1. Pulling the Break Triggers to stop Fluid Loading Jan J. De Waele MD PhD Surgical ICU Ghent University Hospital Ghent, Belgium. @CriticCareDoc Jan.DeWaele@UGent.be

2. Pulling the brake – when to stop fluid loading – Jan J. De Waele Disclosures Consultancy/speaker/advisory board/research grant AstraZeneca, Astellas, Bard, Bayer Healthcare, Cubist, KCI, Medicon, MSD, Pfizer, Smith&Nephew, Sumitomo, WolfeTory, Wyeth Societies ESICM, SIS-E, WSACS Research Research Foundation Flanders

3. Pulling the brake – when to stop fluid loading – Jan J. De Waele

4. Triggers to stop fluid loading Pulling the break – mostly useful, sometimes a necessity

5. Pulling the brake – when to stop fluid loading – Jan J. De Waele Triggers to stop fluid loading Anybody interested? Discussion Type of fluid Technology for monitoring Resuscitation endpoints Stop when you reach the endpoint?? Often not possible

6. Pulling the brake – when to stop fluid loading – Jan J. De Waele Large volume resuscitation Cornerstone of therapy for many diseases Severe sepsis, acute pancreatitis, trauma, … Paradigm change in recent years in trauma resuscitation Risk of adding to the damage Endothelial damage resulting in increased permeability and tissue edema

7. Pulling the brake – when to stop fluid loading – Jan J. De Waele Fluid resuscitation and outcome FEAST study Maitland, K. N Engl J Med 2011 26:2483-2495

8. Pulling the brake – when to stop fluid loading – Jan J. De Waele Fluid resuscitation and outcome Maitland, K. N Engl J Med 2011 26:2483-2495

9. Pulling the brake – when to stop fluid loading – Jan J. De Waele Fluid balance and outcome Micek, ST. Crit Care 2013 5:R246

10. Pulling the brake – when to stop fluid loading – Jan J. De Waele Fluid balance and outcome Micek, ST. Crit Care 2013 5:R246 Adjusted odds ratio 95% CIp APACHE II score1.051.03 – 1.070.035 Age1.021.01 – 1.030.028 Left ventricle ejection fraction 1.041.02 – 1.060.025 Greatest quartile of positive net fluid balance at D8 1.661.39 – 1.980.004

11. Pulling the brake – when to stop fluid loading – Jan J. De Waele SSC guidelines Dellinger, RP. Intensive Care Med 2013 2:165-228

12. Pulling the brake – when to stop fluid loading – Jan J. De Waele Current practice Few detailed data available FENICE study: large variability and little use of functional fluid responsiveness evaluation Large volumes in most sepsis studies EGDT 4.9 (±2.9) L at 6h Fluid overload common Little awareness of total fluid load

13. Pulling the brake – when to stop fluid loading – Jan J. De Waele A new perspective on fluids Side effects of fluids are multiple Fluid overload Organ damage or failure (lungs, brain, kidneys) Hyponatraemia and hypernatraemia Hyperchloraemic metabolic acidosis Coagulation effects Hoste, EA. Br J Anaesth 2014

14. Pulling the brake – when to stop fluid loading – Jan J. De Waele A new perspective on fluids Fluid therapy = drug therapy Hoste, EA. Br J Anaesth 2014

15. Pulling the brake – when to stop fluid loading – Jan J. De Waele Terminology Fluid bolus: a rapid infusion to correct hypotensive shock and typically includes the infusion of at least 500 ml over a maximum of 15 min Fluid challenge: 100–200 ml over 5–10 min with reassessment to optimize tissue perfusion Fluid infusion: continuous delivery of i.v. fluids to maintain homeostasis, replace losses, or prevent organ injury (e.g. prehydration before operation or for contrast nephropathy) Hoste, EA. Br J Anaesth 2014

16. Pulling the brake – when to stop fluid loading – Jan J. De Waele Stopping fluid is part of a process Related to Starting the fluids Choosing the right endpoint Judicious monitoring Recognizing unnecessary fluid administration How to avoid fluid overload?

17. Pulling the brake – when to stop fluid loading – Jan J. De Waele Stopping fluid is part of a process Starting the fluids Choosing the right endpoint Judicious monitoring Recognizing unnecessary fluid administration How to avoid fluid overload?

18. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 0. Consider the cause of shock Severe sepsis / septic shock Fluid depletion common Trauma Hemostatic resuscitation Fluid restriction until bleeding control

19. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 1. Identify where your patient is

20. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 2. Recognize the need Hypoper- fusion Fluid responsive -ness Fluid administra- tion

21. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload Hypoperfusion - how to measure? Mean arterial pressure CVP (Cardiac output) Clinical parameters Lactate S cv O 2 Urinary output

22. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload Hypoperfusion – Problems with lactate Marker of tissue oxygenation Clearance vs. production Local ischemia e.g. GI tract B 2 -stimulation

23. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload Hypoperfusion – Urinary output caveats Acute kidney injury Other causes e.g. intra-abdominal hypertension Fluid loading may aggravate kidney injury

24. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload Hypoperfusion – CVP Affected by right ventricular function, intrathoracic pressure, venous compliance, …

25. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload Fluid responsiveness Passive leg raising SVV/PPV End-expiratory occlusion test IVC collapsibility Fluid responsiveness ≠ in need of fluids

26. Pulling the brake – when to stop fluid loading – Jan J. De Waele Fluid responsiveness 6a00d8341c658953ef0133ed785daa970b.jpg

27. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload Fluid responsiveness caveats SVV and PVV in intra-abdominal hypertension is higher Duperret S, Intensive Care Med 2007 33: 163-171. Normovolemia Hypovolemia

28. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 2. Recognize the need Hypoper- fusion Fluid responsive ness Fluid administrat ion

29. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 3. Identify an endpoint and a target when you start fluid therapy e.g. MAP – 65mmHg, urinary output 40mL/h, lactate – decrease 20%, … Communication to the whole team!

30. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 4. Limit doses Avoid rules of thumb e.g. ‘minimum of 30ml/kg’ Individualize therapy Fluid bolus 250-500mL aliquots Maximum 1000-1500mL ?

31. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to avoid fluid overload 5. Frequent re-evaluation Need for fluids Tissue hypoperfusion Fluid responsiveness Endpoints and targets Don’t necessarily aim for normalization of parameters

32. Pulling the brake – when to stop fluid loading – Jan J. De Waele How to reduce fluid administration 6. Avoid ‘fluid creep’ Reconsider “maintenance fluid” Keep track of other routes/drugs that contribute to fluid overload

33. Pulling the brake – when to stop fluid loading – Jan J. De Waele 6a00d8341c658953ef0133ed785daa970b.jpg

34. Pulling the brake – when to stop fluid loading – Jan J. De Waele Conclusions Fluids may have adverse effects Pulling the brake – essential part of fluid therapy Underappreciated and poorly investigated More restrictive strategy with careful evaluation of fluid needs probably advisable Fluid responsiveness important requirement

35. Pulling the brake – when to stop fluid loading – Jan J. De Waele Thank you for your attention Email: Jan.DeWaele@UGent.beJan.DeWaele@UGent.be @CriticCareDoc