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04/06/2013
1
19/03/201319/03/2013 Role of Extravascular Lung Water at Bedside 2
Vochtoverbelasting niet alleen
een cosmetisch probleem
PUO ziekenhuisapothekers, 4 juni 2013
Dr. Manu Malbrain, ZNA([email protected])
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 3Fluid overload: Poor cosmetics or bad medecine?
Wrap it up…
IntroductionRisks of Fluids
Practical approach
Meta-analysis
3 Hit Model
Pathophysiology
Monitoring
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 7Fluid overload: Poor cosmetics or bad medecine?
a principle in commerce:
without a warranty the
buyer takes the risk…
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 42Fluid overload: Poor cosmetics or bad medecine?
Introduction
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Therapeutic DilemmaA therapeutic conflict is
a situation where each
of the possible
therapeutic decisions
carries some potential
harm
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 44Fluid overload: Poor cosmetics or bad medecine?
When you have a therapeutic dilemma…
Support that organ that is in highest danger!
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 45Fluid overload: Poor cosmetics or bad medecine?
• Any measurement in the ICU stands or
falls with its accuracy and
reproducibility…
• No measurement has ever improved
survival, only a good a protocol can…
Introduction
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 46Fluid overload: Poor cosmetics or bad medecine?
What I really need to know is…
�When do I start giving fluids?
�When do I stop giving fluids?
�When do I start unloading?
�When do I stop unloading?
SEE
MORE
THAN
OTHERS
benefit of fluid administration?benefit of fluid administration?
risk of fluid administration?risk of fluid administration?
benefit of fluid removal?benefit of fluid removal?
risk of fluid removal?risk of fluid removal?
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 47Fluid overload: Poor cosmetics or bad medecine?
Example of a Strange Protocol…
Trof RJ et al. CCM 2012; 40Trof RJ et al. CCM 2012; 40
EVLWI < 10
Fluid Challenge
GEDVI < 850
We must NOT give a fluid challenge
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 48Fluid overload: Poor cosmetics or bad medecine?
788788694694
SURGICALSURGICAL SEPTICSEPTIC
GEDVI < 850 ml/m2 is too high
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 49Fluid overload: Poor cosmetics or bad medecine?
Ebb Phase of SHOCK
“Ashen faces, a thready pulse and
cold clammy extremities…”
The Ebb Phase - Cuthbertson,
Quart. J. Med.25:233,1932
Flow Phase of SHOCK
“The patient warms up, cardiac output increases and the
surgical team relaxes…”
The Flow Phase - Cuthbertson.
Lancet 1:233, 1942
Fluid Guidance:MAP, SVV, PPV,
GEF/GEDVI, PLR, TEO
Fluid Guidance:Positive (Σ) Fluid
balance, IAP, EVLWI
EVLWI is NOT a trigger for Fluids
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 51Fluid overload: Poor cosmetics or bad medecine?medisch-financieel overleg
Fluid Overload
The Risks of Fluids
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 57Fluid overload: Poor cosmetics or bad medecine?
No excess extra-
pulmonary organ failure
No excess extra-
pulmonary organ failure
Better lung
function:
-LIS↓
-FiO2/pO2 ↑
-Pplat ↓
-PEEP ↓
Better lung
function:
-LIS↓
-FiO2/pO2 ↑
-Pplat ↓
-PEEP ↓
RCCT, N=1000
Cum FB: -136±494 ml
Cum FB: 6992±502 ml
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 58Fluid overload: Poor cosmetics or bad medecine?
• AIFR: adequate initial fluid resuscitationWithin 6 hrs from start pressors, fluids up to CVP> 8 mmHg
Murphy et al. Chest 2009;136;102-109
survivors
non-survivors
non-survivors
survivors
• CLFM: conservative late fluid management Within 7 days after start shock: neg FB on 2 consecutive days
Retrospective, N= 212 septic ALI patients
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 59Fluid overload: Poor cosmetics or bad medecine?
Literature data: EBM
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 60Fluid overload: Poor cosmetics or bad medecine?
EBM Question:
• Does a management strategy attempting
to obtain fluid balance in equilibrium or even
negative (conservative fluid strategy) after day
3 result in improved patients outcomes
compared to management strategies that
either accept a liberal fluid management in
critically ill adults in critical care units?
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 61Fluid overload: Poor cosmetics or bad medecine?
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 65Fluid overload: Poor cosmetics or bad medecine?
1 Fluid Balance and Outcome
Survivors SD n
Non-
survivors SD n delta FB
Alsous 2000 Jun 50 400 16 2400 1700 20 -2350
Cordemans 2011 3419 7842 70 6982 9875 44 -3563
Cordemans 2011 123 4971 7737 58 9503 6910 65 -4532
Goldstein 2005 457 403 60 805 858 56 -348
Kuzkov 2006 Apr 18 893 668 16 1782 750 15 -889
Malbrain 2005 Feb 1643 1500 192 6214 2143 73 -4571
Malbrain META 2011 3862 6904 314 5994 7546 413 -2132
Murphy 2009 Jul 9250 625 125 15875 1125 87 -6625
Rosenberg 2009 Jan-Feb 5154 769 159 10308 1923 635 -5154
Schuller 1991 250 1600 43 2000 2800 26 -1750
Shum 2011 880 2320 505 5410 5050 134 -4530
Simmons 1986 7500 4090 11 17220 2045 26 -9720
Vidal 2008 Jun 2100 3900 34 16100 6400 49 -14000
mean Fluid Balance 3109,9 2981,4 1603,0 7737,9 3778,8 1643,0 -4628,0
Standard Deviation 2928,5 2848,3 5716,0 3011,1 3777,0
3109,9
7737,9
-4628
-10000
-5000
0
5000
10000
15000
survivors nonsurvivors DeltaFB
3109,9
7737,9
-4628
-10000
-5000
0
5000
10000
15000
survivors nonsurvivors DeltaFB
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 68Fluid overload: Poor cosmetics or bad medecine?
