All right, thank you all. Quick show of hands. Who in here, not patients, but you personally, how many of you require maintenance fluids every day? Everyone, right? Now, that could be water or that could be a local brew with either caffeine or 5% alcohol by volume or whatever fluid that you so choose, but I do think everyone needs maintenance fluids in some capacity. It's just a matter of can we individualize them and be intentional with how we administer those to patients. I think you've heard all of that already in the introduction, so thank you for that, and unfortunately, I have no relevant financial disclosures. Our objective today is simply to introduce the concept of fluid stewardship and to maybe give you a little bit more of a focus on this concept of maintenance fluid. So very briefly, I wanna introduce the ROSE model for you all. The x-axis, we have the concept or the interval of time, and on the y-axis, we look at cumulative fluid balance with specifically a focus on the administration of fluids to our ICU or critically ill patients. So first, we have R, which is the rescue phase, and this is where we rapidly administer fluids in a life-saving measure to sustain to life in that acute phase. In the minutes to hours immediately following the rescue phase is the optimization phase, where we give smaller aliquots of fluids to really try to optimize our intravascular volume and organ perfusion. And then over the next hours to days to weeks, depending on the specific patient that's in discussion, is the stabilization phase. And then after the stabilization phase, we enter the evacuation phase, and I know there'll be a discussion on this specific phase tomorrow. And that can occur also over hours to days to even weeks, not even specifically while the patient is under our care in the ICU. Now, some of this language you may be less familiar with, we don't talk about rescue and optimizing fluid balance. Collectively, we typically refer to these two phases together as the resuscitation phase. And then we like to think about organ support during, as we're achieving the optimization and stabilization phases. And so together, across this continuum, we have, again, this concept of this ROSE model. And then we have a, it's a construct that was really, we mimicked it from the five rights of medication safety, and we have the four rights of fluid stewardship as we really think about the administration or the prescription of fluids in our ICU patients. And so together, if you look at, if you take the ROSE model and identify the phase that your patient is in, it can help you identify what your specific goal is to achieve with fluids in that patient at that time. And then once you've identified your goal, you can then use the four rights construct to help specify or dedicate, create an evidence-based individualized treatment plan to help you ascertain that goal for that patient. Now I tell you about the four rights construct, there are a couple others, the four Ds of fluid stewardship, for example. But collectively, something with the combination of those two, I think really captures and summarizes what is the practice of fluid stewardship. So then it gives us the question of what is maintenance fluids? And so with a quiet show of every hand in the room, for those of you that participated, we all need maintenance fluids to some capacity. Guidelines on fluids, and here I've captured some guidelines, consensus statements, and some contemporary reviews, but guidelines are typically based on old dietary reference values, and it's heavily derived from oral or volitional intake. And the goal of maintenance fluids is to meet our daily needs of our patients, fluids, electrolytes, and sugar, and that can be dictated by various different metabolic needs, different ongoing or insensible losses, and it's typically recommended as a maintenance dose to be 25 to 30 mils per kilo per day. One specific consistency across all of these different pieces of literature, they differentiate surgical and non-surgical patients. So I've taken a few key statements from several of these different documents to try to paint the picture of what we're trying to deal with with this autopilot treatment that we have in our ICU patients. So, and again, these are straight from some of these selected publications. So hospitalized patients need IV fluid for at least one of these reasons, resuscitation, routine maintenance, replacement, or redistribution. The use of IV fluids purely for maintenance is relatively unusual. Maintenance IV fluids should nearly always be a short-term measure due to risks. And then finally, maintenance IV fluids are used daily in hospitals worldwide, yet evidence to guide this practice is abysmal, okay? Now, certainly there are some specific indications for maintenance IV fluids, and you could go to some different CE talks on every one of these specific topics. This review article tries to capture some of those specifically, and if your patient does, in fact, have a very specific indication that is evidence-based for maintenance fluid, then you have a really good idea of what your goal of