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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”


The dose makes the poison’

Paracelus


  • Identification/diagnosis

  • Therapeutic Monitoring

    • Individualized

  • Early/Aggressive Initial Resuscitation

    • Hemodynamic stabilization

    • Shock reversal

Brierley et al CCM 2009


11.8% vs. 39.2%

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

Oliveira et al ICM 2008


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


74% reached peak %FO <7 days

n=80

Arikan et al Ped CCM 2012



  • “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


Michael et al Pediatr Nephrol 2004 prevention, rather than a treatment, for worsening degrees of fluid overload.”


%FO>10% for PICU Admission: 68.4% vs. 22.1%, p<0.001 prevention, rather than a treatment, for worsening degrees of fluid overload.”

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


15.5 prevention, rather than a treatment, for worsening degrees of fluid overload.”

15.1

9.3

9.2

Foland et al CCM 2004


n prevention, rather than a treatment, for worsening degrees of fluid overload.”=77

Gillespie et al Pediatr Nephrol 2004


n=116 prevention, rather than a treatment, for worsening degrees of fluid overload.”

Goldstein et al KI 2005


%FO ~ prevention, rather than a treatment, for worsening degrees of fluid overload.”adj-OR 1.03

(95% CI, 1.01-1.05)

n=297

Sutherland et al AJKD 2010


%FO stratified by Oxygen Index in first 5 days of PICU prevention, rather than a treatment, for worsening degrees of fluid overload.”

Median OI 11.5

Akikan et al PCCM 2012


Late AKI prevention, rather than a treatment, for worsening degrees of fluid overload.”

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 prevention, rather than a treatment, for worsening degrees of fluid overload.”

Adj-OR death for fluid overload at RRT initiation

2.07, 95%CI, 1.27-3.37

Bouchard et al KI 2009


Prowle et al NRN 2010 prevention, rather than a treatment, for worsening degrees of fluid overload.”


Challenges
Challenges… prevention, rather than a treatment, for worsening degrees of fluid overload.”

  • 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


n=172 prevention, rather than a treatment, for worsening degrees of fluid overload.”

Brandstrup et al Ann Surg 2003


Brandstrup et al Ann Surg 2003 prevention, rather than a treatment, for worsening degrees of fluid overload.”


FACTT - Wiedemann et al NEJM 2006 prevention, rather than a treatment, for worsening degrees of fluid overload.”


Difference in fluid balance excluding initial resuscitation prevention, rather than a treatment, for worsening degrees of fluid overload.”

FACTT - Wiedemann et al NEJM 2006


n prevention, rather than a treatment, for worsening degrees of fluid overload.”=168

Valentine et al CCM 2012


n prevention, rather than a treatment, for worsening degrees of fluid overload.”=168

Valentine et al CCM 2012


Maitland et al NEJM 2011 prevention, rather than a treatment, for worsening degrees of fluid overload.”


24 bags prevention, rather than a treatment, for worsening degrees of fluid overload.”≈9000 mg NaCl ≈


Next steps
Next Steps… prevention, rather than a treatment, for worsening degrees of fluid overload.”

  • 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 prevention, rather than a treatment, for worsening degrees of fluid overload.”

    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 prevention, rather than a treatment, for worsening degrees of fluid overload.”

    (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! prevention, rather than a treatment, for worsening degrees of fluid overload.”

    Questions?

    [email protected]


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