To ebb or to flow ? Fluid management of the stable critically ill - PowerPoint PPT Presentation

To ebb or to flow ? Fluid management of the stable critically ill patient Canadian Society of Internal Medicine Annual Meeting 2019 Critical Care Extended Workshop Halifax, NS Dr. Marko Balan

CSI M Annual Meeting 2 0 1 9 Conflict Disclosures Definition: A Conflict of Interest may occur in situations where the personal and professional interests of individuals may have actual, potential or apparent influence over their judgment and actions. I have no conflicts to declare Com pany/ Organization Details Advisory Board or equivalent Speakers bureau m em ber Paym ent from a com m ercial organization. ( including gifts or other consideration or ‘in kind’ com pensation) Grant( s) or an honorarium Patent for a product referred to or m arketed by a com m ercial organization. I nvestm ents in a pharm aceutical organization, m edical devices com pany or com m unications firm . Participating or participated in a clinical trial

Disclosure The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources of information or your medical judgment. I intend to make therapeutic recommendations for medications that have not received regulatory approval.

Objectives 1. Review risks of fluid administration in critically ill patients. 2. Describe the concept of "active deresuscitation." 3. Examine commonly encountered issues with deresuscitation. 4. Discuss deresuscitation of the critically ill patient with renal injury.

Defining the population Fluid status Optimization Stabilization De-escalation Rescue Time Vincent & De Backer, 2013; Hoste et al, 2014

Question 1 I n post-resuscitated critically ill patients which of the following has been associated with decreased 90-day mortality? A. Prone positioning in early severe ARDS B. I ntensive glucose control targeting 4.5-6.0mmol/ L C. Hydrocortisone in patients with septic shock D. Positive mean daily fluid balance in patients with AKI E. Pantoprazole in patients at risk for GI bleeding

Question 1 I n post-resuscitated critically ill patients which of the following has been associated with decreased 90-day mortality? A. Prone positioning in early severe ARDS ( PROSEVA 2 0 1 3 ) B. I ntensive glucose control targeting 4.5-6.0mmol/ L (NI CE SUGAR 2009) C. Hydrocortisone in patients with septic shock (ADRENAL 2018) D. Positive mean daily fluid balance in patients with AKI (FI NNAKI 2012) E. Pantoprazole in patients at risk for GI bleeding (SUP-I CU 2018)

Fluid… too much of a good thing? • Venous congestion organ edema/ dysfunction • Impaired wound healing • Skin and soft tissue infection, pressure injuries • Issues with venous access • Patient discomfort, impaired mobilization https: / / study.com/ academy/ lesson/ fluid-volume-excess-symptoms-nursing- interventions.html

Fluid overload and clinical outcomes Morbidity Mortality • ↓ MV free days (Wiedermann et al, 2006; • ↑ I CU m ortality (Stein et al, 2012; Vincent et al, 2006) Rosenberg et al, 2009) • ↑ Hosp m ortality (Murphy et al, 2009; Rosenberg • ↑ I CU LoS (Wiedermann et al, 2006; Rosenberg et et al, 2009) al, 2009; Stein et al, 2012; Bellomo et al, 2012) • ↑ 2 8 d m ortality (Sirvent et al, 2014) • ↑ Hosp LoS (Bellomo et al, 2012) • ↑ 6 0 d m ortality (Payen et al, 2008; Bouchard et • ↑ I ntra-abdo HTN (Malbrain et al, 2014) al, 2009) • ↑ RRT (Wiedermann et al, 2006; Bellomo et al, 2012) • ↑ 9 0 d m ortality (Bellomo et al, 2012)

Silversides et al, 2017 • Meta-analysis, 49 studies (11 RCTs) • Critically ill patients with ARDS, sepsis, SIRS, in the post- resuscitation phase Conservative fluid Standard care or management or liberal fluid vs. deresuscitation strategy

Silversides et al, 2017 Mortality RR 0.92 [ 0.82, 1.02]

Silversides et al, 2017 MV free days MD 1.82 [ 0.53, 3.10] I CU LoS MD -1.88 [ -3.64, -0.12]

Malbrain et al, 2014 • Meta-analysis, 47 studies, 11 RCTs • 19 902 critically ill patients Comparator group not Strategy attempting to attempting to achieve obtain negative fluid vs. negative fluid balance balance or equilibrium or equilibrium goal at at day 3 day 3 Mortality : OR 0.42 [ 0.32, 0.55] I AH : MD -2.89 [ -3.95, -1.83]

Take home message • Fluid overload is associated with poor outcomes in stable critically ill patients • Recom m endation : Strategies that limit excessive fluid administration may be preferable over liberal fluid strategies .