therapy is, what's your goal of your measurement and monitoring for safety and for efficacy. So we won't go into any of these specifically, but maintenance fluids can be used for these for either the prevention or treatment of harm. But I will share with you, this is a point prevalence study of 49 ICUs from the ANZICS group, and they looked at almost 700 patients. And you see here on the table on your left in green, of the 650 patients they looked at, two-thirds of them received maintenance IV fluids, right? That's the big take-home from that table. And then further, the table on your right in yellow, this is the specific 400 patients that received maintenance fluids, and you can see where different volumes come from specifically. But more notably, you see that they receive a lot of fluids from a lot of places in addition to their maintenance fluids. And I specifically want to point you here, where even when patients are being rigorously evaluated by investigators, it is purely mythical to quantitatively capture volitional intake from our patients, okay? So we know that when our patients, and here you see roughly 50% had a predominantly oral diet, yet still many of them were receiving IV, maintenance IV fluids, and we don't really have a good sense of how much fluid they were receiving volitionally. This is a nice paper looking at over 15,000 patients covering 130 or so ICU days. And overall, the authors showed that maintenance IV fluids caused volume overload, and it caused a lot of derangements in sodium and chloride. But they also captured, they looked at where the fluids came from in the patients over the course of the first five days of ICU stay. And so the table on the left kind of is a summary for the entirety of the stay in the ICU, and you see a cumulative mean daily fluid intake of over 100 milliliters per hour. And then they have, the authors separated it out day one all the way through day five, but just to kind of summarize what their ICU stay looked like from the first day to the last day of this study, you see that the volume in orange is the resuscitation volume. And as we would expect, the volume that we use to resuscitate patients changed significantly, reduced from day one to day five. Collectively, maintenance fluids in blue and nutritional intake in gray, they collectively took up about the same amount of volume, but they changed, transitioned from maintenance fluid to more oral intake. But then I also want to take a moment here to draw your attention to the yellow piece. And the yellow piece, you see, makes up 25% up to 35% across the ICU stay. It actually increases in volume as their time in the ICU moves forward. And this yellow portion is fluid creep. And we're gonna talk just a little bit more about what fluid creep, what it really is. And fluid creep or hidden fluids or unintentional fluids or discrete fluids are those fluids that aren't necessarily captured. You're not intentionally prescribing them, but they're still there. And so much like the wind outside, you may not be able to see it, but we have surrogate markers that they exist, such as the wind blowing the flags here. And so a question that I would pose to you all when you go back to your practice is knowing that we don't do a good job of capturing it in our I's and O's, what are some other surrogate markers that we can capture to be more aware of all of the fluid intake these patients are receiving, both intentional and unintentional? I won't spend any time on this slide, but again, you get a lot of fluid from a lot of places. And especially when you think about patients are still getting sometimes dietary intake, and whether that's volitional or tube feeds, and we're really quick to say, oh, they have any type of cardiac disease, they're on a 1.5 gram sodium restricted diet, right? But we'll give them three liters of saltwater IV. I'm like, just save that and let them actually have a piece of terrible hospital bacon or something. So we actually, we looked a little bit further to look specifically at where fluids or which specific medications contribute to a lot of this hidden indiscretionary fluid that we aren't necessarily capturing very well. And so we looked at it based on the frequency in which they're prescribed, and the volume that is associated with these medications. And here you see, without too much data, just in general capturing antibacterials, any continuous infusions like sedatives, analgesics, vasopressors, and then we all have the conspicuous electrolyte replacement protocol that's always given IV for a K of 3.9, and no other risk factors, and they get a lot of IV potassium, or mag, or calcium, or whatever else it may be that is also likely one of these autopilot treatments that we could discuss at a different time. So if you take all of these fluids that these patients get just in this maintenance or stabilization phase, and you apply this concept of fluid stewardship, and you assess both discretionary and indiscretionary fluids in a very patient-specific way during your pre-rounds, or own rounds, et cetera, you can make a pretty significant contribution to patient