How to Avoid Fluid Overload?

KONIKA XVII

Jogyakarta, 11 Agustus 2017

1
And We created from water every thing living

QS 21:30

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Why fluid overload

?
2013 : Flood in Jakarta

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Water balance

Regulated by:
• Thirst
• ADH secretion

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Water balance

Knepper MA, Kwon TH, and Nielsen S : Molecular physiology of water balance.
N Engl J Med (2015);372:1349-58.

5
Myburgh JA and Mythen MG. N Engl J Med (2013);369:1243-51.

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 7
Seller MW and Rice TW, Clin Chest Med (2016); 37; 241-251.
Glycocalyx (Endothelial Surface Layer)
• Glycocalyx bound to plasma components, especially albumin.
• Under healthy conditions, resists fluid and solute filtration into
the interstitium.
• Disrupted by inflammatory mediators (in sepsis, ischemia, re-
perfusion, trauma, diabetes, resuscitation, arteriosclerosis)
• Hypervolemia endangers vascular barrier competence
• Inflammatory degradation of endothelial surface layer increases
vascular permeability with trans-capillary escape of albumin
8
 Fluid therapy

• Resuscitation (correct hypovolemia)

• Maintenance (maintain hydration)
• Improved tissue oxygenation (by augmenting
cardiac output through increased stroke
volume)

9
 Critically ill
patients

• Halliday and Segar ?

• For most sick children less IV fluid
is required to maintain normal
volume status (~ no more than 2/3
the calculated full maintenance
intravenous fluid.

Duke T. Paediatr and Intern Child Health (2016);36(3): 165-7,

Halliday MA and Segar WE. Pediatrics(1957);19:823-32. 10

Why avoiding
fluid overload

?
• Fluid overload is associated with
worse outcomes in critically ill
children.
Like a bridge over troubled water, I will lay me down

11
The pathophysiologic effects of fluid overload on
organ systems

Organ systems Effect of fluid overload Clinical manifestation

Impaired cognition
Central nervous system Cerebral edema
Delirium

Increased work of breathing

Pulmonary edema
Respiratory system
Pleural effusions
Myocardial edema
Cardiovascular sytem
Pericardial effusions
Impaired gas exchange
Decreased lung compliance
Increased extravascular lung
water
Impaired contractility
Diastolic dysfunction
Conduction abnormalities

Ogbu OC, Murphy DJ, and Martin GS, Curr Opin Crit Care (2015); 21:315-21. 12
The pathophysiologic effects of fluid overload on
organ systems
Organ systems Effect of fluid overload Clinical manifestation
Malabsorption
Gut wall edema Ileus
Gastrointestinal system
Ascites Bacterial translocation
Intra abdominal hypertension

Cholestasis
Hepatobiliary system Hepatic congestion
Impaired synthetic function

Acute kidney injury

Renal interstitial edema
Renal system Uremia
Elevated renal venous pressure
Salt and water retention

Tissue edema Poor wound healing

Skin and musculoskeletal
Impaired lymphatic drainage Pressure ulcers
system
Deranged microcirculation Wound infection
13
Ogbu OC, Murphy DJ, and Martin GS, Curr Opin Crit Care (2015); 21:315-21.
 Fluid Overload is associated with worse outcomes
No Publication Study population Study design Primary results

Lane PH,et.al. Bone Fluid overload >10% had

1 marrow transplant;
13:613-7. 1994
Goldstein SL,et.al.
2 Pediatrics;107(6):1309-12.
2001
Foland JA, et.al. Crit Care
3 single center chart survivors (15.1%). Fluid overload
Med;32(8):1771-6. 2004
Michael M, et.al.Pediatr
4 26 BMT with AKI
Nephrol;19:91-5. 2004
30 children BMT
Case series decreased chance of renal
on RRT
recovery, 70% mortality.
Degree of fluid overload at
21 children on Retrospective
initiation much lower in survivors
RRT chart review
(16.4% vs 34%)
Survivors was lower in fluid
Retrospective overload (7.8%) than non
113 PICU patients
on CRRT
review independently associated with
survival in patients with MODS
All survivors had
Retrospective fluid overload < 10% using
chart review diuretics or CRRT, 9/15 non-
survivors had fluid overload
14
 Fluid Overload is associated with worse outcomes
No Publication Study population Study design Primary results

Gillespie RS, et.al. Retrospective Fluid overload >10% at CRRT

5 Pediatric Nephrology; Children on RRT single center initiation had RR 3.02 of mortality
16(12):1394-9. 2004 review (95%CI: 1.5 -6.)

