Thread by @iceman_ex

Now debating “endpoints of fluid resuscitation” featuring @Manu_Malbrain and @PrXaMonnet #lives2018

Up first: Manu!

Follow him @Fluid_Academy and check his work annalsofintensivecare.springeropen.com/articles/10.11…

The ROSE concept emphasised by @Manu_Malbrain

https://twitter.com/manu_malbrain/status/844079125740634112?s=21

#lives2018

Magder Shelton: cardiac output is the key component of determining fluid requirements. Stop once CO adequate ncbi.nlm.nih.gov/pubmed/2054368… #lives2018

Perel Azriel to Magder Sheldon:

“Using that you’d give fluid to everyone!!”

#lives2018

.@PrXaMonnet : we should try and predict fluid responsiveness before giving fluids (except in situations where hypovolaemia is obvious eg haemorrhage) annalsofintensivecare.springeropen.com/articles/10.11… #lives2018

(He also just fired a shot at CVP 😉)

Apparently 70% of fluid boluses given in OPTIMISe didn’t increase CO- is this true @rupert_pearse? thebottomline.org.uk/summaries/pom/… #lives2018

@WhistlingDixie4 @avkwong @strachanjamie @Gas_Craic @Aidan_Baron @FOAMecmo

The idea of pushing people to the stop of their starling curve originated with Shoemaker ncbi.nlm.nih.gov/m/pubmed/31917…

But may be harmful- see FEAST from
@KathMaitland nejm.org/doi/full/10.10… #lives2018

.@Manu_Malbrain recommends using stop points with #POCUS and EVLW to limit the amount of fluid you give annalsofintensivecare.springeropen.com/articles/10.11… #lives2018

Question from the audience: how do you know if CO is enough?

@PrXaMonnet: absolute number not important. You need to see how it changes with what you do

#LIVES2018

Should CO monitoring be standard in the management of septic shock?

I’m biased so I say yes

And @Manu_Malbrain agrees #lives2018

What about assessing fluid responsiveness with passive leg raise?

Problems being raised with the awake patient - agitation, discomfort

And you need to measure CO

#lives2018

Sheldon - give volume, looks at the patient, assess CO (he looks for a rise in CI by 0.3 as a marker of fluid responsiveness)

And he still uses CVP 😳😳😳 #lives2018

He ideally wants to give fluid, see a CVP rise of 2 and a CI rise of 0.3

If CI rises alone - fine
If CI rises and CVP doesn’t rise- ? Not enough fluid

He uses 500ml saline or 250ml HAS

🤔#lives2018

FEAST and SSP2 making a mention. Fluid challenges can be associated with mortality thebottomline.org.uk/summaries/icm/…

thebottomline.org.uk/summaries/icm/…

However these patients were very anaemic- was dilution a factor?

(The post hoc analysis of FEAST said nah though) #lives2018

Will continuous monitoring of Hb become standard in ICU, and dilution also be used as a stop point for fluid resus? 🤔 ##lives2018

(It would hopefully reduce the blood gas load)

Now the panel are discussing de-resuscitation. When to start?
@Manu_Malbrain - uses EVLW and PVPI, combones with intraabdominal pressure #lives2018

.@PrXaMonnet - once the patient is not fluid responsive anymore, fluid removal can be safely undertaken

Sheldon- start fluid removal once they are resuscitated #lives2018

Why not just use BP as your fluid guide?

Sheldon- BP tracks CO poorly. Can have rise in CO with no change in BP after a fluid Bolus #lives2018

So in summary:

When people are sick give fluids

When they are getting better see if they still need fluid

Once they are stable and if they are fluid overloaded take fluid off

#lives2018