care. So we actually looked at stewardship of maintenance IV fluids, or all fluid stewardship interventions in a medical ICU. You see 300 patients over 900 patient days, a little over 2,500 pharmacy recommendations captured in electronic surveillance tool. One-fifth of pharmacist-related recommendations were related to fluid stewardship. I'm not going to talk about all of those. You can go read that elsewhere, but just looking at maintenance IV fluids, you see 21% of those 500 fluid stewardship recommendations were to discontinue maintenance IV fluids. Now you see at the bottom, there was also a little 2.5% to change the dose of IV fluids, and I'll tell you it's not very common that I recommend to change the dose. This is more of a sign of negotiation. Patients receiving 100, 150 mils per hour of some erroneous fluid that I don't think they need, I'll recommend to DC it, and I cannot convince the team to DC it, so instead we go into our next phase of this interaction, and that's to negotiate, and say, okay, then we'll decrease it to 50, or 75, or some other random arbitrary number that no one knows what they're actually doing. And then I readdress the same thing about four hours later, and then again tomorrow morning on rounds. So in addition to the stewardship that we do, focused specifically on maintenance fluids, there's also a lot of stewardship that actually a lot of you probably already participate in, which is looking at stewardship of hidden fluids. And you can see here, again, it's the same data set, and looking specifically at hidden fluids, you see a lot of things that you can do are just switching drugs from IV to non-IV routes. And I think a lot of times IV to PO conversions is really captured in our mind as like a cost savings initiative, and sometimes that's definitely true, but I think you're probably underserving yourself for the metrics, or what you're doing for the patient's overall volume status by also switching those medications from IV to PO, or sub-Q, or whatever the case may be. So how do you put fluid stewardship in your ICU? I think some key first steps, and again, this is related specifically to maintenance fluids, consider what the indication is. And if you can't identify an indication, then you may need to rethink the prescription of those fluids. And then if they do have one of those specific indications where maintenance fluids are recommended, what is your therapeutic goal, or your end point? What is your monitoring parameters for safety or efficacy? Are you titrating it to urine pH for methotrexate toxicity, for example, or to serum pH for an aspirin overdose? Are you titrating it to a specific hourly urine output for a rhabdo, or any of these other things, for example? Consider an automatic stop date of 24 or 48 hours that requires a prescriber to reorder them, much like you do physical restraints, or paralytics in my institution, et cetera. It's important, again, that you account for hidden fluids when looking at total intake, remembering that they're not often captured appropriately in our I's and O's. And another easy way to do it in a higher system level is to evaluate your current protocols that currently contain maintenance IV fluids. So we've made some progress, and there's still certainly some next steps that we can do. There's already some small randomized control trials specifically looking at tonicity of maintenance IV fluids. This has been in healthy volunteers and patients in the perioperative setting. I think we're starting to give more attention to the risks associated with volume overload specifically, but also complications of maintenance fluids specifically. We've done a lot of great research from a lot of folks looking at the right drugs, saline versus balanced crystalloids, liberal or conservative fluids. We heard the great presentation on the newly published Clover's trial yesterday. But a lot of it is focused on what type of drug or what type of fluid or how much fluid do we give in the resuscitation, the rescue and optimization phases. But what about the phase after that, the longest phase perhaps of our ICU stay being a stabilization phase? Can we start doing some studies looking at the right patient? Should we start looking at fluids versus no fluids as an intentional IV route or looking maybe more at the volitional intake, et cetera? I think there's been a growing concern looking at, I think in general we're trying to phase out of using abnormal saline all the time because of the hype for chloride. But when we look from the perspective of maintenance fluids, I think there's a growing concern for the sodium load over the spectrum of a patient's hospital stay. And then finally, and again we'll talk about this in another talk tomorrow is looking at effective evacuation strategies after we've already done our harm with all the maintenance fluids that we give on autopilot. So with that, I'll leave you all with one question to self reflect on as you leave. Are you one of the wet bandits in your ICU practice back home? Thank you.

fluid stewardship

ICU

maintenance fluids

ROSE model

individualizing fluid administration