FLUID BALANCE AND ORGAN

DYSFUNCTION IN
PERIOPERATIVE AND
CRITICAL ILLNESS
Yohanes George
Outline:
Fluid accumulation is associated with adverse
outcomes
Pathophysiology of Fluid shifts in critical illness
Relationship of fluid accumulation to multi organ
dysfunction
FLUID ACCUMULATION IS ASSOCIATED
WITH ADVERSE OUTCOMES

INTRODUCTION
SUMMARY OF CLINICAL STUDIES SHOWING AN
ASSOCCIATION BETWEEN FLUID BALANCE AND
CLINICAL OUTCOME
NEGATIVE FLUID BALANCE PREDICTS
SURVIVAL IN PATIENTS WITH SEPTIC SHOCK
Alsous et al: CHEST 2000; 117:1749-1754
Conclusion: These results
suggest that at least 1 day of
negative fluid balance (<500
mL) achieved by the third day
of treatment may be a good
independent predictor of
survival in patients with
septic shock. These finding
suggest the hypothesis that
negative fluid balance
achieved in any of the first 3
day of septic shock portends
a good prognosis, for a
larger prospective cohort
study.
PEDIATRIC PATIENTS: HIGHER PERCENTAGES OF FLUID
OVERLOAD (FO) AT DIALYSIS INITIATION LINKED WITH
INCREASED MORTALITY
Goldstein,
Pediatrics
2001
Foland, Crit
Care Med 2004
Gillespie,
Pediatr
Nephrol 2004
Goldstein, KI
2005
Foland J et al: Crit care Med 2004 Aug: 32 (8): 1771-5
%FO was defined as total input minus output (up to 7 days
before CVVH) for both hospital stay and ICU stay
10%
IN SEPTIC PATIENTS WITH AKI, FLUID OVERLOAD WAS
ASSOCIATED WITH DECREASED AT 60 DAYS
Payen et al. Crtical Care 2008. 12:R74
ACUTE RENAL FAILURE, STRATIFIED BY TIME OF
INITIATION OF RENAL REPLACEMENT THERAPY (RRT)
Payen et al. Crtical Care 2008. 12:R74
IN SEPTIC PATIENTS WITH AKI, FLUID OVERLOAD WAS
ASSOCIATED WITH DECREASED SURVIVAL AT 60 DAYS
Payen et al. Crtical Care 2008. 12:R74
ARF (SOFA Score) = Cr > 3.5 mg/dl or UO < 500 mL/day
Early ARF = Occuring within 2 days of ICU admission
Late ARF = Occuring more than 2 days after ICU admission
EFFECT OF FLUID OVERLOAD IN CRITICALLY ILL
PATIENTS WITH AKI
618 critically ill patients with AKI
396 patients required dialysis
PICARD study
Prospective cohort
5 teaching U.S. hospital
Between 1999 and 2001
Hypothesis:

Fluid overload in
adult AKI
patients treated
with dialysis
would
independently
contribute to
adverse
outcomes
PICARD Data J Bouchard et al Kidney Int, 2009
METHODS
Percentage of FO/body weight (%FO)
%FO = (daily (total input (L) total output (L) x 100
body weight (kg)

Data analysis for fluid overload from 3 days before
consultation until hospital discharge
PICARD Data J Bouchard et al Kidney Int, 2009
BASELINE CHARACTERISTIC
PICARD Data J Bouchard et al Kidney Int, 2009
RESULTS
Survival Non-survival P
Mean %FO at
dialysis initiation
8.8% 14.2% 0.01
Adjusted OR for death with %FO >10% at dialysis initiation:

2.07 (95% CI 1.27-3.37)
PICARD Data J Bouchard et al Kidney Int, 2009
INFLUENCE OF FLUID ACCUMULATION ON
MORTALITY
PICARD Data J Bouchard et al Kidney Int, 2009
DIALYZED PATIENTS: KAPLAN-MEIER SURVIVAL
ESTIMATES BY FLUID OVERLOAD STATUS AT DIALYSIS
INITIATION
PICARD Data J Bouchard et al Kidney Int, 2009
DURATION OF FLUID OVERLOAD
PICARD Data J Bouchard et al Kidney Int, 2009
EFFECT OF CORRECTION OF FLUID OVERLOAD
PICARD Data J Bouchard et al Kidney Int, 2009
%FO < 10% %FO > 10% P
Survival rate 65% 44% 0.004
Survival Non-survival P
Mean %FO at
dialysis cessation
13.0% 22.1% 0.004
Adjusted OR for death with %FO > 10% at dialysis cessation: 2.52
(95% CI 1.55-4.08
Effect of fluid overload on survival when %FO > 10%
at dialysis initiation:
INFLUENCE OF MODALITY ON FLUID
OVERLOAD
PICARD Data J Bouchard et al Kidney Int, 2009
SUMMARY OF RESULTS
%FO > 10% at dialysis initiation:
2 fold increase in mortality
Duration and correction of fluid overload
influences mortality rates
%FO > 10% at dialysis cessation:
2.5 fold increase in mortality
Modality choice influences fluid management

