How to monitor de-resuscitation (#ISICEM18 #IFAD2018)

How to monitor de-resuscitation (#ISICEM18 #IFAD2018)

How to guide fluid therapy during de-resuscitation

What are we talking about?

De-resuscitation is defined as active fluid removal in patients with GIPS (global incresaed permeability syndrome) or a positive cumulative fluid balance (fluid overload defined as 10% increase in body water). It can be done with diuretics or RRT with ultrafiltration. But the best option is to avoid it! Below is a list of potential parameters or monitoring tools that could help to assess fludi overload and how to guide and monitor the de-resuscitation phase.

Clinical parameters

  • Body weight
  • Fluid balance
  • Cumulative FB
  • Pitting edema
  • 2nd and 3rd space fluid accumulation (orthopnee)
  • JVP and HJR
  • Capillary refill

Biochemical parameters

  • AKI, urinanalysis
  • Urine albumin/creat ratio
  • Dilutional anemia
  • Low albumin, protein
  • Infection, inflammation
  • Increased CLI (CRP/alb)
  • Low osmol, COP
  • BNP and NT-pro-BNP

Imaging

  • Cardiomegaly, congestive hili, Kerley B-lines, pleural effusions, lung edema
  • Ascites
  • E/e’, LVOT VTI
  • IVVCI (IVC > 2.5cm)
  • LA volume >34ml/m2
  • B-lines, comet-tail

Hemodynamic monitoring

  • MAP, HR
  • High CVP, PAOP
  • High GEF/GEDVI
  • High RVEF/RVEDVI
  • Absence of FR
  • Low PPV, SVV
  • Negative PLR
  • Negative EEO

Organ function monitoring

  • EVLWI/PVPI
  • P/F ratio
  • ORI
  • GIPS
  • ICP, CPP (=MAP-ICP)
  • IAP, APP (=MAP-IAP)
  • AKI: biomarkers (N-GAL, cystatin C), CARS

Other techniques

  • V/Q match
  • TBW
  • ECW/ICW ratio
  • Volume excess
  • IVF vs EVF
  • Total CBV (technetium albumin)
  • BVI

In this lecture given by @manu_malbrain during the 38th #ISICEM18 meeting held in Brussels the above mentioned concepts are explained and discussed.

Why wait, just start with fluid stewardship now avoiding fluid overload and GIPS:

Go to Video

 

Suggested Reading

Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N: Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 2014, 46(5):361-380.

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