Reverse (fluid) resuscitation Should we be doing it? NAHLA IRTIZA ISMAIL

Reverse (fluid) resuscitation Should we be doing it? NAHLA IRTIZA ISMAIL

65 Male, 60 kg D1 in ICU Admitted from OT intubated Diagnosis : septic shock secondary to necrotising fasciitis of the R lower limb Patient was given 3.5 L of fluid since admission On Noradrenaline infusion Urine output : 20 30 mls/ hr I/O : + 2.5 l

D2 in ICU Still requires Noradrenaline infusion Doubling of Serum Creatinine Already started on feeding and on maintenance drip Given boluses of crystalloid Urine output :30 40 mls/ hr I/O positive + 2.0 l

D3 in ICU Able to taper Noradrenaline infusion further On low ventilator setting Creatinine static I/O + 1.0 l The wife updated regarding progress

At this point cumulative balance is already +5.5 l for the past 3 days since admission.

Since patient was already started on feeding perhaps we should have cut down the IVD further. Should we allow for smaller positive balance or maybe even balance? Can we aim for a negative fluid balance? The kidney? Maybe we should give some frusemide now? Perhaps we should have done it earlier?

Is positive fluid balance harmful?

Why do we need to give our patient fluids? Shock

Aim of administrating fluid Optimisation of intravascular volume status increase cardiac output improvement in global oxygen delivery

Phases of fluid therapy RESCUE OPTIMIZATION STABILIZATION DEESCALATION Vincent JL et al. NEJM 2013; 369(18):1726-34 Hoste E et al BJA 2014;113(5):740-7

Rescue Optimization Stabilization Deresuscitation/ Deescelation Principles Life saving Organ rescue Organ support Organ recovery Goals Correct shock Optimize tissue perfusion Aim for even or-ve fluid balance Mobilize accumulated fluid Time frame Min Hours Days Days weeks Phenotype Shock Unstable Stable Recovering Fluid therapy Bolus Fluid Titration Fluid challenge Conservative fluid Avoid unnecessary fluid

Resuscitation Administration of fluid for immediate management of life threatening conditions associated with impaired tissue perfusion

Opposite Reverse resuscitation Deresuscitation Deescalation Late Goal Directed Fluid Removal

Reverse (fluid)resuscitation more aggressive and active fluid removal by means of diuretics and renal replacement therapy with net ultrafiltration Malbrain et al, Anaesthesiology Intensive Therapy 2014

What are the problems with fluid administration? Increased capillary permeability Accumulation of large volumes of fluid in the interstitium Impaired oxygen delivery at the cellular level

Is this all?

Respiratory System Pulmonary oedema Pleural effusion Altered pulmonary and chest wall elastance Impaired gas exchange PaCO2 increased PaO2 reduced Extravascular lung water increase Lung volumes Prolonged ventilation Difficult weaning Hepatic system Hepatic congestion Impaired synthetic function Increase cholestasis Hepatic compartment syndrome GIT system Ascites Gut oedema Malabsorption Ileus Abdominal perfusion pressure reduce Reduce bowel contractility Increase Intra-abdominal Hypertension Reduce successful enteral feeding Increase intestinal permeability Increase bacterial translocation CNS Increase ICP, CPP, IOP Cerebral oedema Delirium CVS Increase in CVP and PAOP Reduce venous return Reduce stroke volume and CO Myocardial depression Pericardial effussion Myocardial oedema Conduction disturbance Renal System Renal interstitial oedema Renal blood flow decrease Glomerular filtration rate reduce Uremia increase Salt and water retention Renal compartment syndrome Abdominal wall Tissue oedema increase Impaired lymphatic drainage Poor wound healing Wound infection Pressure ulcers Skin oedema Abdominal compliance reduce

Deresuscitation Should we be doing it? When should we do it? How to do it? When should we stop?

Aim : A goal of zero to negative fluid balance by day 3 Keep cumulative fluid balance as low as possible Deresuscitation should be considered when fluid overload and fluid accumulation negatively impact end-organ function such as: P/F ratio < 200 EVLWI > 12 ml/kg PBW Increase IAP

PAL - treatment P A L high PEEP for 30 minutes (= to IAP) to drive fluid from the alveoli into the interstitium Albumin administration 2 x 100 ml 20% albumin over 60 minutes on Day 1, then titrated to albumin >30 g/l) to pull fluid from the interstitium into the circulation Frusemide ( Lasix ) infusion started 60 minutes after albumin at 60 mg/h for 4 hours, o then titrated between 5-20 mg/h to maintain UO >100 ml/h Cordemans C et al. Ann Intensive Care.Suppl 1:S15, 2012

Deresuscitation In anuric patient may consider RRT with ultrafiltration

When should we stop? Overzealous fluid removal hypoperfusion and tissue hypoxia Monitor organ function

Summary Fluid resuscitation is core in the management of shock but there are consequences Positive fluid balance is harmful May consider deresuscitation when fluid overload and fluid accumulation negatively impact end-organ function

Thank you