116 PICU patients Retrospective Increased fluid administrtaion

Goldstein SL, et.al.Kindey
6 with MODS on multi-centernchart from PICU admission to CRRT
Int;67(2)):653-8. 2005 initiation is an independent risk
CRRT review
factor for mortality
Randolph AG, te.al.Pediatr Cumulative fluid balance did not
301 children on
7 Crit Care Med;6(6):642-7. Prospective cohort predict prolonged weaning or
CMV
2005 extubation failure

Fluid intake in the first 24 hours

Szekley A, et.al.Pediatr
411 children after Prospective case was independently associated
8 Anaesthesia;16(11):
CPB series with extended length of
1166-75. 2006
mechnaical ventilation
15
 Fluid Overload is associated with worse outcomes

No Publication Study population Study design Primary results

OR 10.06 for PMV in those

Shi S, et.al. Chest;134(4): 172 neonates after Retrospective chart
9 with positive post-operative
768-74. 2008 CPB review
fluid balance
Fluid overload >20% at CRRT
Hayes LW, et.al. Crit Care; 77 PICU patients Retrospective chart
10 start significantly associated
24(3):394-490. 2009 on CRRT review
with increased mortality

Prospective Fluid overload >20%: 3%

Sutherland SM, et.al. Amer 297 PICU patients increased mortality for every
11 observational multi-
J Kid Dis;55(2);316-25. 2010 on CRRT 1% increase fluid overload
center trial
(OR 8.5)
Children with a positive fluid
Grist G, et.al.J Extracorp 1540 children after Retrospective chart
12 balance had an adjusted OR
Tech;43(4):215-26. 2011 CPB review
1.73 for mortality

16
 Fluid Overload is associated with worse outcomes
Study
No Publication Study design Primary results
population

Selewski DT, et.al. Crit 53 children on Fluid overload at CRRT start

Retrospective chart
13 Care Med; 40(9):2694-9. ECMO and remained the most consistent
review
2012 CRRT predictor of mortality

Arikann AA, et.al. Pediatr 80 children Higher peak fluid overload

Retrospective chart
14 Crit Care Med;13(3): with respiratory predicted higher peak
review
253-8. 2012 failure Oxygenation Index

Increasing fluid balance on day 3

Valentine S, et.al.Crit Multi-center
168 children in children with ALI is
15 Care Med;40(10):2883-9. retrospective cohort independently associated with
with ALI
2012 study fewer ventilator-free days

Mortality is more common in

children who are <10 kg at the
Askenazi DJ, et.al. J time of CRRT.
84 Children on Prospective cohort
16 Pediatr;162:587-92.e3 Urine output and Fluid overload
RRT analysis
2013 at CRRT initiation are
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independently associtaed with
mortality
 Fluid Overload is associated with worse outcomes
Study
No Publication Study design Primary results
population

Early postoperative fluid overload

Hazle MA, et.al. Pediatr is associated with suboptimal
Prospective chart
17 Crit Care Med;14(1):44-9. 49 infants on CPB outcomes in infants following
review
2013 cardiac surgery. Fluid overload
important risk factor for AKI

Fluid overload was associated

Wilson DF, et.al. Pediatr
110 children ALI/ Multi-center with worsening oxygenation, a
18 Crit Care Med;14(7):666-72.
ARDS prospective RCT longer ventilator course, and
2013
increased mortality

Infant with AKI have a higher

Askenazi DJ, et.al.Pediatr Prospective cohort mortality (lower survival rate) than
19 58 neonates
Nephrol;28(4):661-6. 2013 analysis non-AKI. Fluid overload was
associated with AKI

