Fluid is A Drug That Should Be Dosed: Putting it All Together When Resources are Abundant Stuart L. Goldstein, MD Professor of Pediatrics University of Cincinnati College of Medicine Director, Center for Acute Care Nephrology Nephrology and Hypertension The Heart Institute Cincinnati Children’s Hospital Medical Center

Thank You Faculty Participants Organizing Committee Tim Bunchman

12 Minutes to Put it All Together: What I Will Try To Convince You There are 3 phases of fluid therapy in critical illness/AKI Resuscitation Maintaining fluid balance homeostasis/prevention of fluid overload Fluid removal Goal directed fluid therapy Each phase requires different fluid dosing Volume and timing are critical Fluid Accumulation is an outcome variable and predictor Treating FLUID AS A DRUG by considering its toxic cumulative effects to guide optimal dosing may improve outcome

The AKI Fluid Epidemiology Paradigm Maintenance/ Homeostasis R E S U C I T A O N Fluid Balance Removal/ Recovery Time

1st Phase of Fluid Therapy in Critical Illness Resuscitation Restore end-organ perfusion Goal directed to achieve physiological endpoints CVP Mixed venous saturation THEN reassess and DETERMINE if and when the resuscitative phase is complete

2nd Phase of Fluid Therapy in Critical Illness Maintenance of fluid balance homeostasis and/or prevention of worsening fluid overload Assess patient’s needs for all fluids (nutrition, medications, blood products) and associated daily volumes Assess patient’s ability to maintain fluid balance UOP Stool losses Chest tubes Assess patient’s current fluid accumulation status

The AKI Fluid Epidemiology Paradigm S U C I T A O N Fluid Balance Time

The AKI Fluid Epidemiology Paradigm Maintenance/ Homeostasis Fluid Balance Time

The Dilemma and Decision If the patient with AKI cannot tolerate the needed fluid volumes without developing or worsening fluid overload Fluid restrict Consider renal replacement therapy to maintain fluid homeostasis

The Potential ICU Perspective

Fluid Is a Drug An MD has to write an order for it An RN has to take off the order The Pharmacy has to send it How to Dose It? Depends on fluid therapy phase Response to the need for fluid vs. a non-fluid related symptom Not all hypotension needs fluid Has the patient already been overdosed?

Goldilocks Paradigm Too Little Too Much Fluid Dose Meter

212 adult patient retrospective cohort study Adequate Initial Fluid Resuscitation (AIFR) > 20 ml/kg bolus before vasopressors CVP > 8 mmHg after vasopressors within 6 hours Conservative Late Fluid Management (CLFM) Even to negative fluid balance for at least two consecutive days in the first 7 days after sepsis onset Primary Outcome: hospital survival

Net negative fluid balance began Daily fluid balances Net negative fluid balance began Day 3-4 for survivors

Why Do We Give So Much Fluid? To reverse shock To restore end organ perfusion Surviving Sepsis calls for fluid attain a CVP 8-12

Retrospective review from the VASST (vasopressin) 778 patients Septic shock Fluid balance in first 4 days assessed Daily CVP Mortality as endpoint

Lessons for Practice View fluid as a drug Dose it appropriately Determine when fluid accumulation has turned into fluid overload (overdose) MEASURE fluid accumulation DETERMINE a threshold (10-20%?) Consider CRRT after resuscitation to maintain homeostasis in the appropriate clinical context

CACN AKI Mantra “We don’t wait for an at-risk patient to become pulseless and apneic before intubating them, so why do we wait for them to have complete renal failure before starting renal replacement therapy”

The AKI Fluid Epidemiology Paradigm Maintenance/ Homeostasis R E S U C I T A O N 10-20% FO? Fluid Balance Removal/ Recovery Time