1. Flu d
In Some ICU situations
Optimization
i
Emad Z. Kamel
a Professor of Anesthesia and Surgical IC.
Assiut faculty of Medicine
1

2. AGENDA
• Introduction
• Fluids available
• Fluids in ARDS
• Fluids in Hepatic
• Fluids in Renal
Fluids
Emad Zarief 2023 2

3. Fluids &
ICU Outcomes
• Type of fluid
• Volume of fluid
• Rate of infusion
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4. The fluid challenge is a fluid bolus given at a defined
quantity and rate to assess fluid responsiveness.
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5. Emad Zarief 2023 8

6. Ideal Fluid
• In shock, it should have a composition like plasma to
support cellular metabolism and avoid organ dysfunction
• Should be able to achieve a sustained ↑ in intravascular
volume to optimize CO.
• Unfortunately, no ideal fluid exists.
• The available fluids : crystalloids, colloids, and blood
products.
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7. Colloids
• Of large molecules →remain intravascular for
several hours, ↑plasma osmotic pressure .
• In sepsis → alterations in glycocalyx and ↑
endothelial permeability → extravasation of
colloids molecules → ↑ the risk of global ↑
permeability syndrome and abolishes the primary
advantage.
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
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8. • The molecular leakage has demonstrated either
no effect or detrimental consequences in
critically ill patients, ↑ AKI.
• Thus, the use of semisynthetic colloids in shock
patients should be abandoned.
Colloids
Intensive Care Medicine Experimental. 2022;10(1):46.
acute kidney injury (AKI).
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9. • Its role in shock is still debated.
• Although theoretically promising for its anti-
inflammatory and anti-oxidant proprieties, and for
its supposedly longer intravascular confinement,
clinical data have been conflicting.
Albumin
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
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10. Albumin
• Intravascular albumin leaks / hour into the
extravascular space [transcapillary escape rate (TER)] →
half-time of about 15 h.
• Distributed in intravascular and extravascular fluid (In
health, up to 5% of) and increase up to 20% or more in
septic shock.
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
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11. • (SAFE) study : albumin should be avoided in patients
with TBI.
• It is recommended for patients with chronic liver
disease and in combination with terlipressin for
patients with hepatorenal syndrome.
• The most recent Surviving Sepsis Guidelines also
suggest using albumin in patients with sepsis who
have received large volume crystalloid resuscitation.
Albumin
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
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12. Emad Zarief 2023 19

13. • Non anion gap metabolic acidosis
• Renal arteriolar VC
• May impair cardio contractility
• Neutrophil activation and pulmonary
inflammation
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14. • Ringer’s lactate, Ringer’s acetate and Plasmalyte.
• Lower chloride concentration and lower osmolarity
…….(280 - 294mosm/l)
• buffered with lactate or acetate to maintain
…electroneutrality.
Intensive Care Medicine Experimental. 2022 Nov 4;10(1):46.
Balanced Solutions
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15. Intensive Care Medicine Experimental. 2022;10(1):46.
Balanced Solutions
• In sepsis may be associated with improved
outcomes compared with chloride-rich solutions and
the lack of cost effectiveness
• balanced crystalloids are recommended (weak
recommendation) as first-line fluid type in patients
with septic shock.
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18. Fluid Handling in
Selected Situations
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19. Intensive Care Med. 2020 Dec;46(12):2252-2264.
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20. • Optimal fluid management in ARDS
remains challenging and
controversial.
• It should provide adequate DO2 to
the body & avoiding inadvertent ↑
in lung edema
Intensive Care Med. 2020 Dec;46(12):2252-2264.
In ARDS
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21. In ARDS
• Net positive fluid balance occurs in most patients
at the onset of ARDS even when closely monitored.
• It predicts prolonged mechanical ventilation, longer
ICU and hospital stay, and higher mortality
Intensive Care Med. 2020 Dec;46(12):2252-2264.
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22. Emad Zarief 2023 30

23. Emad Zarief 2023 31

24. J Hepatol. 2023 Jul;79(1):240-246.
• →Require larger volumes of fluids to expand central blood
volume and improve sepsis-induced organ hypoperfusion
• Fluid overload should be avoided, as it can worsen portal
hypertension, ascites, and pulmonary edema
• Monitoring tools →echocardiography for bedside
assessment of fluid status and responsiveness.
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25. • Balanced crystalloids preferred over normal saline,
because normal saline can exacerbate acidosis and
hyperkalemia
• Experimental data suggest albumin is superior to
crystalloids at controlling systemic inflammation and
preventing acute kidney injury.
J Hepatol. 2023 Jul;79(1):240-246.
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26. Renal patient
• In patients with CKD or heart failure, slower and smaller
fluid boluses (e.g., 250 mL over 1 to 2 hours) may be safer
to avoid fluid overload and pulmonary edema.
• The end point → based on clinical and hemodynamic
parameters, such as blood pressure, heart rate, urine
output, central venous pressure, lactate, and oxygen
saturation
Nephron (2019) 143 (3): 170–173.
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27. Hyperchloremia may be encountered because of chloride-liberal fluid replacement strategy
→hyperchloremic metabolic acidosis and renal vasoconstriction that may ↓↓ eGFR and
UOP in major surgeries, and prolong the time to first micturition
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28. • Results: A total of 5037 patients were recruited from 53 ICUs .
• 2515 patients were randomly assigned to the BMES group and 2522 to the saline group.
• 90-Day Death in 21.8% in the BMES group and in 22.0% in the saline group, (P = 0.90).
• New RRT in 12.7% BMES group and in 12.9% the saline group
• The number of adverse and serious adverse events did not differ meaningfully between the groups.
• Conclusions:→ no evidence that the risk of death or acute kidney injury among critically ill adults in the
ICU was lower with the use of BMES than with saline.
• (Australia and the Health Research Council of New Zealand; NCT02721654.).
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29. Metanalysis 10 489 patients with sepsis concluded that risk for AKI
was significantly lower in patients receiving balanced crystalloids
(11.3%) compared with normal saline (12.7%) without differences
in the need for renal replacement therapy or duration of ICU stay
J Clin Med. 2022 Apr 1;11(7):1971
Therefore, the type and amount of fluid should be
individualized based on the patient’s clinical condition and
laboratory results.
Am Fam Physician. 2019;100(11):687-694
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30. Emad Zarief 2023 38

31. • The ideal fluid for critically ill patients does not
exist; however, crystalloids should be used as first
choice.
• Balanced crystalloid solutions may be associated
with better outcomes, but the evidence is still low.
• Albumin infusion may have a role in already fluid
resuscitated patients at risk of fluid overload.
Final Notes
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32. • Ideal fluid
• Volume of fluid
• Rate of infusion
Matters
Final Notes
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33. emadzarief@aun.edu.eg
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34. Emad Zarief 2023 42