sean m bagshaw, md, msc division of critical care medicine faculty of medicine and dentistry,...
TRANSCRIPT
Sean M Bagshaw, MD, MScDivision of Critical Care Medicine
Faculty of Medicine and Dentistry, University of Alberta
1st International Symposium on AKI in Children
Cincinnati, OhioSeptember 28, 2012
Fluid is a Drug: Late
Conservative Fluid
Management
Disclosure Summary
• Sean M Bagshaw, MD, MSc– Consultancy: Gambro Inc.– Speaking: Gambro Inc., Alere Inc.
Learning Objectives
• Review and Discuss:
–Fluid Overload
–Fluid Management
–Concept of “De-Resuscitation”
Brierley et al CCM 2009
• Identification/diagnosis
• Therapeutic Monitoring– Individualized
• Early/Aggressive Initial Resuscitation– Hemodynamic
stabilization– Shock reversal
11.8% vs. 39.2%HR 3.8; 95% CI, 1.6-7.2,
p=0.002Oliveira et al ICM 2008
Fluids (mL/kg)
0-6 6-72 0-72
Crystalloid Control Active
528
100
8090
Red Cells Control Active
15.745.1
43.131.4
58.868.6
Inotrope Control Active
7.829.4
22.419.6
29.449.0
Han et al Pediatrics 2003
Outcomes Appropriate Fluid Therapy(n, %)
All patients (n=91) 41 (45)
Shock Reversed (n=24)
24 (100)
Persistent Shock (n=67)
17 (25)
Survivors (n=65) 32 (49)
Non-Survivors (n=26)
9 (35)
Shock reversal ~ >9-fold ↑ OR survival
Persistent shock (per hour) ~ >2-fold ↓ OR survival
Percent Fluid Overload (%FO)
%FO = Σ [FLUID IN – FLUID OUT] [Admission Weight (kg)]
x 100
Goldstein et al Pediatrics 2001
• “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
%FO>10% for PICU Admission: 68.4% vs. 22.1%, p<0.001
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
Payen et al Crit Care 2008
Any ARF 36% (n=1120)
Early ARF 75% (n=842)
Late ARF 25% (n=278)
CRRT 25% (n=278)
Early AKI
Late AKI
No AKI
Mean fluid balance (L/24hr) HR 1.21, 95%CI, 1.13-1.28,
p<0.001
Fluid Overload at RRT Initiation
Bouchard et al KI 2009
Adj-OR death for fluid overload at RRT initiation
2.07, 95%CI, 1.27-3.37
Challenges…
• 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
Brandstrup et al Ann Surg 2003
ComplicationConservat
ive(n=69)
Liberal(n=72)
p
Pulmonary edema (%)
0 5.6 0.20
Pulmonary congestion (%)
2.9 11.1
0.09
Pneumonia (%) 4.3 12.5 0.13
Cardiac arrhythmia (%)
0 9.7 0.03
Cardiopulmonary* (%)
7.2 23.60.007
Tissue Healing (%) 15.9 30.60.04
FACTT - Wiedemann et al NEJM 2006
Variable CON LIB p
Death (d 60) (%)
25.5 28.4 0.30
Ventilator-free days (d 1-28)
14.6 12.10.00
1
ICU-free days (d 1-28)
13.4 11.20.00
1
RRT (day 60) (%)
10 14 0.06
Next Steps…
• 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
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
• (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