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    4 Phases of IV Fluid Therapy Final

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    Luqmanul Hakim Junaidden
    This document discusses 4 phases of IV fluid therapy: rescue, optimisation, stabilisation, and de-escalation. It provides details on each phase, including appropriate fluid administration techniques (e.g. bolus vs. challenge). Monitoring and individualizing treatment based on patient status is emphasized. Context-specific applications are reviewed, such as fluid resuscitation in the perioperative period and for preventing organ damage. The importance of tailored, phase-dependent fluid therapy for each patient is stressed.

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    4 Phases of IV Fluid Therapy Final

    Uploaded by

    Luqmanul Hakim Junaidden
    56 views29 pages
    This document discusses 4 phases of IV fluid therapy: rescue, optimisation, stabilisation, and de-escalation. It provides details on each phase, including appropriate fluid administration techniques (e.g. bolus vs. challenge). Monitoring and individualizing treatment based on patient status is emphasized. Context-specific applications are reviewed, such as fluid resuscitation in the perioperative period and for preventing organ damage. The importance of tailored, phase-dependent fluid therapy for each patient is stressed.

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    Iv fluid therapy

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    This document discusses 4 phases of IV fluid therapy: rescue, optimisation, stabilisation, and de-escalation. It provides details on each phase, including appropriate fluid administration techniques (e.g. bolus vs. challenge). Monitoring and individualizing treatment based on patient status is emphasized. Context-specific applications are reviewed, such as fluid resuscitation in the perioperative period and for preventing organ damage. The importance of tailored, phase-dependent fluid therapy for each patient is stressed.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    56 views29 pages

    4 Phases of IV Fluid Therapy Final

    Uploaded by

    Luqmanul Hakim Junaidden
    This document discusses 4 phases of IV fluid therapy: rescue, optimisation, stabilisation, and de-escalation. It provides details on each phase, including appropriate fluid administration techniques (e.g. bolus vs. challenge). Monitoring and individualizing treatment based on patient status is emphasized. Context-specific applications are reviewed, such as fluid resuscitation in the perioperative period and for preventing organ damage. The importance of tailored, phase-dependent fluid therapy for each patient is stressed.

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    © All Rights Reserved
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    of 29

    4 Phases of IV Fluid

    Therapy
    DR CHARLIE
    Introduction
     IV fluid therapy plays a fundamental role in management of
    hospitalised patients.
     Correct usage can be life saving, but with risks.
     Inappropriate usage of fluids occur in up to 20% of patient receiving
    fluid therapy
     Too little? (inadequate resuscitation, tissue hypoperfusion)
     Too much? (tissue edema and severe electrolyte derangements)
     Coagulation Abnormalities
     Fluid therapy should be regarded as drug therapy with dose-effect
    relationship and side effects, individualised to each patient.
     6S Study
     Higher mortality and incidence of AKI in patients receiving HES
    compared with carrier solution of Ringer’s acetate.
     SAFE study
     Higher mortality in patients with traumatic brain injury treated with
    albumin solution

     Workgroup tasked by 12th ADQI conference to consider WHEN and


    HOW to administer fluid in critically ill patients by addressing 3
    questions:
     1) Define goals of IV therapy
     2) Identify monitors of fluid need and effect
     3) Identify fluid therapy in different context (eg, pre-hospital
    setting/OT/ICU)
    Physiology of Fluid Resuscitation
     Previously, fluid therapy was based on Classic
    Compartment Model
     Intracellular, Interstitial, Intravascular
     Hydrostatic and oncotic pressure gradients across
    semipermeable membrane responsible for transvascular
    exchange.
     However, recent descriptions questioned these models,
    identifying a web of glycoproteins and proteoglycans on
    luminal side of endothelial cells.
     “ Endothelial Glycocalyx Layer”
     Subglycocalyx space produces colloid oncotic pressure,
    determines the transcapillary flow.
     Absorption of fluid from interstitial space occurs through small
    number of large pores and returned to circulation as lymph.
     Structure and function of glycocalyx layer determines
    membrane permeability.
     Therefore, “leakiness” of this layer causes the development of
    interstitial edema.
     Loss of this integrity of the layer can be due to inflammatory
    conditions such as sepsis, surgery, trauma, or when
    resuscitation fluids are commonly used.
    FLUID RESUSCITATION
     Fluid resuscitation includes
     Time- dependent, phase of illness
     Rate and volume of fluid administration
     Groups of patients not included:
     children (,16 yr), pregnant women, burns patients, and patients
    with acute shock who have chronic conditions (chronic renal
    failure, hepatic failure, diabetic ketoacidosis, and hyperosmolar
    states).
    Terminology
     Fluid bolus: a rapid infusion to correct hypotensive
    shock. It typically includes the infusion of at least 500
    ml over a maximum of 15 min
     Fluid challenge: 100–200 ml over 5–10 min with
    reassessment to optimize tissue perfusion
     Fluid infusion: continuous delivery of i.v. fluids to
    maintain homeostasis, replace losses, or prevent
    organ injury (e.g. prehydration before operation or
    for contrast nephropathy)
     Maintenance: fluid administration for the provision of
    fluids for patients who cannot meet their needs by oral
    route. This should be titrated to patient need and
    context and should include replacement of ongoing
    losses. In a patient without ongoing losses, this should
    probably be no more than 1 –2 ml kg-1 h-1
     Daily fluid balance: daily sum of all intakes and outputs
     Cumulative fluid balance: sum total of fluid
    accumulation over a set period of time
     Fluid overload: cumulative fluid balance expressed as a
    proportion of baseline body weight. A value of 10% is
    associated with adverse outcomes
    4 Phases of Fluid Therapy

