The Great(est) Fluid Debate

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Resuscitation fluids save lives in humans with life-threatening hypovolaemia. The fluid of choice should have biochemical characteristics close to the type of fluid lost and replaced at a rate and volume sufficient to correct severe fluid deficit. Then stop and consider the early use of catecholamines. There are few indications to give critically ill patients resuscitation fluids after 24 hours of admission. There is no place for synthetic colloids of non-physiological crystalloids. The effects of unnecessary fluids last well beyond the initial resuscitation period and are associated with adverse effects and harm to the patient. Fluids are toxic drugs and must be used with great care.

The greatest fluid debate
@DogICUma
@toddrice_ICU
@JAMyburgh

The greatest fluid debate
@srrezaie
@DogICUma
@toddrice_ICU
@JAMyburgh

The greatest fluid chat
@DogICUma
@toddrice_ICU
@JAMyburgh

45 year old diabetic
male
Severe generalised
abdominal pain
Vomiting
Rigors
Calls an ambulance

High heart rate
– 140bpm
High fever
– 39°C
Low blood pressure
– 78/40

Septic shock
Abdominal source

Fluids first
vs.
Fluids + pressors
vs.
Pressors first

An echo is mandatory
vs.
An echo is generally helpful
vs.
An echo is generally unhelpful

Balanced crystalloid
vs.
0.9% Saline
vs.
Colloid

8L +ve & 8kg heavier
On mod. dose noradrenaline
Intravascularly deplete

@DogICUma
@toddrice_ICU
@JAMyburgh
all icons: https://thenounproject.com

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Sepsis is a common presentation in the prehospital and retrieval environment, with most cases having a respiratory, urinary or soft tissue origin. However the best practice for identifying and management sepsis in the prehospital environment remains unclear. Despite sepsis having been a priority for in hospital guidelines and protocols for decades now, relatively little attention has been paid to prehospital sepsis management. Traditional teaching is that early antibiotics in sepsis save lives, however trials examining this are observational and confounded by outdated ICU care. An appropriately sensitive and specific tool for the prehospital identification of sepsis remains elusive. NEWS2 is common and lactate-modified QSOFA emerging (although prehospital lactate measurement remains difficult). The role of prehospital antibiotics, and the most appropriate one are also unclear. Most ambulance services that carry antibiotics use ceftriaxone. The retrieval environment is similar, with sepsis probably being the single commonest reason to call a retrieval service. For more head to our podcast page #CodaPodcast

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A Speech Pathology Perspective with Amy Freeman-Sanderson Sepsis causes organ and tissue dysfunction in response to severe infection, resulting in significant physical and cognitive morbidities. For patients diagnosed with severe sepsis, admission to an intensive care unit and use of an artificial airway are often required. The sequalae of severe sepsis necessitating critical care can result in significant changes to a patient’s swallowing and communication function. These negative changes and impacts to function can occur during and after a diagnosis of sepsis, and ultimately impact a patient’s health and functional status. The nature and long-term recovery of swallowing and communication function is still to be completely understood; however evidence affirms recovery continues well beyond hospital discharge. This presentation will focus on tasks we do daily – eating, drinking and speaking. Specifically, the nature of swallow impairments will be described, and the impact of this new disability will be explored from the perspective of the patient’s body structure, function and activities. Core components of swallowing safety and efficiency will be described, alongside the role of assessment and management within and beyond the ICU. Changes to communication including altered voice, speech and language function will be described. Outcomes of altered communication function over the continuum of care during, and after hospital will be explored. The evidence base and the lived experience of sepsis and patient stories will underpin the content delivered in this presentation. The final aim of the presentation will be to describe and highlight the role of speech pathology, an allied health profession, in the management of swallowing and communication function. Following the workshop attendees will be able to (1) describe the characteristics of swallowing and communication disorders; (2) have knowledge of the impact of these new disabilities; and (3) will be able to describe the role of speech pathology in the healthcare team for the patient with sepsis. For more head to our podcast page #CodaPodcast

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The Great(est) Fluid Debate

1. The greatest fluid debate @DogICUma @toddrice_ICU @JAMyburgh

2. The greatest fluid debate @srrezaie @DogICUma @toddrice_ICU @JAMyburgh

3. The greatest fluid chat @DogICUma @toddrice_ICU @JAMyburgh

4. 45 year old diabetic male Severe generalised abdominal pain Vomiting Rigors Calls an ambulance

5.

6. High heart rate – 140bpm High fever – 39°C Low blood pressure – 78/40

7.

8. Septic shock Abdominal source

9. Fluids first vs. Fluids + pressors vs. Pressors first

10.

11. An echo is mandatory vs. An echo is generally helpful vs. An echo is generally unhelpful

12. Balanced crystalloid vs. 0.9% Saline vs. Colloid

13. 8L +ve & 8kg heavier On mod. dose noradrenaline Intravascularly deplete

14. @DogICUma @toddrice_ICU @JAMyburgh all icons: https://thenounproject.com

Notas do Editor

The title of this session is ‘the greatest fluid debate’ but we are all friends here and agree about everything all of the time so, it’s really more of a chat.
We hope you will get involved. Please send questions and comments to the Twitter moderator
We hope you will get involved.
Ambulance comes. Patient looks sick.
The sick patient arrives in hospital.
The provisional diagnosis here is septic shock with a primary abdominal source
“So, you might have noticed that this icon is called ‘saline drip’. I want to put that to one side for now. John / Todd – let’s start with a philosophical discussion. In general terms, tell us which camp you belong to and why?” Among other things, I think that this would be an opportunity to talk about the CENSER trial: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201806-1034OC & the REFRESH pilot RCT: https://link.springer.com/article/10.1007%2Fs00134-018-5433-0 There are also couple of recent retrospective studies that highlight the association between duration of hypotension and mortality that could be mentioned: https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-018-0448-9 https://link.springer.com/article/10.1007%2Fs00134-018-5218-5 We could a twitter Poll or take some comments from Twitter here.
While the philosophical discussion is ongoing, the emergency physician swoops in with an ultrasound machine and says, “look, the patient is hypovolaemic and needs volume”. Todd/John – any thoughts or comments. “Vigorous empty ventricle from low SVR and from hypovolaemia look the same – my view is that this echo actually does not help much apart from confirming appearances are consistent with septic shock. Still don’t know whether this means we should give fluid.”
...and where do you stand on this spectrum. Twitter comments / questions? Twitter poll?
“So, let’s just say you decide to give a fluid bolus. Let’s talk about this. Todd, you go first...” Twitter comments? Live Twitter Poll?
Some time later the patient, who has been to the OR and had a gangrenous perforated appendix chopped out, is in the ICU. Using your expert clinical judgement you decide that the patient has a combination of total body fluid overload and intravascular depletion. Where do you stand on fluid boluses for this patient? Twitter comments? Live Twitter Poll? Once the time comes to take fluid away, where do you stand on diuretics? Twitter comments? Live Twitter Poll?