Fluids in the Rx of ShockLess is more ! DR GNANAM R PAEDIATRIC INTENSIVIST AND ER CONSULTANT MANIPAL HOSPITAL, BANGALORE FLUIDS IN PEDIATRIC CRITICAL ILLNESSS Getting the fluid just right is a challenge, even to the most experienced intensivist.
Usual ICU care leads to Fluid Overload Fluid boluses during resuscitation Blood products Nutrition
Sedatives and Analgesics Vasoactive drugs Antimicrobials
Miscellaneous: Insulin infusions,H2 blockers etc. Concerns about too much fluid Exacerbation of edema in lungs,heart,gut, brain and other tissues Ventilator days and associated
complications in ARDS patients Impaired pateints wound healing in post operative Fluids in Shock Phased Rx Resuscitative phase (Golden few hours)Resuscitation with fluids and inotropes .Positive fluid balance is expected
Resuscitated shock- Strict watch on fluid balance and avoidance excessive fluids/positive balance Deresuscitative /Recovery phase- active measures undertaken for fluid removal Phase 1: Resuscitative phase Assess & Classify shock in the ER Compensated
vs hypotensive Hypovolemic vs Distributive vs Cardiogenic Etiologic classification (Septic, Dengue, AGE, myocarditis,neurogenic etc) Shock-No substitute for clinical
monitoring Look for and reassess after each intervention Tachycardia. Prolonged capillary refill and toe-core temp gradient Low urine output (<1ml/kg/hr). Poor pulse volume or bounding pulses. Low blood pressure Resuscitative phase Distributive shock Aim- Restoration of circulating blood volume, organ perfusion & tissue oxygenation
Start oxygen Secure two large bore IV access( preferably UL) Administer crystalloid fluid bolus upto 40( to 60 ) ml/kg
Administer first dose of Antibiotic Start pressors/ionotropes early Fluids during Resuscitation-Septic shock Haemodynamic profile of septic shock: Early phase: N/ C.O capillary leak and vasomotor tone VR
sympathetic tone with tachycardia and restoration of MAP Fluids during Resuscitation-Septic shock Haemodynamic profile of septic shock: Late phase: SVR and C.O Progression from high to low C.O may occur over any time period.
Impact of fluid a bolusResuscitative phase Early phase of septic shock: Ventricular filling pressures are low capillary leak,dilated capacitance vessels, oral intake and ISWL. Fluid boluses intravascular volume and C.O, augment tissue perfusion and stave off organ failure. Preload in the Resuscitative phase Preload- Wall stress at the end of diastole Preload
Stroke volume and C.O The clinical end points of fluid therapy are achieved only if the physiologic effects occur Estimates of Preload in the Resuscitative phase Clinical: BP, HR, capillary refill, urine, CXR
Static indices: CVP Dynamic indices: PLR Echo 1
3 Fluid Responsiveness and the Starling curve The response to fluid by a given patient depends on 2 factors 1. The position on the Frank Starling curve 2. The ventricular function (slope of curve) 14 FS curve-Do we know the childs position!
Simple bedside FS context based diagnosis of central hypovolemia by using passive leg raising. 1 6 Caveat during PLR: Do not perform if patient has IAP! Critical Care Medicine: September 2010 FS curve-Do we know the childs position! Bedside FS testAdminister a 10 ml/kg of crystalloid as a pull/push technique and assess the
clinical response Repeat (upto 40 ml/kg) if clinical response predictable FS curve-The function! Context based monitoringRole of Echo Hypovolemic shock
Distributive shock Obstructive shock Cardiogenic shock.caution Resuscitative phaseContext based monitoring
Clinical monitoring Bedside FS test Bedside PLR Echocardiogram in select patients
A syndromic approach to the Rx of septic shock with administration of 60-80ml/kg fluids,inotrope infusion,correction of hypoglycemia and early intubation had a favourable impact on survival. Ped Em Care 2008 At 12 hrs,patients with CVP>12 had the highest risk of mortality.Those with CVP<8 had a survival advantage over those with CVP of 8-12. Crit Care Med 2011 Large volumes of fluid given rapidly (in
compensated shock) significantly increased 48 hr mortality. NEJM 2011 Fluids in the resuscitative phase- compensated shock Smaller aliquots if fluids- 5- 10 ml /kg over half to 1 hour ,with repeated clinical assessments Repeated as needed depending on the clinical response and etiology Phase 2-Resuscitated shock
Aim- Maintenance of intravascular volume homeostasis and prevent excessive fluid accumulation To optimally fill the heart To keep the lungs dry To keep the kidneys wet Will more fluids reverse the hypoperfusion?? Fluids in resuscitated
sepsis-less is more! Despite fluids/ionotropes circulation may remain impaired with low/normal MAPs and persistent lactic acidosis. In the absence of myocardial dysfunction Further fluid boluses may not achieve the desired response Is there an ideal tool to assess fluid responsiveness! Static measures- CVP,PAOP,RVEDV index,LVED area and Global EDV are unreliable in predicting volume responsiveness.