2 Fluid Balance and Intervention
Interven
tion SD N control SD N Delta FB
Cordemans 2011 126 8180 57 9902 5863 57 -9776
Balogh 2003 Jun 6857 1000 71 12286 2143 85 -5429
Brandstrup 2003 3240 2000 69 6888 4000 72 -3648
Martin 2002 Oct -3300 1000 19 500 1000 18 -3800
Martin 2005 Aug -5480 4384 20 -1490 5480 20 -3990
Mc Ardle 2009 2570 977 9 8242 714 11 -5672
Mitchell 1992 142 3632 52 2239 3695 49 -2097
O'Mara 2005 May 12300 9300 16 22100 12800 15 -9800
Oda 2006 14474 4202 14 23369 5393 22 -8895
Rivers 2001 Nov 8 8625 5162 130 10602 6216 133 -1977
Stewart 2009 -4115 825 122 4651 917 122 -8766
The SAFE Study 2004 422 1633 2190 553 1732 2182 -131
Wiedemann 2006 -136 491 503 6992 502 497 -7128
mean Fluid Balance 2748,1 3291,2 3272,0 8218,0 3881,2 3283,0 -5469,9
Standard Deviation 6186,1 2884,5 7700,9 3415,6 3202,3
2748,1
8218
-5469,9
-10000
-5000
0
5000
10000
15000
Interven on Control DeltaFB
2748,1
8218
-5469,9
-10000
-5000
0
5000
10000
15000
Interven on Control DeltaFB
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 70Fluid overload: Poor cosmetics or bad medecine?
2 Forest Plot (FB – Outcome)
Restrictive
1443/6488 = 22.2%
Liberal
1859/6384 = 29.1%
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 130Fluid overload: Poor cosmetics or bad medecine?
PATHOPHYSIOLOGY: Fluid Overload
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 131Fluid overload: Poor cosmetics or bad medecine?
Diffusion
problem
Convective
problem
Fluid load
Pe
rio
pe
rati
vem
orb
idit
y
risk
Hypovolaemia
Normo-
volaemia
Hypervolaemia
Bellamy MC. Br J Anaesth 2006;97:755–757
Interstitial Edema•diffusion distance�
•Pulmonary edema�
•IAP �
•wound healing�
•recovery gut function �
•Mortality �
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19/03/201319/03/2012 132Fluid overload: Poor cosmetics or bad medecine? 132Fluid overload: Poor cosmetics or bad medecine?
• Scanning electron microscopy
normal endothelial cell junction
1 to 5 minutes after insult (substance P)Donald McDonald 1999
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 136Fluid overload: Poor cosmetics or bad medecine?
Stewart Says…
Saline Sucks!
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 137Fluid overload: Poor cosmetics or bad medecine?
Fluid resuscitation:
when less becomes more…
The 4 fluids of life
Avoid futile overresuscitation
The GOOD
The BAD
The UGLY
The TERMINATOR
My Favourite Movie
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 138Fluid overload: Poor cosmetics or bad medecine?
IFAD Faculty Dinner 18/11/2011
www.fluid-academy.com
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 140Fluid overload: Poor cosmetics or bad medecine?
IncreasedIAP
Mesenteric veincompression
Venous hypertension
Fluidresuscitation
Intestinaledema
Visceralswelling
Viciouscycle
cause
effect
Avoid futile overresuscitation !
19/03/2013
Dilemma…
• Patients don’t
die from
anasarca they
die from MOF…
Dry lungs are
happy lungs
A dry liver is
A dead liver
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 142Fluid overload: Poor cosmetics or bad medecine?
Consequences of Fluid Overload…
= ANASARCA
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 143Fluid overload: Poor cosmetics or bad medecine?
• Pinsky M. Chest 2007;132;2020-2029
• Hemodynamic Evaluation and Monitoring in the ICU
Anasarca = Cosmetic?
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 144Fluid overload: Poor cosmetics or bad medecine?
Effect of fluid resuscitation on gut edema
0
2
4
6
8
Colloidcristalloid
4,9
7,3
Gut Wet-to-Dry ratio
• 16 rabbits• Group 1: 12ml/kg LR +
20ml/kg HAES (n=9)• Group 2: 36ml/kg LR +
20ml/kg NS (n=7)
Lobo SM Braz J Med Biol Res 2008; 41: 634
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 146Fluid overload: Poor cosmetics or bad medecine?
æ
Contractile activityDecreased GUT
contractility
VH= venous hypertension = IAH
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19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 148Fluid overload: Poor cosmetics or bad medecine?
The Pathofysiology of shock
INJURYInflammation����
Microvascular
Flow ����
Permeability ����Edema
AscitesIAP ����
Lymph
Flow ����
Lymph
fluid ����
ACS
19/03/2013 Fluid overload: Poor cosmetics or bad medecine? 149Fluid overload: Poor cosmetics or bad medecine?
Pathophysiology of MODS
INJURYInflammation����
Permeability ����
THIRD
Space Fluids
Toxic IS
EDEMA
Toxic
ASCITES
Toxic
LYMPH
SECOND
Space Fluids