1. 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

2. Thank You
Faculty
Participants
Organizing Committee
Tim Bunchman

3. 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

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

5. 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

6. 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

7. The AKI Fluid Epidemiology ParadigmS U C I T A O N
Fluid
Balance
Time

8. The AKI Fluid Epidemiology Paradigm
Maintenance/
Homeostasis
Fluid
Balance
Time

9. 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

10. The Potential ICU Perspective

11. 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?

12. Goldilocks Paradigm
Too Little
Too Much
Fluid Dose Meter

14. 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

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

19. 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

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

22. 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

23. 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”

24. 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