PICARD Data J Bouchard et al Kidney Int, 2009
PATHOPHYSIOLOGY OF FLUID
SHIFT IN CRITICAL ILLNESS
COMPOSITION OF BODY COMPARTEMENTS
Intra
cellular
Inters
titial
plasma
%

o
f

t
o
t
a
l

b
o
d
y

w
e
i
g
h
t

0
10
20
30
40
50
60
Extracellular
Volume (ECV)
14L
Intracellular
Volume (ICV)
28L
The distribution of total body
water divided into the
intracellular (ICV) and
extracellular (ECV) spaces. For
an adult man 70 kg, the body
water is equivalent to 60% of
total body weight.
This amounts to approximately
42L, distributed as 40%
intracellular volume (28L) and
20% extracellular volume (14L),
of which 10.5L is interstitial and
3.5L is plasma volume (red cell
volume is a component of
intracellular volume).
42L
The Third Space The Old Paradigm
trapped
The third space in its
traditional interpretation is a
functionally separated part of
the extra-cellular
compartment which cannot
be localised, but primarily
consumes fluid in the
perioperative context.

It is currently no more than a
myth to explain the otherwise
apparently unexplainable
perioperative fluid shifting
Classic perioperative fluid management
Deficits:
Estimate
Preop NPO (hourly maintenance x duration)
Preop bowel preparation (1-1.5L)
Preop blood loss (trauma) or fluid loss (burns)
Typically replaced over first 2-4 hours
Maintenance:
(4-2-1 rule):
4 ml/kg/hr for first 10 kg of body weight
2 ml/kg/hr for 2nd 10 kg of body weight
1 ml/kg/hr for each kg of body weight above 20 kg
3
rd
Space:
Third space 2-10 ml/kg/hr
Blood loss:
3 to 1 ratio of crystalloid to EBL
1 to 1 for colloid or blood
(or hypertonic saline)

TRADITIONAL CONCEPT OF PERIOPERATIVE
FLUID LOADING
Chappell D et al. Anesthesiology 2008;109:723
Median blood volume status of 13 patients
with ovarian cancer before and after major
abdominal surgery, receiving a standard
infusion regimen (crystalloids: approximately
12 ml/kg/h; blood loss replaced 1:1 with
colloid)
5100
3800
2000
1700
750
4621
5800
2450
1. Preoperatively fasted
2. Insensible lost
3. 3
rd
space
4. Vasodilatation of anesthesia
Direct blood volume
measurements (double-label
technique)
Fluid shift
Where did they
go?..interstitial
Chappell D et al. Anesthesiology 2008;109:723
TRADITIONAL CONCEPT OF PERIOPERATIVE
FLUID LOADING
Chappell D et al. Anesthesiology 2008;109:723
Perioperative weight gain
increases with the
perioperative amount of
infused crystalloids
IMPACT OF TRADITIONAL CONCEPT OF FLUID
LOADING

THIRD SPACE: FACT OR FICTION?
M. Jacob et al. Best Practice & Research Clinical Anaesthesiology 23 (2009) 145157
1. The third-space uid losses have never been measured directly, and the
actual location of the lost uid remains unclear
2. Most of the data do not support the existence of a third space.
FLUID DYNAMICS ACROSS THE CAPILLARY BEDS
The classical Starling principles of vascular barrier functioning and capillaries on inward-directed colloid
osmotic pressure gradient is opposed to an outward-directed hydrostatic pressure of fluid and colloids. The
thick arrows symbolize the two schematically opposing forces across the vascular wall, the small one the
small net filtration outwards assumed according to this model.
Jv, net filtration; Kf, filtration coefficient; Pc, capillary hydrostatic pressure; Pi, oncotic pressure in the
interstitial space; Pi, hydrostatic pressure in the interstitial space; Pc, oncotic pressure in the vascular lumen;
Pc, hydrostatic pressure in the vascular lumen; s, reflection coefficient
ALBUMIN PHARMACOKINETICS
Normal Critical Illness

leakage
leakage
Lymph
Lymph
synthesis
catabolism
catabolism Urinary/Gut
loss
Haemorrhage
infusion
I
n
t
e
r
s
t
i
t
i
a
l


