IFAD Day 2

IFAD Day 2

IFAD2015 Day 2 Blog summary

PLENARY SESSION (Chairs: A. Perel - D. Lobo)

Opening Lecture: Perioperative fluids - How restrictive should we go? (M. Mythen)

Distinct from the critical care situation

Guiding fluid therapy - Knowledge and experience vs advanced haemodynamic monitoring

BJA 2015 Lilot – dependent on anaesthesia provider. Huge variation in amount given (http://bja.oxfordjournals.org/content/early/2015/01/13/bja.aeu452)

It’s not the water that does the harm, it’s the SALT

Is it the restriction of fluid or the avoidance of overload that is of benefit?

http://www.ncbi.nlm.nih.gov/pubmed/22253274 - meta-analysis

Perioperative Fluid Utilization Variability and Association With Outcomes - http://journals.lww.com/annalsofsurgery/Abstract/publishahead/Perioperative_Fluid_Utilization_Variability_and.97236.aspx

The definition of liberal and restrictive fluid strategies are very different between the studies

REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery: RELIEF Study -

https://clinicaltrials.gov/ct2/show/NCT01424150

Perioperative fluid management: Consensus statement from the enhanced recovery partnership - http://perioperativemedicinejournal.biomedcentral.com/articles/10.1186/2047-0525-1-2

http://cheers-dream.com

PRO-CON Debate: Blood Transfusion on the ICU

CON: Don't exaggerate! (A. Perner)

Transfusion issues – expensive and limited resource, known side-effects, benefits vs harm

Risk of anaemia – low DO2, ischaemia, organ dysfunction

Risk of transfusion – infectious and non-infectious

Cochrane review - http://www.ncbi.nlm.nih.gov/pubmed/22513904

TRISS trial - http://www.nejm.org/doi/full/10.1056/NEJMoa1406617

TITRE2 trial - http://www.nejm.org/doi/full/10.1056/NEJMoa1403612

Association of Blood Transfusion With Increased Mortality in Myocardial Infarction

A Meta-analysis and Diversity-Adjusted Study Sequential Analysis - http://archinte.jamanetwork.com/article.aspx?articleid=1485987

PRO: Don't hold back! (C. Ince)

Blood transfusions are the only effective therapy to improve oxygen delivery

The original TRICC trial - http://www.nejm.org/doi/full/10.1056/NEJM199902113400601

Problem with trials - absence of evidence is not evidence of absence

Single centre trials are better than multicenter trials?

PRO-CON Debate: Blood Transfusion on the ICU

CON: Don't exaggerate! (A. Perner)

Transfusion issues – expensive and limited resource, known side-effects, benefits vs harm

Risk of anaemia – low DO2, ischaemia, organ dysfunction

Risk of transfusion – infectious and non-infectious

Cochrane review - http://www.ncbi.nlm.nih.gov/pubmed/22513904

TRISS trial - http://www.nejm.org/doi/full/10.1056/NEJMoa1406617

TITRE2 trial - http://www.nejm.org/doi/full/10.1056/NEJMoa1403612

Association of Blood Transfusion With Increased Mortality in Myocardial Infarction

A Meta-analysis and Diversity-Adjusted Study Sequential Analysis - http://archinte.jamanetwork.com/article.aspx?articleid=1485987

PRO: Don't hold back! (C. Ince)

Blood transfusions are the only effective therapy to improve oxygen delivery

The original TRICC trial - http://www.nejm.org/doi/full/10.1056/NEJM199902113400601

Problem with trials - absence of evidence is not evidence of absence

Single centre trials are better than multicenter trials?

ARDS & SEPSIS (Chairs: A. Wilmer - Ph. Jorens)

What everyone should know about treating ARDS! (L. Gattinoni)

Lung protective strategy = less energy + more homogeneous lung

Recipe

  • Assess Severity
  • Select Tidal Volume
  • Select PEEP
  • Select RR-IE
  • Watch haemodynamics

Severity = P/F ratio at 5cmH2O PEEP (300 200 100 Berlin definition)

Tidal volume = 6mls/kg IBW (check plateau pressure)

PEEP = based on gas exchange http://www.ncbi.nlm.nih.gov/pubmed/24196193

  • Mild ARDS <10cmH2O
  • Mod ARDS 10-15 cmH2O
  • Severe ARDS > 15cmH2O

PRO-CON Debate: ARDS 

The monitored approach: D. Reuter

Individualised care – understand pathophysiology à determined individual therapy

Fluid therapy in ARDS - http://journal.publications.chestnet.org/article.aspx?articleid=1089902

Assessing Extracellular Lung Water Index is difficult (Clinical vs Monitors)

The clinical approach: JL. Vincent

Do we need ARDS? - http://link.springer.com/article/10.1007%2Fs00134-015-4120-7

Avoid fluid overload! Which patients will benefit from fluids (pic)

Patients die with ARDS not because of ARDS

What's left of GDT in sepsis? (A. Perel)

10 Short Beliefs in ICM - http://link.springer.com/article/10.1007/s00134-015-3733-1

Bench-to-bedside review: the initial hemodynamic resuscitation of the septic patient according to Surviving Sepsis Campaign guidelines--does one size fit all? - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2592726/

The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study) - http://link.springer.com/article/10.1007%2Fs00134-015-3906-y

Management of septic shock: a protocol-less approach - http://www.ncbi.nlm.nih.gov/pubmed/26088759

