Optimal fluid therapy in Eric Hoste Department of Intensive Care Medicine Ghent University Hospital Ghent University

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1 Optimal fluid therapy in 2013 Eric Hoste Department of Intensive Care Medicine Ghent University Hospital Ghent University

2 EGDT: fluids are good & prevent AKI Lin et al, Shock 2006

3 EGDT and AKI Prowle et al. Crit Care 2012

4 Fluid bolus? The FEAST trial N = 3141 children Severe infection Maitland et al. NEJM 2011

5 Optimal fluid therapy in 2013 Not too little and not too much Colloids? Crystalloids?

6 The oliguria therapy reflex

7 Sepsis: Variables associated with mortality OR (95%CI) P SAPS II (/pt) 1.0 ( ) <0.001 Fluid balance (/L) 1.1 ( ) Age (/yr) 1.0 ( ) SOFA (/pt) 1.1 ( ) Blood stream infection 1.7 ( ) Cirrhosis 1.6 ( ) Pseudomonas infection 1.6 ( ) Medical admission 1.4 ( ) Female gender 1.4 ( ) Vincent, the SOAP study, Crit Care Med 2006

8 Conservative Liberal P 7 d volume balance (ml) -136 ml ± ± 502 <0.001 Death at 60 days 25.5% 28.4% 0.30 Ventilator free days 14.6 ± ± 0.5 <0.001 ICU free days: Day ± ± 0.1 <0.001 Day ± ± 0.4 <0.001 Wiedemann, N Engl J Med 2006

9 Fluid-Management in ARDS 16% 12% RRT to day 60 P = % 4% 0% conservative liberal Wiedemann et al. N Engl J Med 2006

10 Volume and outcome in AKI-RRT 90-d mortality 70% 60% 50% 40% 30% 20% 10% 0% < >15 Fluid accumulation (% of body weight) Bouchard et al. KI 2009, Payen et al. Crit Care 2008, Grams et al. CJASN 2011, Teixeira et al. Crit Care 2013, Vaara et al. Crit Care 2012

11 Negative FB during CRRT is good Bellomo et al. Crit Care Med 2012

12 Is fluid the best medicine? Murugan, Kellum, Crit Care Med 2012

13 Optimal fluid therapy in 2013 Not too little and not too much Colloids? Crystalloids?

14 What to choose? Colloids Less for more IV volume Faster effect Less oedema Albumin: its human! Crystalloids Water and salt : its human! Cheap

15 What to choose? Colloids Less for more IV volume Faster effect Less oedema Albumin: its human! Crystalloids Water and salt : its human! Cheap AKI Pruritus More expensive Volume overload Hyperchloremic metabolic acidosis

16 AKI after gelatin Observational N = 1383 HES N = 1528 GEL MVR adjusted Risk for AKI after >33mL/kg GEL: OR 1.99 ( ) HES: OR 1.85 ( ) Schabinski et al. Intensive Care Med 2009

17 Dose-effect relationship! Mortality P = Brunkhorst et al NEJM 2008

18 Dose-effect relationship! AKI Brunkhorst et al NEJM 2008

19

20 HES in severe sepsis Mortality RRT LOS Perner et al. NEJM 2012

21 CHEST: HES in general ICU HES Saline P Blood products (ml) <0.001 AKI RRT Bilirubin Pruritus Skin rash Transfusion Myburgh et al. NEJM 2012

22 6% HES 130/0.42 and -/0.4 kill? 6S study Severe sepsis CHESTstudy General ICU Perner et al. NEJM 2012, Myburgh et al. NEJM 2012

23 CHEST: no effect in subgroups Myburgh et al. NEJM 2012

24 HES kills patients? No for 6% HES 130/0.4, waxy maize HES Yes: Severe sepsis, AND 6% HES 130/0.42, potato HES

25

26 Mortality: No More AKI More RRT More transfusion Haase et al. BMJ 2013

27 Haase et al. BMJ 2013

28 Kidney function in CHEST? Δ = 0.11 mg/dl Statistical significance = Clinical significance? Myburgh et al. NEJM 2012

29 Kidney function in CHEST? Statistical significance = Clinical significance? Myburgh et al. NEJM 2012

30 Shaw & Kellum CJASN 2013

31 RRT HES Control P CHEST S

32 RRT: small difference! HES Control P CHEST Δ S Δ No predefined criteria for initiation of RRT!

33 Need for RRT Gattas et al. Intensive Care Med 2013

34 Hypovolemia by blood loss <24h, and 90 d of follow up kidney function

35 Drug dosing defines benefit or harm Benefit Harm ml of HES

36 Drugs with toxicity ACEI NSAID Aminoglycosides Heparin Calcium blockers β-blokkers (ab)normal saline

37 External validity? CHEST and 6S: Trial fluids for all fluid resuscitation till ICU discharge Death 90 d

38 HES in perioperative setting mortality AKI Gillies et al. BJA 2013, Martin et al. Anesthesiology 2013

39 Better resuscitation Capillary flow Lactate clearance Dubin et al. J Crit Care 2010 James et al. BJA 2011

40 CABG: 10% HES 250/0.5 vs. saline PRCT N = 262 In favour of HES In favour of saline Magder et al. Crit Care Med 2010

41 Less AKI in penetrating trauma HES Saline P Penetrating trauma <0.001 RIFLE-Risk 3% 19% RIFLE-Injury 0% 16% RIFLE-Failure 0% 6% Blunt trauma RIFLE-Risk 35% 27% RIFLE-Injury 20% 14% RIFLE-Failure 8% 5% NS James et al. BJA 2011

42 Less fluid needed HES Saline P Guidet 1,379 1, CHEST d <0.001 CHEST volume balance S Vincent et al. Crit Care Med 2006

43 Is there a place for HES? Heterogeneous studies: more questions than answers More homogeneous studies

44 PRCT s on albumin n Survival AKI Bleeding/coag ulation SAFE 6997 Same More PC SAFE TBI 460 Worse More PC FEAST sepsis 3141 Worse SAFE severe sepsis 1218 No diff (trend) No diff No diff EARSS severe sepsis 792 No diff No diff ALBIOS severe sepsis 1818 Better No diff No diff ALIAS stroke 481 Worse

45 Optimal fluid therapy in 2013 Not too little and not too much Colloids? Crystalloids?

46 Crystalloids? Abnormal saline Kellum, Crit Care Med 2002

47 HCMA & inflammatory mediators Kellum et al. Chest 2006

48 Saline vs. Plasmalyte? N = 30,994 vs. 926 Major abd surgery Saline = More complications and use of resources: Major infection Dialysis Blood transfusions Electrolyte disturbances Shaw et al. Ann Surg 2012

49 Chloride liberal/restrictive fluid therapy AKI stage 2-3 Yunos et al. JAMA 2012

50 Summary Fluid overload is bad! Surrogate marker? Colloids GEL: <<< evidence HES: AKI and death (?) hypovolemic shock Not for sepsis/burns/critically ill Albumin: better in severe sepsis Crystalloid HCMA: un-physiologic/not normal saline!

51 Thank You

52 Thank you for your attention!

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