P
l
a
s
m
a

I
n
t
e
r
s
t
i
t
i
a
l


P
l
a
s
m
a

In critical illness
leakage >> lymph
flow tissue edema
SCHEMATIC REPRESENTATION OF CAUSES OF
HYPOALBUMINAEMIA IN CRITICALLY ILL PATIENTS
J.-L. Vincent, Best Practice & Research Clinical Anaesthesiology 23 (2009) 183191
RESPONSE TO FLUID ADMINISTRATION
RESPONSE TO FLUID ADMINISTRATION
Svensn et al., Anesthesiology (1997), 87
K
i

V
V
K
b

K
r

(V - V)
V
V = expandable space of volume
V = target volume
K
i
= constant fluid infusion rate
K
b
= basal rate of fluid elimination
(perspiration, basal diuresis)

Controlled rate of fluid elimination
proportional by a constant K
r
to
the relative deviation of v from V
One-compartment Volume of Fluid Space Model
RESPONSE TO FLUID ADMINISTRATION
Svensn et al., Anesthesiology (1997), 87
Two-compartment Volume of Fluid Space Model
K
i

V
1

V
1

K
b

K
r

(V
1
- V
1
)
V
1

K
t

V
2

V
2

Secondary fluid space
The net rate of fluid exchange between the 2 compartments is
proportional to the difference in relative deviations from the target
volumes by a constant K
t

colloids
crystalloid:
75-80% leaves vasculature after 20 minutes
5% dextrose
capillary
membrane
cell
membrane
o Clearance of crystalloid during anesthesia and
surgery is 10-20% of that in awake volunteers
o Crystalloid leaves the plasma space, equilibrates
with interstitial space after 20-30 min
Hahn RG. Anesth Analg 2007; 105-304
Plasma
Volume 4.3%
Interstitial
fluid 15.7%
VOLUME KINETICS FOR INFUSION CYSTALLOID IN
HEALTHY VOLUNTEER AND ANESTHESIA

VOLUME KINETICS FOR INFUSION FLUIDS
Hahn GR, Anesthesiology 2010
Hahn GR, Anesthesiology 2010
VOLUME KINETICS FOR INFUSION FLUIDS IN
DISEASES
Hahn GR, Anesthesiology 2010
VOLUME KINETICS FOR INFUSION OF
CRYSTALLOID DURING SURGERY AND PRE-
ECLAMPSIA
VOLUME EFFECT OF CRYSTALLOID
WHAT ABOUT COLLOID?
According classical starlings principle, infused iso-
oncotic colloids do not change the intravascular
colloid osmotic pressure and cannot cross the
barrier.
Therefore, they should remain theoretically by 100%
within the circulatory space
INTRAVASCULAR VOLUME EFFECT OF COLLOID
Normovolemia/
hemodilution
Volume loading
Hypervolemia
Not only crystalloids are shifted out of the
vasculature, but also colloids
INTRAVASCULAR VOLUME EFFECT OF COLLOIDS
IN HEALTH AND DISEASES