When stratified for mortality risk,

Retrospective increased fluid intake and positive
Abulebda K, et.al.Crit Care 317 children with analysis of a multi- fluid balance after ICU admission
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Med;42(2):397-403. 2014 septic shock center sepsis are associated with worse outcome
database in pediatric shock patients with a
low initial mortality risk
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 Fluid Overload is associated with worse outcomes
No Publication
Hassinger AB, et.al. Pediatr
21 Crit Care Med; 15(2): 131- 8.
2014
Chen J, et.al. PLos One
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11(7):e0160093. 2016
Sutawan IBR, et.al. Crit Care
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Shock;19:8-13. 2016
Ingelse SA, et.al. Pediatr Crit
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Care Med 18: e106-11. 2017
Study population Study design Primary results
5% fluid overload with 2 days longer in
98 children after Retrospective The ICU and on mechanical
CPB cohort study ventilation; Fluid overload proceded
AKI
Both early and acquired daily fluid
overload were independently
202 children with Retrospective chart associated with PICU mortality in
severe sepsis review children with severe sepsis (AUC
0.74,sensitivity 67.2% and specificity
80.1%)
Fluid overload is associated to a risk
120 children were
factor for mortality in critically
hospitalized in Case-control study
patients in PICU (OR 11.5 with CI 3.7 -
PICU 35.6, p <0.01)
135 children with
Early fluid overload is an independent
viral lower tract
Retrospective predictor of prolonged mechanical
infection requiring
cohort study ventilation in young children with viral
mechanical lower respiratory tract diseases
ventilation
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Conclusions:
Both EARLY and LATE fluid
management of septic shock
complicated by Acute Lung
Injury can influence patient
outcome.

Murphy CV, et.al., Chest (2009);

136(1):102- 9.

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 Hypervolemia and Endothelial Surface Layer

Colloid induced hypervolemia:

• 60% to interstitial compartment (edema)

• Reduced ESL volume to 1/3 of the Rehm M, et.al., Anesthesiology (2001);95:849-56.

original value
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 Hypervolemia and oxygenation
Air

Compromises oxygen delivery to the

mitochondria at:
Alveoli
1. Alveolar-arterial membrane
2. In the tissues (Oxygen extraction
from capillaries and. CO2 clearance ) pO2
kPa

Tissues

Atmosphere Mitochondria

Raman S and Peters MJ,Pediatr Nephrol (2014);

29:23-34.
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Pediatr Crit Care Med (2017);XX:00-00

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Pediatr Crit Care Med (2017);18:614-22

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25
J Crit Care(2017);39:209-13

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 Why avoiding
fluid overload
• Neonates. N = 279
• Septic Shock. N = 317
• ARDS. N =277
• Respiratory failure. N = 277
• On ECMO. N = 53
• After CPB. N = 2093
• CRRT. N = 66
• BMT. N = 56

• Fluid overload is associated

with worse outcomes in Like a bridge over troubled water, I will lay me down
critically ill children.
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 How to avoid
fluid overload

?
• Fluid overload is associated with
worse outcomes in critically ill
children.

28
How to avoid fluid overload
1. Monitoring
2. Assess fluid responsiveness for every fluid
resuscitation/bolus
3. Monitor fluid overload using lung USG for finding
covert fluid

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1. Monitoring

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1. Monitoring

31
 Critically ill patients

• Halliday and Segar ?

• For most sick children less IV fluid is
required to maintain normal volume status
(~ no more than 2/3 the calculated full
maintenance intravenous fluid.

Duke T. Paediatr and Intern Child Health (2016) ;36(3): 165-7.

Halliday MA and Segar WE. Pediatrics;19:823-32, 1957

32
1. Monitoring

Duke T. Paediatr and Intern Child Health (2016) ;36(3): 165-7.

33
1. Monitoring

Duke T. Paediatr and Intern Child Health (2016) ;36(3): 165-7.

34
1. Monitoring

Duke T. Paediatr and Intern Child Health (2016) ;36(3): 165-7.

35
2. Assess fluid responsiveness for
every fluid resuscitation/bolus Pre-load
non-
responsive

Pre-load
Pre-load responsive
Pre-load
non-
responsive
responsive
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37
2. Assess fluid responsiveness for
every fluid resuscitation/bolus

38
2. Assess fluid responsiveness for
every fluid resuscitation/bolus

39
3. Monitor fluid overload using lung USG for
finding covert fluid

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 B-Lines on Lung Ultrasound Images

Normal lung 1 B-Line 2 B-Lines 3 B-Lines

Allinovi M, et.al, Nephrol Dial Transplant (2017) 32:541-7.
41
Allinovi M, et.al, Nephrol Dial Transplant (2017) 32:541-7.
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Take home messages
• Fluid overload is associated with worse outcomes in critically
ill children.
• Avoiding fluid overload is very important in the management
of fluid therapy
• Reassess and monitor fluid balance
• Monitor fluid overload using lung USG for finding covert fluid

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 QS 7:31

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Thank You

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