Dynamic measures- Utilize a controlled but reversible variation in preload and measure the haemodynamic response Dynamic Indices to assess fluid responsiveness Group A: SV related haemodynamic changes with mechanical ventilation-PPV,SVV Group B:Non SV related haemodynamic changes with mechanical ventilation-IVC/ SVC changes Group C:Indices based on preload redistribution-PLR
Assessing preload responsivenessSVV Fluids in resuscitated sepsis No substitute for repeated clinical assessment Smaller aliquots of fluid challenges for the bedside FS test
Optimisation of ionotropes/pressors Echo to assess pump and tank function Monitor markers of tissue perfusion Phase -3
Recovery/De-resuscitative phase Clinical end points achieved and maintained Symptoms/signs at presentation receding Complications related to positive balance
apparent and worsening Fluids need to be cut down or stopped and measures for active diuresis undertaken Fluids In Dengue Shock Syndrome- Less is more Goals of Rx-Early recognition and reversal of shock, simultaneously preventing fluid overload. Fluid therapy-Relatively rapid boluses in hypotensive shock. Slower /smaller aliquots in compensated shock Titrated fluid therapy to match
ongoing losses. . DSS- Time the leaky phase to titrate fluids 32 Time of onset of warning symptoms-severe abdominal pain and persistent vomiting
Time of sudden drop in platelet count Day of illness (D5-D6 coincides with the leaky phase) DSS- 3D approach to monitoring and management Clinical examination
Smaller aliquots of fluids (10 ml per kg over 15-20 min) Consider albumin if hypotensive after 30 ml/kg of crystalloids Continue crystalloids+/_ albumin at lower rates ,titrated to perfusion and U.O
DSS- Resuscitative phase Compensated shock- Hct normal/ bicarbonate 5- 10 ml per kg aliquots of crystalloids over 1- 2 hours titrated to perfusion and U.O Continue crystalloids at lower rates ,titrated to perfusion and U.O DSS Resuscitative
phase Pearls in monitoring Dynamic illness during the leaky phase Frequent monitoring imperative Titrate fluids to perfusion and U.O(1 ml/kg/hr)
Hct and HCO3 twice a day will assist in Fluid Rx Dengue Recovery phase Ensure fluids are cut down/stopped once into recovery
A small dose of furosemide (0.01-0.05 mg/kg) may help if the child has extensive third spacing Less is more- revisiting Burn resuscitation Fluid resuscitation central tenet of Rx Can be associated with morbid anasarca and associated complications
Aggressive monitoring- (especially U.O) and early use of albumin may circumvent the complications The crystalloid vs colloid debate! 6% excess risk of death in critically ill patients resuscitated with albumin Cochrane Database Syst Rev 1998 SAFE study-Use of either 4% albumin or NS for
resuscitation resulted in similar outcomes at 28 days N Engl J Med 2004 Synthetic colloids should not be routinely used as resuscitation fluid as they may be harmful and are probaby unnecssary Crit Care 2009 The crystalloid vs colloid debate! Clinicians should consider albumin containing fluids as first line in the resuscitation of patients with sepsis
Annals of Emergency Med 2012 There is no evidence that resuscitation with colloids reduces the risk of death Cochrane Database Syst Rev 2012 Crystalloid vs Colloid debate Comparison of three fluid regimens for resuscitation in DSS-RL and synthetic colloids had the same clinical response in moderately severe shock. N Engl J Med 2005 Colloids may be the preferred fluid if BP has to be restored urgently in DSS .Colloids have been shown to restore the cardiac index and reduce
the Hct faster in patients with intractable shock WHO 2012 guidelines Crystalloid vs Colloid debate Earlier albumin infusion, between 8 and 12 hours after injury, in pediatric patients with burns greater than 1545% TBSA reduced the need for crystalloid fluid infusion during resuscitation Ped Crit Care Med 2016 The results of a meta-analysis suggest that resuscitation with albumin may result in lower mortality compared with resuscitation with other fluids in septic shock
Crit Care Med 2016 Fluids in ARDS- less is more Non cardiogenic pulmonary edema in ARDS capillary leak intravascular hydrostatic pressure Restrictive fluid management protocolassociated with increased ventilator free days and improve oxygenation. Fluid restriction (and active diuresis) should be practiced only after the these children have been adequately resuscitated. Chest 2007 Fluids in Diabetic Ketoacidosis- Less is more
Goals of Rx in DKA Slow Replacement of diminished circulating volume. Repletion of electrolytes. Recovery of GFR to further eliminate glucose and ketones .
Avoidance of complications during treatment. Fluids in DKA- Less is more Fluid boluses avoided at presentation( do not exceed 20 ml/kg if in hypotensive shock)
Deficit and maintenance to be administered over 48 hours Parenteral fluids to be cut down as soon as child is able to accept oral feeds Fluids in Pediatric Critical Illness Edema is of cosmetic concern-.T/F? If some urine is
good, more urine is better-T/F? Fluids in Paediatric Critical illness Strike a balance and get the fluid right Thank You
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