QUESTIONS RAISED
What is the underlying pathomechanism by which
hypervolaemia has the power to impair the
functioning of a primarily intact vascular barrier?
For the answer, we have to extend our view on
vascular physiology towards a small structure that
was unknown to Ernest Starling.
The Endothelial Glycocalix
Fluid Dynamics Across Capilarry Beds
Revised Starling Principle
M. Jacob et al. Best Practice & Research Clinical Anaesthesiology 23 (2009) 145157
THE ENDOTHELIAL GLYCOCALIX
Healthy vascular endothelium coated by endothelial glycocalyx a
layer of membrane-bound proteoglycans and glycoproteins.
THE ENDOTHELIAL GLYCOCALIX
Glycocalyx affect endothelial permeability.
Prevent leukocyte and platelet adhesion.
Decreases inflammation.
Bounds plasma proteins and fluids.
700 ~ 1000 mL of non-circulatory plasma
fixed within.
Maintains oncotic gradient despite
intravascular and extravascular equilibration.
Jacob M. et al: The endothelial glycocalix affords compatibility of starlings
principle and high cardiac interstitial albumin level. Cardiovasc Res 2007; 73:575-
86
Levick J. R. J Physiol;2004;557:704-704
STARLING PRINCIPLE NEEDS UPDATE
POSSIBLE PERIOPERATIVE FLUID MANAGEMENT
TRIGGERS FOR SHEDDING OF THE ENDOTHELIAL
GLYCOCALYX
hyperglycemia
reperfusion injury
oxidized-LDL
Mechanical stress,
Endotoxin exposure,
Mediator SIRS, and ANP
(Atrial Natriuretic Peptide)
Intact glicocalix Loss glicocalix
Response to Volume Expansion
Volume expansion
Intake of salty food and fluids
excessive IV fluids / hypervolemia
Right atrial distension
increase venous capacitance
secretion of Atrial Natriuretic Peptide (ANP)
increased renal NaCl and H
2
O excretion
vasodilation
inhibit renin secretion
inhibit aldosterone secretion
Pouta AM: Effect of intravenous fluid preload on vasoactive peptide
secretion during Caesarean section under spinal anaesthesia.
Anaesthesia 1996: 51.128-132
Responses in the concentrations of ANP in central () and peripheral () veins before and
during spinal anaesthesia for Caesarean delivery after a volume load of 2 1000 ml of
crystalloid solution (a) and 500 ml of colloid + 1000 ml of crystalloid solution (b). **p <
0.01, ***p < 0.001 (ANOVA for repeated measures).
2 1000 ml of crystalloid
500 ml of HES +
1000 ml of crystalloid
Acute hypervolemia Acute hypervolemia
Net extravasation of
HES representing
the product of
transudate flow and
HES concentration
in transudate
HES 6%, 200
with hypovolemia
HES 6%, 200
with hypervolemia
Intact glicocalix
Loss glicocalix
Leakage tissue
edema
Perioperative liberal fluid management
hypervolemia
secretion of ANP
degradation of glycocalix
fluid shift
interstitial edema
Fluid shifting is not only an intraoperative problem but
a postoperative problem.
Peak of fluid shifting at 5 hrs after trauma and persists
up to 72 hrs depending on location and duration of
surgery.
Robarts WM: Nature of the disturbance in the body fluid compartements
during and after surgical operations. Br J Surg 1979; 66:691-5
FLUID SHIFTING
FACTORS INFLUENCING FLUID BALANCE AND
ELECTROLYTES IN CRITICALLY ILL PATIENTS
Hypovolemia,
makes kidney
more retain water
or anuria
(overload), even
kidney maybe
function
RELATIONSHIP OF FLUID
ACCCUMULATION TO AKI
FLUID BALANCE AND AKI
What is the relationship of fluid
accumulation and AKI
Marker of severity
Consequence
AKI
Mortality
Fluid
Overload
FLUID ACCUMULATION AND AKI
Aggressive fluid
strategies adversely
affect every system and
organ
Prowle JR et al. Nat Rev Nephrol 2010;6:107
Tissue Edema
Diffusion Distance
FLUID ACCUMULATION AND AKI
THE CONSEQUENCES OF TISSUE EDEMA
THE IMPORTANCE OF LOCAL CAPILLARY OXYGEN TENSION
AND DIFFUSION DISTANCE IN DETERMINING THE RATE OF
OXYGEN DELIVERY AND THE INTRACELLULAR PO
2
Leach RM. Thorax 2002;57:170177
Normal
distance
Tissue
edema
AN INCREASED INTERCAPILLARY DISTANCE, AS WOULD OCCUR WITH TISSUE
OEDEMA, REDUCING DO
2
BY PROGRESSIVE FALLS IN ARTERIAL OXYGEN
TENSION RESULTS IN A CHANGE IN THE DO
2
/VO
2
RELATIONSHIP WITH VO
2

