo2 Crystalloid Colloid CVP 8 -12 mm Hg Vasoactive agents MAP ³65 and £90 mm Hg Transf. of RBC until Hct ³30% Inotropic agents ScvO2 ³70% Goals achieved Hospital admission

8. Crit Care Med 2013; 41:580–637

9. International Guidelines 2013

10. International Guidelines 2013

14. Conclusion CHEST The results of this study suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56% (no better than flipping a coin). Furthermore, an AUC of 0.56 suggests that there is no clear cutoff point that helps the physician to determine if the patient is “wet” or “dry.”

15. 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.

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

17. Lets go back 25 years

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

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

20. 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

21. SOAP :Critical Care 2008, 12:R74

22. Fluid Overload :>10% increase in body weight

23. Fluid and kidney

24. 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.

25. 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

26. 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

27. To be Wet is Not good.

28. Fluid is Foe in ARDS

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

30. Fluid Overload is BAD

32. What about sepsis?

33. Fluid Expansion as Supportive Therapy (FEAST study)

34. 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.

35. Fluid and sepsis

36. 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

38. 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

39. 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)

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

41. Why patients Gain Fluid?? • 1-Once fluid order is written, it will continue on and on.

42. Why patients gain fluid?? • 2- using CVP to guide the fluid therapy. • The EGDT used CVP only for the first 6 hours.

43. Why patients gain fluid?? • 3- Not checking the weight of the patient on daily basis.

44. Why patients gain fluid?? • 4- Fall in Love with potassium, and Mg, Phosphate replacement .

45. Why patients gain fluid?? • 5- Flooding the Kidney to pee.

46. 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.

47. 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???

48. Fluid in ICU, Friend or Foe?Facts Revealed

49. “Iatrogenic Drowning” • Each time you give more fluid to save your patient , you are actually making him to drown.

50. “Fluid overload is a Biomarker” Critical Care 2008, 12:169