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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(manu.malbrain@skynet.be)

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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a principle in commerce:

without a warranty the

buyer takes the risk…

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Introduction

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Therapeutic DilemmaA therapeutic conflict is

a situation where each

of the possible

therapeutic decisions

carries some potential

harm

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When you have a therapeutic dilemma…

Support that organ that is in highest danger!

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• 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

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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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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

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788788694694

SURGICALSURGICAL SEPTICSEPTIC

GEDVI < 850 ml/m2 is too high

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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

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Fluid Overload

The Risks of Fluids

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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

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• 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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Literature data: EBM

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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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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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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

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2 Forest Plot (FB – Outcome)

Restrictive

1443/6488 = 22.2%

Liberal

1859/6384 = 29.1%

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PATHOPHYSIOLOGY: Fluid Overload

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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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• Scanning electron microscopy

normal endothelial cell junction

1 to 5 minutes after insult (substance P)Donald McDonald 1999

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Stewart Says…

Saline Sucks!

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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

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IFAD Faculty Dinner 18/11/2011

www.fluid-academy.com

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IncreasedIAP

Mesenteric veincompression

Venous hypertension

Fluidresuscitation

Intestinaledema

Visceralswelling

Viciouscycle

cause

effect

Avoid futile overresuscitation !

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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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Consequences of Fluid Overload…

= ANASARCA

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• Pinsky M. Chest 2007;132;2020-2029

• Hemodynamic Evaluation and Monitoring in the ICU

Anasarca = Cosmetic?

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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

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æ

Contractile activityDecreased GUT

contractility

VH= venous hypertension = IAH

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The Pathofysiology of shock

INJURYInflammation����

Microvascular

Flow ����

Permeability ����Edema

AscitesIAP ����

Lymph

Flow ����

Lymph

fluid ����

ACS

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Pathophysiology of MODS

INJURYInflammation����

Permeability ����

THIRD

Space Fluids

Toxic IS

EDEMA

Toxic

ASCITES

Toxic

LYMPH

SECOND

Space Fluids

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Pathophysiology of MODS

Toxic IS EDEMAToxic ASCITESToxic LYMPH

Ongoing Systemic Inflammation����

Distant Organ Injury����

AKIAIPSALI AHIMODSAGI