FALLING AT MUCH HIGHER LEVELS OF GLOBAL DO
2
Leach RM. Thorax 2002;57:170177
THE EFFECT OF TISSUE EDEMA ON KIDNEY
FUNCTION
Fluid overload
Splanchnic Edema
Renal Interstitial Edema:
1. Reduced GFR (Uremia)
2. Water and salt retention
Immunoparalysis
Nosokomial infection -
Sepsis
Acute Kidney Injury
Fluid accumulation tissue edema - Acute
Kidney Injury
Sepsis post AKI: AKI
cause fluid
accumulation leads to
soft tissue and gut
edema, which can
impair barriers to
infection; in particular,
bowel edema may
facilitate translocation
of gut flora, potentially
contributing to the
development of sepsis
and multiorgan failure
and increased mortality.
SEPSIS POST AKI
Mehta et al. Sepsis as a cause and consequence of acute kidney injury: Program to
Improve Care in Acute Renal Disease. Intensive care med 2011
Cause
AKI
Fluid
Overload
Consequence
AKI
Mortality
Fluid
Overload
FLUID ACCUMULATION AND AKI
Cause
AKI
Fluid
Overload
Consequence
AKI
Mortality
Fluid
Overload
Mortality
FLUID ACCUMULATION AND AKI
THE EFFECT OF TISSUE EDEMA ON
GASTROINTESTINAL FUNCTION
Lobo DN. Fluid, electrolytes and nutrition: physiological and clinical aspects. Proc Nutr Soc.
2004;63:453 466
Salt and water overload
Splanchnic oedema
Raised intra-abdominal pressure
Decreased mesenteric blood flow
Decreased tissue oxygenation
Intramucosal acidosis
Ileus
Increased gut permeability
Impaired wound healing
Anastomostic dehiscence
Hypothesis Proposed For The Effects Of Overload On Gastrointestinal
Function
Bacterial translocaton
SIRS - SEPSIS
CONSEQUENCES OF FLUID OVERLOAD
Marjanovic et all. Ann Surg 2009
Fluid overload
Gut Edema
Lower Bursting
pressure
Weight Gain
Increased gur permeability
Impaired wound healing
Anastomostic dehiscence
CONSEQUENCES OF FLUID OVERLOAD
Impact of Different Crystalloid Volume Regimes
on Intestinal Anastomotic Stability
Marjanovic et all. Ann Surg 2009
CONSEQUENCES OF FLUID OVERLOAD
Impact of Different Crystalloid Volume Regimes on Intestinal Anastomotic Stability
Marjanovic et all. Ann Surg 2009
Upper row: an overwiev of the
anastomoses in the liberal (A) and
volume restricted (B) groups on 4th
postoperative
day (HE stain, 25). Lower row: a
higher magnification of intact
intestinal walls in both groups. In
animals of the liberal group (C) the
submucosal layer is clearly visible as
a pale band (dashed arrow) below the
mucosa indicating a submucosal
edema, whereas picture (D) shows
the same region in an animal of the
volume restricted group. Here, the
submucosal layer (bold arrow) is
narrow and dense (HE stain, 100).
CONSEQUENCES OF FLUID OVERLOAD
Colloid vs. crystalloid infusions in gastrointestinal surgery and their different impact on the
healing of intestinal anastomoses
Marjanovic et al. Int J Colorectal Dis (2010) 25:491498
CONSEQUENCES OF FLUID OVERLOAD
Colloid vs. crystalloid infusions in gastrointestinal surgery and their different impact on the
healing of intestinal anastomoses
Marjanovic et al. Int J Colorectal Dis (2010) 25:491498
CONSEQUENCES OF FLUID OVERLOAD
Mechanotrasduction as a mechanistic explanation for edema-induced intestinal
dyscfunction. Intestinal edema results in profound changes in the characteristics of
intestinal tissue, including increased interstitial pressure
CONSEQUENCES OF FLUID OVERLOAD
Shah et all: Resuscitation-induced intestinal edema and related dysfunction:
State of the science. J Surg Res . 2011 March ; 166(1): 120130
Gatt et al: Aliment Pharmacol Ther 2007. 25, 741-757
CONSEQUENCES OF FLUID OVERLOAD
BACTERIAL TRANSLOCATION
The gut origin of
sepsis
hypothesis, with
bacterial
translocation as
a potential
stimulus for
ongoing
inflamation
ABDOMINAL COMPARTEMENT SYNDROME
Modified from Saggi B et al: J of trauma 1999 45: 597-609
Vidal et al. Crit Care Med 2008
INCIDENCE AND CLINICAL EFFECTS OF INTRA-ABDOMINAL
HYPERTENSION IN CRITICALLY ILL PATIENTS
Vidal et al. Incidence and clinical effects of intra-abdominal hypertension in
critically ill patients. Crit Care Med 2008
DAILY OR CUMULATIVE FLUID BALANCE?
FLUID BALANCE AND ACCUMULATION
Definition:
1. Fluid balance: Daily difference in all intakes and outputs
a. Generally doesnt include insensible loss
b. May not correlate with weight
c. Should include dialysis fluid removal
2. Cumulative fluid balance: Sum total of fluid accumulation
over a set periode of time
a. More important and relevant to assess change over time
b. Amount and duration key parameters associated with
outcome
c. Response to treatment
3. Fluid Overload: Cumulative fluid balance expressed as a
percent of body weight at baseline (ICU admission)
a. Cut off of 10% has been associated with increased mortality

