Fluids, a never ending story…

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A series of talks about someitnhg at the heart (no pun intended) of intensive care.

(Patho)Physiology of replacement—Matthias Wolff

  • The old Startling Principle is derailed by our understanding that there is a glycocalyx.
  • Sepsis and iatrogenic effects on the glycocalyx have a deleterious effect on fluid shifts
  • The volume effects of IV solutions depends on the glycocalyx
  • Hyperchloraemia is a uniquely (iatrogenic mostly) intravascular origin acidosis

Albumin: Evidence—Ib Jammer

  • Was there a ‘signal’ that albumin was good for sepsis in SAFE? Not shown in the ALBIOS study of course.
  • Meta-analyis in the BMJ showed no benefit though.
    • But 4 Boldt non-retracted papers
    • ‘UnBoldted’ though, still no effect.
  • So the bottom line here is that there is currently no difference between albumin and crystalloids.
    • But it’s fairly expensive
    • But it’s not recombinant, and so although SAFE, still a potential risk (IMHO)

Peri-operative GDT—Rupert Pearse

  • A lot of (European) variation in how people use cardiac output monitoring or CVP to assess fluids
  • SCVO2 reflects the balance between DO2 and VO2
  • Recommends to stick with tried & tested non-invasive CO monitoring currently
  • SVV and PPV were not shown to be good predictors of fluid responsiveness in the OPTIMISE trial see here. (Proud to be a part of that).

POC coagulation management—Christian von Heymann

  • Each POC device does a limited range of indications
  • No device yet does anti factor-Xa activity
  • They don’t help with NOACs
    • They detect the effect
    • Not correlated to plasma drug levels though
  • Great meta-analysis (significant benefit conferred in terms of blood product reduction) using ROTEM or TEG in bleeding.
  • Looks like POC TEG may detect sepsis by picking up clot lysis (better than PCT anyway)

Transfusion thresholds—Kenneth Christopher

  • Severe anaemia confers poor outcomes (good to start with that one)
  • Transfusion threshold should be 70g/L (see here)
    • But this is not appropriate at all in massive haemorrhage
  • FFP has a content I certainly didn’t realise. Not insignificant.

There are fluids and then there are fluids. Once size doesn’t fit all. Tailored and individualised fluid therapy, that’s the key. Both in the giving, and the removing potentially too. We could fill a whole week on this of course!