Treating septic shock responsibly

CU5RR5bWsAA0Odg.jpg large

PERIOPERATIVE FLUID MANAGEMENT (Chairs: D. Lobo - M.Mythen)

BEFORE SURGERY: Do we need prophylactic colloids? (R. Hahn)

Rationale - Pre-loading prevents undetected hypovolaemia

Interactions between the volume effects of hydroxyethyl starch 130/0.4 and Ringer´s acetate -http://www.ccforum.com/content/17/3/R104

No role for prophylactic colloid

Crystalloids fluids have better plasma volume expanding properties

Colloids should only be given on special indications only

DURING SURGERY : Fluid choices in the Elderly (D. Lobo)

AAGBI Guidelines Peri-operative Care of the Elderly 2014

https://www.aagbi.org/sites/default/files/perioperative_care_of_the_elderly_2014.pdf

WTOTW - http://www.anaesthesiauk.com/documents/elderly.pdf

Fluids and GI function - http://www.ncbi.nlm.nih.gov/pubmed/21681086

AFTER SURGERY: Colloids vs Crystalloids in Postop Shock (D. Annane)

SAFE study - http://www.nejm.org/doi/pdf/10.1056/nejmoa040232

CHEST study - http://www.nejm.org/doi/full/10.1056/NEJMoa1209759

CRISTAL study - http://jama.jamanetwork.com/article.aspx?articleid=1752245

AFTER SURGERY: Enhancing surgical recovery (M. Mythen)

Royal College of Anaesthetist UK film on perioperative medicine - http://www.rcoa.ac.uk/periopmed/animation

Why is the high-risk surgical patient still at risk? http://bja.oxfordjournals.org/content/106/3/289.full.pdf+html

Enhancing Recovery Pathway patients are eating, drinking and mobilizing within 24 hours

Pillars or ERS – minimally invasive surgery, manage pain and fluids

http://www.erasuk.net

http://www.ebpom.org

http://sortsurgery.com

Enhanced recovery from surgery in the UK: an audit of the enhanced recovery partnership programme 2009–2012 -http://bja.oxfordjournals.org/content/115/4/560.long

FLUID OVERLOAD (Chairs: A. Wilmer - D. Annane)

Is hypervolemia really so bad? In the operating room (R. Hahn)

Risk of hypervolaemia leads to increased risk of pulmonary oedema and increased secretion of ANP (increase protein extravasation and causes albuminuria)

Hypervolemia increases release of atrial natriuretic peptide and shedding of the endothelial glycocalyx -http://www.ccforum.com/content/18/5/538

Must hypervolaemia be avoided? https://www.google.be/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahUKEwjt8KKErrPJAhVBKg4KHQlvBKsQFggsMAE&url=https%3A%2F%2Fjournals.viamedica.pl%2Fanestezjologia_intensywnaterapia%2Farticle%2Fdownload%2FAIT.a2015.0062%2F29991&usg=AFQjCNEiJqdG5oRsn1t75G0qH9rddUacsA

Is hypervolemia really so bad? In the ICU (JL. Vincent)

The adverse effect (if any) of the hypervolaemic state on ICU is dependent on the time course of the patient’s illness

Higher vs. lower fluid volume for septic shock: clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort -http://www.ccforum.com/content/16/3/R76

SOSD approach – Salvage Optimisation Stabilisation De-escalation

4 phases of IV fluid therapy - http://bja.oxfordjournals.org/content/113/5/740.abstract

Sepsis in European intensive care units: results of the SOAP study - http://www.ncbi.nlm.nih.gov/pubmed/16424713

FINAKKI study - http://www.ccforum.com/content/16/5/R197

Furosemide 5mg as a test to see if a patient is ready for de-escalation is advocated by Prof Vincent and Dr Perel

Is de-resuscitation the solution? (I. De laet)

Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death - http://www.ncbi.nlm.nih.gov/pubmed/25247784

How to avoid fluid overload -http://www.ncbi.nlm.nih.gov/pubmed/26103147

Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice - http://www.ncbi.nlm.nih.gov/pubmed/25432556

How to de-resuscitate? Furosemide or ultrafiltration.

Ensure absence of shock or tissue hypoperfusion

  • Define clinical endpoint
  • Set fluid balance goal
  • Set perfusion and renal safety precautions
  • Re-evaluate after 24 hours
  • Adjust plan accordingly

CLOSING SESSION (Chairs: D. Himpe - P. Elbers) 

Non-invasive monitoring of oxygen delivery: new frontiers (A. Perel)

  • ORI oxygen reserve index – non invasive and continuous device made by Masimo
  • Continuous non-invasive Hb monitoring
  • Pleth variation index

Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery -http://www.ncbi.nlm.nih.gov/pubmed/25797725

Pleth variability index is a weak predictor of fluid responsiveness in patients receiving norepinephrine -http://www.ncbi.nlm.nih.gov/pubmed/23103777

Non-invasive monitoring of oxygen delivery in acutely ill patients: new frontiers -

http://www.annalsofintensivecare.com/content/pdf/s13613-015-0067-7.pdf

Intensive Care Anno 2015 - What can we do better? (L. Gattinoni)

Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Failure A Randomized Prospective Study - http://jama.jamanetwork.com/article.aspx?articleid=367396

Gattinoni – ICM (pic)

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