Alsous et al: Negative fluid balance predicts survival in patients with septic shock
CHEST 2000; 117:1749-1754
Daily fluid balance Cumulative fluid balance
Died
Survived
DELAYED DIAGNOSIS OF ACUTE KIDNEY INJURY IN CRITICALLY ILL
PATIENTS
253 patients in PICARD database (n=618) with consecutive increase in serum
creatinin over 3-7 days prior to any dialysis
Correction of creatinine value for fluid balance
Serum creatinine values were adjusted according to he cumulative daily
fluid balance using the formula:
Creatinine adjusted = serum creatinine x correction factor
Correction factor = [hospital admission weight (kg) x 0.6 + total (daily fluid
balance)]/hospital admission weight x 0.6
Reference creatinine first value in the consecutive increase period of
serum creatinine
Using creatinine non-adjusted and creatinine adjusted for fluid balance
we applied AKIN and RIFLE criteria to compare the timing of AKI diagnosis
A delay in recognizing AKI (LAG) was defined as a difference in meeting
sCr AKI criteria in one or more day

Macedo et al. Picard Study grup 2010
DAILY CUMULATIVE FLUID BALANCE AND SCR
(ADJUSTED AND NON-ADJUSTED)
Delayed diagnosis of acute kidney injury in critically ill patients. Macedo et al. Picard Study
grup 2010
THE STRATEGY
Procedure
Comorbidities
Preop hydration
Bowel preparation
Anaesthesia/neuroaxial
blockade
Bowel ischemia Bowel oedema
normovolemia Hypovolemia Hypervolemia
Morbidity
risk of:
Organ hypoperfusion
SIRS
Sepsis
MOF
risk of:
Oedema
Ileus
PONV
Pulm complication
cardiac demands
Bundgaard-Neilsen M et al. Acta Anaesthesiol Scan 2009;53:843
TOO MUCH, TOO LITTLE OR JUST RIGHT?
Goal-
directed
Restrictive Liberal
EARLY GOAL-DIRECTED THERAPY IN THE TREATMENT
OF SEVERE SEPSIS AND SEPTIC SHOCK
Rivers. NEJM 2001
overload
COMPARISON OF TWO FLUID-MANAGEMENT
STRATEGIES IN ACUTE LUNG INJURY

The National Heart, Lung, and Blood Institute Acute Respiratory Distress
Syndrome (ARDS) Clinical Trials Network. NEJM 2006
COMPARISON OF TWO FLUID-MANAGEMENT
STRATEGIES IN ACUTE LUNG INJURY

The National Heart, Lung, and Blood Institute Acute Respiratory Distress
Syndrome (ARDS) Clinical Trials Network. NEJM 2006
COMPARISON OF TWO FLUID-MANAGEMENT
STRATEGIES IN ACUTE LUNG INJURY

The National Heart, Lung, and Blood Institute Acute Respiratory Distress
Syndrome (ARDS) Clinical Trials Network. NEJM 2006
FLUID-MANAGEMENT STRATEGIES
IN ACUTE LUNG INJURY-LIBERAL,
CONSERVATIVE, OR BOTH?
Editorial: Rivers NEJM 2006
Murphy ert al: CHEST 2009; 136-102-109
THE IMPORTANCE OF FLUID MANAGEMENT IN ACUTE
LUNG INJURY SECONDARY TO SEPTIC SHOCK
Adequate initial fluid resuscitation (AIFR):
was defined as the administration of an initial fluid bolus of > 20 mL/kg prior to and
achievement of a central venous pressure of > 8 mm Hg within 6 h after the onset
of therapy with vasopressors.

