Keynote lecture on fluids at EVECC congres Ghent

(Video of the presentation will be posted after the meeting)After a couple of years of social distancing, the European Veterinary Emergency and Critical Care Society and the European College of Veterinary Emergency and Critical Care are looking forward to seeing each other face to face again at the 19th?annual European Veterinary Emergency and Critical Care Congress from 2-4 June 2022 in Ghent, Belgium.

I am honoured to be invited as guest speaker from human medicine at next EVECC congress to deliver the keynote lecture on the 7D's conceptual framework of fluid therapy on saturday June 4th at 11:30 (https://www.evecc-congress.org/programme). This would have been my first time ever on a veterinary critical care meeting. Unfortunately, heatlh related issues do not allow me to participate in person but I have prerecorded my lecture and will post it here after the meeting.

Lecture summary: 7D’S OF FLUID THERAPY AND STEWARDSHIP

Administration of intravenous fluids is one of the most frequent therapeutic options in critical care. However, it is about time that fluids should be treated as drugs. A conceptual framework of the 7 D’s is presented with a focus on definitions (fluid status, preload, fluid responsiveness), diagnosis (hypo- eu- and hypervolemia, organ and tissue perfusion), drug (type of fluids, indications, contraindications, adverse effects, rate, objectives and limits), dose, duration, de-escalation, and discharge. The 4 indications for fluid administration will be discussed: resuscitation, maintenance, replacement and nutrition. The 4 questions: when to start IV fluids, when to stop them, when to start fluid evacuation and when to stop fluid removal. The 4 phases and the ROSE concept: resuscitation, optimization, stabilization and evacuation. The 4 hits, the 4 compartments and much more. It is time for fluid stewardship, defined as a series of coordinated interventions, introduced to select the optimal fluid, dose and duration of therapy that results in the best clinical outcome, prevention of adverse events and cost reduction...

(Full video of the presentation can be watched here: https://vimeo.com/718441763)

EVECC Interview

Dear EVECCS members, is a great honor for us to introduce the main speaker of EVECCS CONGRESS 2022: PROF. MANU MALBRAIN MD, PhD, Internal Medicine - Intensive Care, First Department Anaesthesiology and Intensive Therapy, Medical University, Lublin, Poland, President International Fluid Academy, Lovenjoel, Belgium

Hi Professor Malbrain and thank you for your taking the time for this small interview!

D: You are our invited “medicine speaker” for the next congress, could you tell us what are your main topics of research and clinical activity?

R: I am an internal medicine physician with specialisation in critical care and have been working in different hospitals and intensive care units during for more than 25 years. The last years I have also been in management and leadership positions. I am the founding president of the Abdominal Compartment Society (formerly known as the World Society of the Abdominal Compartment Syndrome, www.wsacs.org) and the International Fluid Academy?(www.fluidacademy.org) and am currently affiliated to the First department of anaesthesiology and intensive therapy at the medical university of Lublin in Poland. My main research interests are abdominal pressure, less invasive hemodynamic monitoring, ARDS and lung water, BIA, fluids, fluid overload, capillary leak, and organ-organ interaction. Over the years I coined many new medical terms like the polycompartment syndrome, capillary leak index, the ROSE concept, the 4 D’s of fluid therapy and fluid stewardship, deresuscitation etc…

D: We know that one of your best fields of interest is fluid therapy, what fascinates you about this topic?

R: It all started back in 2011 in the ZNA Stuivenberg hospital in Antwerp. At that time, we decided to introduce balanced (or better buffered) crystalloid solutions and wanted to inform the doctors why we had chosen some specific fluids. What started as one lecture ended up with a full day on fluids with international speakers. And so, the International Fluid Academy was born. Because we saw there were so many knowledge gaps and there was such a huge interest (for this first meeting there were 250 participants and on later events more than 500, the last virtual and hybrid meetings had an attendance of 1500) we continued this effort and celebrated our 10th?anniversary IFAD last year.

D: What difficulties do you encounter in managing fluid therapy in the human field?

R: There are still so many unanswered questions; basically, fluid therapy comes down to 4 questions: when to start IV fluids (because the best fluid is the one that has not been given unnecessarily); when to stop IV fluids (if the patient is no longer in shock and no longer fluid responsive); when to remove fluids (in case of deleterious effects on organ function because of fluid accumulation syndrome); and finally when to stop fluid removal (in case of hypoperfusion). Still we lack good monitoring tools to answer these questions and guide us through the different phases (within ROSE concept: Resuscitation – Optimization – Stabilization - Evacuation) and to assess fluid status (for instance it is quasi impossible to measure circulating blood volume at the bedside unless one uses a complicated isotope labelled albumin dilution technique); how to monitor glycocalyx and endothelial function; how to quantify capillary leak, etc. Even simple measures like daily body weight, daily fluid balance, urinary output could be performed in a much more precise way. We also need to understand better the role for (new) technologies like BIA, EIT, transpulmonary thermodilution or noninvasive cardiac output monitors,…

D: In your opinion which is the main diagnostic techniques can be used to help us in the decisions concerning fluid therapy administration (e.g ultrasound?)

R: Ultrasound is the modern stethoscope and I am fully in favour, however it is user-dependent and there are many pitfalls that may lead to wrong decision making when in un-experienced hands. For instance inferior vena cava collapsibility index has many limitations (eg right heart failure, positive pressure ventilation, PEEP, intra-abdominal pressure,…etc.). Other assessments have been developed like the veXus score looking at venous congestion in hepatic, renal and caval veins. Personally I believe that next to POCUS less invasive monitoring is the future, we see this trend coming from smart watches and PPG patches.

D: How often do you use intrabdominal pressure monitoring and why you find it so useful in your field?

R: Intra-abdominal is just another vital parameter like MAP, CVP or urine output. It should be measured when there are more than 2 risk factors present for IAH (related to decreased abdominal wall compliance, increased intraluminal content, increased intra-abdominal content , or fluid overload,…). Yet, also within this domain there is a general lack of clinical awareness on this topic and knowledge can be improved

IAP can be easily measured via the bladder every 4 to 6 hours. When it is increased above 12 mmHg it has a tremendous impact on the way we monitor and treat our ICU patients (effect on filling pressures, recruitment, best PEEP settting, enteral nutrition,..). Moreover increased IAP is the canary in the coalmine in understanding development of AKI. Measuring is knowing.

D: What you think will be the next future developments and areas of research in the field of fluid therapy in critically ill patients?

R:I think that the era of the big fluid trials that started in early 2010 has come to an end with the BASICS and PLUS trials showing no difference between saline and balanced (multi electrolyte) crystalloids. Yet these were pragmatic studies with randomization sometimes after 12-24 hours and equal amounts of non-study drug administration in this prerandomization period. Also, the amount of study drug in some studies was really small (approximately 2-4 litres within first week of ICU stay). To me the only message coming from these studies is that it is safe to dilute your drugs (antibiotics, sedatives, pain killers, etc) in small amounts of abnormal saline. I call it abnormal because humans usually don’t have plasma sodium and chloride levels up to 154 mmol/L.

I believe we need more real world data (registries or via the European Ehden project) and more animal research on pathophysiology regarding glycocalyx and capillary leak that can afterwards be translated into humans.

Prof Malbrain once again thank you so much for your time. We look forward to meeting you in person in Ghent!!!

EVECC congress website: https://www.evecc-congress.org/

Registration: https://www.evecc-congress.org/registration

EVECCS society website: https://eveccs.org/