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Fluid is a Drug: Late Conservative Fluid Management

This presentation by Dr. Sean M. Bagshaw discusses the importance of fluid management in critically ill children, highlighting the concepts of fluid overload and "de-resuscitation." Various studies and key findings related to fluid balance, shock reversal, and outcomes in children with acute kidney injury are presented, emphasizing the need for individualized, conservative fluid management strategies. The talk also touches on challenges in the available literature and the potential benefits of early initiation of continuous renal replacement therapy. The importance of optimizing fluid dosing and treatment initiation based on markers like Neutrophil Gelatinase-Associated Lipocalin (NGAL) is highlighted, with a focus on improving patient outcomes in critically ill children with AKI.

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Fluid is a Drug: Late Conservative Fluid Management

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  1. Fluid is a Drug: Late Conservative Fluid Management Sean M Bagshaw, MD, MSc Division of Critical Care Medicine Faculty of Medicine and Dentistry, University of Alberta 1st International Symposium on AKI in Children Cincinnati, Ohio September 28, 2012

  2. Disclosure Summary • Sean M Bagshaw, MD, MSc • Consultancy: Gambro Inc. • Speaking: Gambro Inc., Alere Inc.

  3. Learning Objectives • Review and Discuss: • Fluid Overload • Fluid Management • Concept of “De-Resuscitation”

  4. ‘The dose makes the poison’ Paracelus

  5. Identification/diagnosis • Therapeutic Monitoring • Individualized • Early/Aggressive Initial Resuscitation • Hemodynamic stabilization • Shock reversal Brierley et al CCM 2009

  6. 11.8% vs. 39.2% HR 3.8; 95% CI, 1.6-7.2, p=0.002 Oliveira et al ICM 2008

  7. Shock reversal ~ >9-fold ↑ OR survival Persistent shock (per hour) ~ >2-fold ↓ OR survival Han et al Pediatrics 2003

  8. Percent Fluid Overload (%FO) %FO = Σ [FLUID IN – FLUID OUT] [Admission Weight (kg)] x 100 Goldstein et al Pediatrics 2001

  9. 74% reached peak %FO <7 days n=80 Arikan et al Ped CCM 2012

  10. Goldstein et al Pediatrics 2001

  11. “It is possible that in some cases CVVH/D may be a prevention, rather than a treatment, for worsening degrees of fluid overload.” • “Early initiation of CVVH to allow for sufficient blood product and nutrition administration, while preventing fluid overload may improve patient survival…” Goldstein et al Pediatrics 2001

  12. Michael et al Pediatr Nephrol 2004

  13. %FO>10% for PICU Admission: 68.4% vs. 22.1%, p<0.001 Risk factors for %FO>10% ~ smaller children; AKI Indications for CRRT Initiation ~ FO in 39% %FO at CRRT Initiation ~ 10.6% vs. 13.9% (p=NS) Benoit et al Pediatr Nephrol 2007; Flores et al Pediatr Nephrol 2008

  14. 15.5 15.1 9.3 9.2 Foland et al CCM 2004

  15. n=77 Gillespie et al Pediatr Nephrol 2004

  16. n=116 Goldstein et al KI 2005

  17. %FO ~ adj-OR 1.03 (95% CI, 1.01-1.05) n=297 Sutherland et al AJKD 2010

  18. %FO stratified by Oxygen Index in first 5 days of PICU Median OI 11.5 Akikan et al PCCM 2012

  19. Late AKI Early AKI Any ARF 36% (n=1120) Early ARF 75% (n=842) Late ARF 25% (n=278) CRRT 25% (n=278) Mean fluid balance (L/24hr) HR 1.21, 95%CI, 1.13-1.28, p<0.001 No AKI Payen et al Crit Care 2008

  20. Fluid Overload at RRT Initiation Adj-OR death for fluid overload at RRT initiation 2.07, 95%CI, 1.27-3.37 Bouchard et al KI 2009

  21. Prowle et al NRN 2010

  22. Challenges… • Available literature: • Small sample size • Retrospective or Registry data • Few data from INTERVENTIONAL trials: • Focused specifically on children! • Fluid management AFTER initial resuscitation • Focused on strategies for fluid management: • Volume: “Conservative” vs. “Liberal” (standard) • Type: Crystalloid or Colloid; Isotonic or Balanced

  23. n=172 Brandstrup et al Ann Surg 2003

  24. Brandstrup et al Ann Surg 2003

  25. FACTT - Wiedemann et al NEJM 2006

  26. Difference in fluid balance excluding initial resuscitation FACTT - Wiedemann et al NEJM 2006

  27. n=168 Valentine et al CCM 2012

  28. n=168 Valentine et al CCM 2012

  29. Maitland et al NEJM 2011

  30. 24 bags ≈9000 mg NaCl ≈

  31. Next Steps… • Body has not evolved a natural mechanism to remove excess ↑ Na+ and water • “De-resuscitation” in MODS/AKI? • When can fluid be ideally removed? Triggers? • How much fluid should/must be removed? • What is the timeline for active elimination?

  32. NGAL-Directed RRT Initiation Use of Neutrophil Gelatinase-Associated Lipocalin (NGAL) to Optimize Fluid Dosing, Continuous Renal Replacement Therapy (CRRT) Initiation and Discontinuation in Critically Ill Children With Acute Kidney Injury (AKI) ClinicalTrials.gov Identifier: NCT01416298 Available at: http://www.clinicaltrials.gov/ct2/show/NCT01416298?term=NCT01416298&rank=1

  33. Summary (Excessive) fluid accumulation is bad Contribute to and/or worsen AKI/MODS Short/longer term injury to non-renal organs ↑ Risk morbidity/poor outcomes Need to better understand ideal strategies to (safely) mitigate and/or remove excess extravascular fluid

  34. Thank You For Your Attention! Questions? bagshaw@ualberta.ca

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