Just an association? • Dose effect • Confounders • Timing of fluid overload

Murphy et al, 2009 • Retrospective analysis of 212 pts with septic shock and ALI IV bolus ≥20mL/kg • CVP ≥8mm Hg Adequate initial fluid resuscitation • • within 6h after initiation of vasopressors • Even to negative fluid balance on ≥2 consecutive days during first 7d Conservative late fluid management • • after septic shock onset

Cumulative fluid balance nonsurvivors survivors Murphy et al, 2009

Mortality by group I nitial Adequate Adequate I nadequate I nadequate resuscitation Post- Conservative Liberal Conservative Liberal resuscitation Murphy et al, 2009

Shum et al, 2011 • Retrospective single centred cohort observational study • 639 general ICU pts admitted for ≥3d

Shum et al, 2011 Rank Correlation Tertile of Coefficient APACHE I V P value ( SMR and ROD fluid gain d2 + 3 ) 0-13% 0.4 0.39 13-42% 0.9 0.07 > 42% 1 0 .0 4

Sakr et al 2017 • Observational international cohort study, 730 ICUs • 1808 pts with sepsis • septic shock 61% , ICU mortality 27.6% , hospital mortality 37.3% • Stratified according to quartiles of cumulative fluid balance at 24h and 3d after ICU admission

Adjusted 28d mortality P = 0 .6 5 6 P = 0 .0 0 3 Sakr et al, 2017

Just an association? • Dose effect  the more fluid the worse the outcome • Confounders  + FB independently associated with worse outcome • Timing of fluid overload  days 2-3 appear to be a critical period • This may be particularly important in the sickest pts

Take home message • Recom m endation : Consider using ICU day 2-3 as an overall fluid management reassessment point, much like antibiotic stewardship practices.

Question 2 • During a patient’s entire ICU admission which of the following is responsible for the largest amount of fluid administered? A. Resuscitative fluids B. Enteral nutrition and oral fluids C. Maintenance fluids and medications D. Blood product transfusion

Question 2 • During a patient’s entire ICU admission which of the following is responsible for the largest amount of fluid administered? A. Resuscitative fluids B. Enteral nutrition and oral fluids C. Maintenance fluids and m edications D. Blood product transfusion

Fluid Creep • Unintentional, insidious and often unnoticed fluid • Initially described in burn resuscitation literature (Pruitt 2000)

Regenmortel et al, 2018

Regenmortel et al, 2018 • 131 + / - 137mmol Na per day • 130 + / - 111mmol Cl per day • Not including sodium as part of fluids to dissolve medications • Guideline recommendation is 1mmol/ kg/ d of Na and Cl each (NICE, 2017)

A sensible look at insensible losses • “4-2-1” rule (Holliday & Segar, 1957) • Pts on enteral/ parenteral nutrition: 10ml/ kg/ d (Cox, Acta Anaesthesiol Scand, 1987) • Ventilated: ↓ ~ 30-40% • Febrile: ↑ 13-25% per degree above 37°C

Take home message • Majority of fluids administered to critically ill patients is “unintentional” yet significant in volume • Recom m endation : • Avoid routine use of maintenance fluid • Consider IV  PO medications • double concentrate IV infusions (heparin, norepinephrine) • HIGH threshold for fluid bolus administration in stable critically ill patients

Fluid removal • Spontaneous by patient • Pharmacologically managed Active deresuscitation • Mechanical fluid removal • Context-specific • Goal directed • Safety checkpoints • Frequent reassessments

Silversides et al, 2018 • Retrospective cohort study in UK and Canada • 400 critically ill adults receiving invasive MV for ≥24h • ~ 5L cumulative fluid balance over 7d (higher in non-survivors) • 52.3% of all pts had deresuscitative measures, typically initiated on days 2 or 3 • Practices varied significantly by site

Silversides et al, 2018 • Fluid balance on day 3 was an independent risk factor for 30d mortality, OR 1.26/ L • Greater fluid balance on day 3 associated with greater organ dysfunction, longer ICU LoS, and duration of MV • Negative fluid balance achieved with deresuscitative measures was associated with lower mortality • Pts with positive fluid balance on day 3, deresuscitative measures were not associated with increased 30d mortality

Wiedermann et al, 2006 • Multicenter prospective RCT of pts with ALI (P: F < 300) • ARDSnet lung protective ventilation protocol • Randomized to conservative vs liberal fluid strategy CVP PAOP Conservative < 4 < 8 Liberal 10-14 14-18