Fluid is a drug late conservative fluid management
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Fluid is a Drug: Late Conservative Fluid Management. Sean M Bagshaw, MD, MSc Division of Critical Care Medicine Faculty of Medicine and Dentistry, University of Alberta 1 st International Symposium on AKI in Children Cincinnati, Ohio September 28, 2012. Disclosure Summary.

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Fluid is a drug late conservative fluid management

Fluid is a Drug: Late Conservative Fluid Management

Sean M Bagshaw, MD, MSc

Division of Critical Care Medicine

Faculty of Medicine and Dentistry, University of Alberta

1st International Symposium on AKI in Children

Cincinnati, Ohio

September 28, 2012


Disclosure summary

Disclosure Summary

  • Sean M Bagshaw, MD, MSc

    • Consultancy: Gambro Inc.

    • Speaking: Gambro Inc., Alere Inc.


Learning objectives

Learning Objectives

  • Review and Discuss:

    • Fluid Overload

    • Fluid Management

    • Concept of “De-Resuscitation”


Fluid is a drug late conservative fluid management

‘The dose makes the poison’

Paracelus


Fluid is a drug late conservative fluid management

  • Identification/diagnosis

  • Therapeutic Monitoring

    • Individualized

  • Early/Aggressive Initial Resuscitation

    • Hemodynamic stabilization

    • Shock reversal

Brierley et al CCM 2009


Fluid is a drug late conservative fluid management

11.8% vs. 39.2%

HR 3.8; 95% CI, 1.6-7.2, p=0.002

Oliveira et al ICM 2008


Fluid is a drug late conservative fluid management

Shock reversal ~ >9-fold ↑ OR survival

Persistent shock (per hour) ~ >2-fold ↓ OR survival

Han et al Pediatrics 2003


Percent fluid overload fo

Percent Fluid Overload (%FO)

%FO = Σ [FLUID IN – FLUID OUT]

[Admission Weight (kg)]

x 100

Goldstein et al Pediatrics 2001


Fluid is a drug late conservative fluid management

74% reached peak %FO <7 days

n=80

Arikan et al Ped CCM 2012


Fluid is a drug late conservative fluid management

Goldstein et al Pediatrics 2001


Fluid is a drug late conservative fluid management

  • “It is possible that in some cases CVVH/D may be a prevention, rather than a treatment, for worsening degrees of fluid overload.”

  • “Early initiation of CVVH to allow for sufficient blood product and nutrition administration, while preventing fluid overload may improve patient survival…”

Goldstein et al Pediatrics 2001


Fluid is a drug late conservative fluid management

Michael et al Pediatr Nephrol 2004


Fluid is a drug late conservative fluid management

%FO>10% for PICU Admission: 68.4% vs. 22.1%, p<0.001

Risk factors for %FO>10% ~ smaller children; AKI

Indications for CRRT Initiation ~ FO in 39%

%FO at CRRT Initiation ~ 10.6% vs. 13.9% (p=NS)

Benoit et al Pediatr Nephrol 2007; Flores et al Pediatr Nephrol 2008


Fluid is a drug late conservative fluid management

15.5

15.1

9.3

9.2

Foland et al CCM 2004


Fluid is a drug late conservative fluid management

n=77

Gillespie et al Pediatr Nephrol 2004


Fluid is a drug late conservative fluid management

n=116

Goldstein et al KI 2005


Fluid is a drug late conservative fluid management

%FO ~ adj-OR 1.03

(95% CI, 1.01-1.05)

n=297

Sutherland et al AJKD 2010


Fluid is a drug late conservative fluid management

%FO stratified by Oxygen Index in first 5 days of PICU

Median OI 11.5

Akikan et al PCCM 2012


Fluid is a drug late conservative fluid management

Late AKI

Early AKI

Any ARF 36% (n=1120)

Early ARF 75% (n=842)

Late ARF 25% (n=278)

CRRT 25% (n=278)

Mean fluid balance (L/24hr)

HR 1.21, 95%CI, 1.13-1.28, p<0.001

No AKI

Payen et al Crit Care 2008


Fluid overload at rrt initiation

Fluid Overload at RRT Initiation

Adj-OR death for fluid overload at RRT initiation

2.07, 95%CI, 1.27-3.37

Bouchard et al KI 2009


Fluid is a drug late conservative fluid management

Prowle et al NRN 2010


Challenges

Challenges…

  • Available literature:

    • Small sample size

    • Retrospective or Registry data

  • Few data from INTERVENTIONAL trials:

    • Focused specifically on children!

    • Fluid management AFTER initial resuscitation

    • Focused on strategies for fluid management:

      • Volume: “Conservative” vs. “Liberal” (standard)

      • Type: Crystalloid or Colloid; Isotonic or Balanced


Fluid is a drug late conservative fluid management

n=172

Brandstrup et al Ann Surg 2003


Fluid is a drug late conservative fluid management

Brandstrup et al Ann Surg 2003


Fluid is a drug late conservative fluid management

FACTT - Wiedemann et al NEJM 2006


Fluid is a drug late conservative fluid management

Difference in fluid balance excluding initial resuscitation

FACTT - Wiedemann et al NEJM 2006


Fluid is a drug late conservative fluid management

n=168

Valentine et al CCM 2012


Fluid is a drug late conservative fluid management

n=168

Valentine et al CCM 2012


Fluid is a drug late conservative fluid management

Maitland et al NEJM 2011


Fluid is a drug late conservative fluid management

24 bags ≈9000 mg NaCl ≈


Next steps

Next Steps…

  • Body has not evolved a natural mechanism to remove excess ↑ Na+ and water

  • “De-resuscitation” in MODS/AKI?

    • When can fluid be ideally removed? Triggers?

    • How much fluid should/must be removed?

    • What is the timeline for active elimination?


  • Ngal directed rrt initiation

    NGAL-Directed RRT Initiation

    Use of Neutrophil Gelatinase-Associated Lipocalin (NGAL) to Optimize Fluid Dosing, Continuous Renal Replacement Therapy (CRRT) Initiation and Discontinuation in Critically Ill Children With Acute Kidney Injury (AKI)

    ClinicalTrials.gov Identifier: NCT01416298

    Available at: http://www.clinicaltrials.gov/ct2/show/NCT01416298?term=NCT01416298&rank=1


    Summary

    Summary

    (Excessive) fluid accumulation is bad

    Contribute to and/or worsen AKI/MODS

    Short/longer term injury to non-renal organs

    ↑ Risk morbidity/poor outcomes

    Need to better understand ideal strategies to (safely) mitigate and/or remove excess extravascular fluid


    Thank you for your attention

    Thank You For Your Attention!

    Questions?

    [email protected]


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