Conservative late fluid management (CLFM):
was defined as even to negative fluid balance measured on at least 2 consecutie
days during the first 7 days after septic shock onset.
Murphy ert al: CHEST 2009; 136-102-109
THE IMPORTANCE OF FLUID MANAGEMENT IN ACUTE
LUNG INJURY SECONDARY TO SEPTIC SHOCK
Murphy ert al: CHEST 2009; 136-102-109
Daily fluid balance Cumulative fluid balance
Survival
Survival
Non-Survival
Non-Survival
THE IMPORTANCE OF FLUID MANAGEMENT IN ACUTE
LUNG INJURY SECONDARY TO SEPTIC SHOCK
Murphy ert al: CHEST 2009; 136-102-109
THE IMPORTANCE OF FLUID MANAGEMENT IN ACUTE
LUNG INJURY SECONDARY TO SEPTIC SHOCK
AIFR
CLFM
FLUID BALANCE AND URINE VOLUME ARE INDEPENDENT
PREDICTORS OF MORTALITY IN ACUTE KIDNEY INJURY

Teixeira et al. Critical Care 2013, 17:R14
No oligouria
Oligouria
FLUID BALANCE AND URINE VOLUME ARE INDEPENDENT
PREDICTORS OF MORTALITY IN ACUTE KIDNEY INJURY

Teixeira et al. Critical Care 2013, 17:R14
In summary, both fluid
balance and urine volume
were found to be
independent predictors of
mortality in adult critically
ill patients with AKI.

Of interest, diuretic use
appeared to be
independently associated
with better survival in this
study
Diuretics
No-diuretics
PERIOPERATIVE RESTRICTIVE
FLUID MANAGEMENT

POSTOPERATIVE FLUID OVERLOAD
Lowell JA, et al. Crit Care Med. 1990;18(7):728-733.
M
o
r
t
a
l
i
t
y

(
%
)

Weight Gain (%)
10%
11-20%
> 20%
All patients
General surgery
Cardiac surgery
% Increase in Weight
* % of patients studied that gained weight
*
*
*
*
FLUID MANAGEMENT IN MAJOR SURGERY
META-ANALYSIS: RESTRICTIVE VS LIBERAL
Corcoran T, et al. Anesth Analg. 2012;114(3):640-651.
Restrictive strategy reduced
Incidence of pulmonary edema
Incidence of pneumonia
Time to first bowel movement
Length of stay
High dose Ringers Lacate
+
Voluven

Low dose Ringers Lactate
+
Voluven

5050
High fluid
1640
Low fluid
Post-operative complications
TAKE HOME MESSAGES
Fluid shift into the interstitial space can be divided
into two types:
Type 1 physiologic shift :
Colloid-free fluid and electrolytes (crystalloid)
Vascular barrier intact
Type 2 pathologic shift :
Protein-rich fluids (colloid)
Functionally altered vascular barrier
Perioperative uid shifting
Type 2 shift - pathologic shift, result of 2 iatrogenic
problems.
Surgical:
Endothelial damage due to mechanical stress, endotoxin exposure,
ischemia-reperfusion injury and SIRS.
Anesthesiolgic:
Acute hypervolemia...!!!! Atrial Natriuretic Peptide
Perioperative uid shifting
Preserve endothelial glycocalyx to inhibit type 2
Pathologic shift.
Inflammatory mediators, stress, ischemia-reperfusion injury
can hardly be avoided, minimally invasive surgery
Maintaining vascular normovolemia.
Key to protection of endothelial glycocalyx
Prevent interstitial edema.
Perioperative uid shifting
APPROACH TO FLUID MANAGEMENT
The intravascular deficit after fasting is usually low.
Basal fluid loss via insensible perspiration
approximately 0.5 mL/kg/hr,
Extending to only 1 mL/kg/hr during
major abdominal surgery.
APPROACH TO FLUID MANAGEMENT
Minimize type 1 shifting
Use crystalloids only when replacing urine production and
insensible perspiration.
Use colloids or blood products for substitution of acute
blood loss
Minimize type 2 shifting
Goal-directed method with available parameters
Conservatively to avoid acute hypervolemia
Use colloids instead of crystalloids.
APPROACH TO FLUID MANAGEMENT
TERIMA KASIH