• Capillary refill is LIKELY better to follow for resuscitation than lactate.[r]
(1)Fluids in Critical Care
JOSHUA SOLOMON, MD
ASSOCIATE PROFESSOR OF MEDICINE NATIONAL JEWISH HEALTH
(2)Outline
• Background
• Timing of fluid?
◦ Early vs late
• Type of Fluid?
◦ Crystalloid, colloid and balanced solutions
• When to give more?
(3)(4)(5)Study Setting EGDT Usual Care
Rivers Single Center
4.4 3.9
ProCESS USA (31) 2.8 2.2
ARISE Aus/NZ (51) 2.5 1.7
ProMISE England (56)
2.2 2.0
After enrollment (L)
(6)Study Setting EGDT Usual Care EGDT Usual Care
Rivers Single Center
4.4 3.9 7.4 6.9
ProCESS USA (31) 2.8 2.2 4.9 4.3
ARISE Aus/NZ (51) 2.5 1.7 5.1 4.3
ProMISE England (56)
2.2 2.0 4.2 4.0
After enrollment (L) Total in 6hrs (L)
(7)Sepsis Resuscitation Volume
• There are no randomized trials looking at :
◦ Cardiac output before and after 30 cc/kg
◦ Rate or amount of fluid administration in initial resuscitation
• Four major sepsis trials (EGDT, ARISE, PROCESS and PROMISE) required SBP <90 after fluid
administration (30cc/kg in EGDT and L in the others)
(8)Lee et al Chest 2014
(9)Vincent et al Crit Care Med 2006
Late Fluid in sepsis….
(10)7 Day Fluid Balance Conservative Liberal
Shock (30%) 2.9L 10.1L1 Non-shock (70%) -130 ml 7L
(11)Late Fluid in Sepsis
• Enrolled late in
resuscitation (>6hr)
• Net 7L balance at baseline
• Measured response to 500cc NS challenge
• Limited CI response in all patients
(12)(13)NEJM 2004;350: 2247-56
• 6997 patients in 167 hospitals
• Patients who met criteria to receive fluid got either 4% albumin or normal saline
• No difference in 28d mortality, organ failure, days in ICU, renal replacement
(14)NEJM 2007;357: 874-84
79.6%
66.8%
(15)NEJM 2014;370: 1412-21
• 1818 patients in 100 ICUs
• Patients who met criteria to receive fluid got either 4% albumin or normal saline
• Received 20% albumin+
crystalloid or crystalloid alone
(16)2018 update
• Early fluid critical
• 30 ml/kg fluid within first hour
• Use crystalloid
◦ No benefit to colloid/albumin ◦ Albumin more expensive
• The data are limited for the resuscitation amount
(17)Saline vs Balanced Solution
Animal Studies
• Chloride infusion causes renal vasoconstriction, decreased renal perfusion and GFR
• Effect doubles with volume depletion Humans
• 20 healthy males, isotonic solution caused
decreased renal cortical tissue perfusion on MRI
• Balanced solution did not
(18)Raghunthan et al, Crit Care 2014 Yunos et al, JAMA 2012
(19)• Cluster-randomized, multiple crossover trial
• ICUs at Vanderbilt in Nashville, TN USA
• 15,802 adults
• Randomized to either 0.9% NS or Lactated Ringers/Plasma-Lyte A
• Primary endpoint - major adverse kidney event in 30d (death, RRT or creatinine > 200% of baseline
(20)(21)Outcome Balanced Crystalloids
Saline Odds Ratio P value
Primary Outcome
Major adverse kidney event 1139 (14.3%) 1211 (15.4%) 0.90 (0.82 to 0.99) 0.04 In hospital death before 30d 818 (10.3%) 875 (11.1%) 0.90 (0.80 to 1.01) 0.06 New renal replacement therapy 189 (2.5%) 220 (2.9%) 0.84 (0.68 to 1.02) 0.08 Final cr > 200% 487 (6.4%) 494 (6.6%) 0.96 (0.84 to 1.11) 0.60
Secondary Outcome
In hospital death before 60d 928 (11.7) 975 (12.4) 0.92 (0.83 to 1.02) 0.13
Median ICU-free days 25.3 25.3 1.00 (0.89 to 1.13) 0.22
Mean renal replacement free days 25+/- 8.6 24.8 +/- 8.9 1.11 (1.02 to 1.20) 0.01
(22)(23)• No difference in hospital-free days
• Lower incidence of major adverse kidney events at 30 days 4.7% vs 5.6%, OR 0.82, 95%CI 0.70 to 0.95, P=0.01
(24)(25)When to give more fluids?
• Static Indices◦ BP, HR
• Static Vascular Filling Pressures
◦ CVP, Wedge Pressures
• Dynamic Indices
◦ Pulse Pressure Variation
◦ Stroke Volume Variation
• Other
◦ Central Venous Oxygen Saturation
◦ Passive Leg Raise
(26)CVP for assessing volume status
Marik P Chest 2008;134(1):172-178 Shippy CR Crit Care Med 1984 12:107-112
Pooled area under ROC curve 0.56
CVP for predicting volume
(27)(28)(29)(30)• 28 ICUs, 424 patients with septic shock
• Resuscitation at normalizing capillary refill or normalizing or decreasing lactate by 20% within hours
• Outcome - all cause mortality 28 days
(31)(32)(33)(34)Summary
• Early volume is good, late volume (and cumulative volume balance) is bad
• For sepsis resuscitation, balanced fluids are better
• Dynamic indicators are better to assess volume status
• CVP is worthless
(35)