    R
    escue
    O ptimisation
    S tabilisation
    D eescalation

     Occuring over a time course


    when the severity of illness
    decreases.
    Rescue
     Immediate escalation of therapy
     Resuscitation of life threatening shock
     Characterised by low arterial pressure and signs of impaired perfusion
     Fluid BOLUS

    Optimisation
     In COMPENSATED shock
     Fluid therapy to be given cautiously
     Aim: Optimise cardiac function to improve tissue perfusion.
     Mitigate organ dysfunction.
     Fluid CHALLENGE
    Stabilisation
     ABSENCE of Shock
     Steady stat: maintenance or ongoing loss of
    fluid.

    De-escalation
    • Fluid REMOVED from patient
    • Promote NEGATIVE balance
    Monitoring and reassessment
     Individualised to each patient.
     In Rescue phase,
     combine clinical and haemodynamic parameters with
    near patient diagnostics.
     No need for sophisticated assessment like ECHO.
     Reassessment and re-challenge without leaving the
    bedside and continuous observation.
     ECHO/Doppler, CVP, SCVO2 can be used to determine
    appropriate time to transition to Optimisation phase.
     In Optimisation phase,
     Ensuring adequate blood and O2 delivery to at-risk organs.
     Aim to prevent subsequent organ dysfunction and failure
    caused by hypoperfusion and tissue oedema.

     In Stabilisation and De-escalation phase,


     Patients need to be seen every few hours and prescribed
    either IV Fluids/diuretics accordingly on the basis of
    physical examination, blood chemistry and likely clinical
    course.
    Relevance to clinical trials
     FIRST trial
     Patients severely injured with high injury severity scores and
    significantly elevated plasma lactate level post trauma.
     Given in excess of 5L of IV fluids within 24 hours
     CRISTAL trial
     severely hypotensive septic patients requiring very large volumes
    of fluid.

     FIRST Trial and CRISTAL trial  Rescue Trial


     SAFE and CHEST studies, including ~7000 ICU patients.
     Noted that most patients was in the optimisation phase
    evidenced by significantly lower volumes of fluid administered.
    Fluid Resuscitation in perioperative
    period
     Using minimally invasive monitors of fluid responsivesness to guide
    goal directed fluid therapy to optimise tissue oxygen delivery.
     Employ lung protective ventilation strategies
     LOW TIDAL VOLUME:
     reduction in changes in intrathoracic pressure during respiratory
    cycle
     Decrease in variation in venous return and resulting stroke
    volume/systolic pressure
     Less pulmonary and extra pulmonary complications within first week
    of surgery.
    Fluid Therapy for prevention of
    organ damage in specific cohorts
     Fluid administration before contrast administration
     Consensus guidelines: 1-1.5ml/kg/hour 12hour before and after
    procedure
     When 12 hours pre-hydration regime not possible, 3ml/kg/hour
    recommended for 1 hour before and 6 hours before procedure.
     Carefully titrated towards comorbidities (eg decreased renal
    function & heart failure)
     Appropriate de-escalation of fluids- prevent cumulative effect.
    Conclusions

     “Fit for purpose fluid therapy’


     Tailored to specific indications, time, phase dependent variables,
    and the patient.
     Difference between fluid bolus and fluid challenge
     4 phases
     Rescue, Optimize, Stabilise, De-escalation
     Fluid Resuscitation perioperative period
     Considering lung protective ventilation strategy
    References

     E.A.Hoste1,2,K.Maitland3,4,C.S.Brudney5 et al; Four phases of


    intravenous fluid therapy : a conceptual model, BritishJournal of
    Anaesthesia113(5): 740–7(2014) AdvanceAccesspublication9
    September2014 . doi:10.1093/bja/aeu300
     John A. Myburgh, M.B., B.Ch., Ph.D., and Michael G. Mythen, M.D.,
    M.B., B.S; Resuscitation Fluids, N Engl J Med 2013;369:1243-51. DOI:
    10.1056/NEJMra1208627
     Manu L.N.G. Malbrain1 , Paul E. Marik2 , Ine Witters1 et al; Fluid
    overload, de-resuscitation, and outcomes in critically ill or injured
    patients: a systematic review with suggestions for clinical practice,
    Anaesthesiology Intensive Therapy 2014, vol. 46, no 5, 361–380 ISSN
    1642–5758 DOI: 10.5603/AIT.2014.0060
    Thank you

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