Thank you for the introduction. It normally only takes one cup of conference coffee to help me start diuresing, but unfortunately in the ICU it's not quite as simple. So we're going to hopefully give you guys a little bit of idea on the phases of fluid management and how to maybe successfully evacuate fluids from our patients. Unfortunately I have no relevant conflicts of interest or financial disclosures. And today our goal, just very briefly in 10 minutes, is to review the phases of fluid management with some specific attention to the maintenance and de-resuscitation phases. So very briefly I'll bring you to this schematic. On the x-axis we have an interval of time, and on the y-axis we have cumulative fluid balance or the administration of fluids, if you will. And in the very first imminent minutes of a patient presentation, we rapidly administer fluids in the first phase of what we call the ROSE model. And the first phase is what we call the rescue phase, where we are providing life-sustaining fluid therapy to at least keep the patient alive momentarily while we can start other life-saving measures. Over the next several minutes to maybe hours we then enter the optimization phase, where we give smaller aliquots of fluids to better optimize our intravascular volume for organ perfusion. Then we enter the stabilization phase, which may take hours or days or sometimes weeks depending on the phase of your critical illness of the patient that you're managing. And then finally, over the last several hours or weeks or days even, is the evacuation phase, or some may call it the de-resuscitation phase. So you may not hear the terminology of rescue and optimize as often, because we collectively typically refer to this as just general resuscitation. Then we have the construct of fluid stewardship, where we adopted a model from the five rights of medication safety, and that being the right patient, the right drug, the right dose, and the right route. And so in combination, if you use the ROSE model to identify the phase in which the patient is in that you're managing, it can help you identify your specific treatment goals and targets, and then you can apply your four rights model to develop a construct that's individualized and intentional with your patient to then help you attain that goal of fluid therapy. And so again, collectively we would like to think that this is the practice of fluid stewardship. So with attention to the stabilization phase, this is where we're trying to maintain organ perfusion, maybe have a net neutral or even slightly negative balance. And there's a question, is this where maintenance fluids go, or is there a role for maintenance fluids? And there was a lot of discussion yesterday on maintenance fluids as an autopilot treatment modality in our ICU patients, so I won't spend any time on that. But very briefly, maintenance fluids are fluids that we think meet the daily needs of our patients, roughly 25 to 30 mils per kilo per day. But it's based on old dietary reference values, typically from volitional intake. And if you look at various guidelines, consensus statements, and contemporary reviews, they do specify and separate out surgical and non-surgical patients. And while there are some very specific indications for maintenance IV fluids for various different issues with our patients, a lot of times we can typically achieve that maintenance fluid intake from other sources. And I won't go through all of these for the sake of time, but this, I think, really these are some specific phrases coming from some of these guidelines and documents that really highlight the controversy of maintenance fluid therapy, where the first you see where hospitalized patients need IV fluid for at least one of these reasons. And then you go to the very bottom and you see maintenance fluids are used daily in hospitals worldwide, yet evidence to guide this practice is abysmal. And maintenance fluids don't have to be intentionally prescribed. This is a study looking at maintenance fluids that showed that it contributed to volume overload and electrolyte derangements, namely sodium and chloride. But collectively, over the first five days of ICU stay, you see that they had a cumulative fluid intake of over 100 milliliters per hour. And I'll draw your attention, they have it separated from this study, day one through day five separately, but the big takeaway is just looking at the progression from day one to day five, where you see the orange section represents resuscitation fluids, and as we would hopefully expect, you see that that significantly decreases over the course of that ICU stay. The blue is maintenance IV fluids, and the gray is nutritional intake. And they primarily take up the same amount of the total volume intake over the course of the ICU stay, but it transitions from maintenance to internal sources. But I also want to draw your attention to the large yellow section that actually increases in the amount of volume that we contribute to our patients, and that's from this hidden fluid or fluid creep. So it really begs the attention that just because we can't see that it's not there doesn't mean that it isn't there. And so similar to the wind that we have evidence that the wind is blowing from the flags moving, and so similarly in our patients, just because we don't have a very qualitative or quantitative capture of their Is and Os, we may have some other surrogate markers of getting these fluids maybe indiscretionately. So looking at the type of fluid that contribute to this hidden fluid balance, we looked at over the first three days of patients' ICU stays based on the frequency that they got these medications and the volume contributed. You see antibacterials, and then most of our continuous infusions of sedatives and analgesics and vasopressors contributed substantially. And then finally, that elephant in the room, which is our electrolyte replacement protocol, which we also know has an indication creep that we very rarely actually need to do in a lot of our ICU patients. And then after the maintenance phase, so again, we don't necessarily need to give maintenance fluids as a prescriptive therapy. They get them indiscretionally regardless. And that tends to cause our patients to have volume overload, which is going to be the rest of the discussions from our other panelists about how do we remove that fluid once that happens. And so you can do that passively or actively, and if you do that actively, you can use pharmacologic strategies or mechanical strategies. And diuresis in general I think is challenging because I'm not so sure that we know what to do or how to do it effectively and in what progressive strategies that we may need to do that. So hopefully we'll shed some more light on that here soon. And we have some evidence to say that we don't really know what we're doing as well. Only 39% of resuscitated septic patients started on diuretic therapy during their ICU stay. We did see some data from the CARESS-HF trial presented in the last session. But those trials for fluid removal and heart failure are often scrutinized because they're unrealistically aggressive. But is that necessarily a wrong strategy to partake in? We also heard about the FACT trial and the very nuanced and specific strategies that they used to diurese. They also had what would be arguably some aggressive diuretic targets to a CVP of less than four. They didn't achieve that goal in a lot of their patients, but they still saw more mechanical ventilation-free days. So what would have been those outcomes if they did achieve their targets in all of their patients as they initially intended? And then finally, protocolized diuresis, we do know that it improves fluid balance, ICU length of stay, and the need for renal replacement therapy at the expense of electrolyte derangements. But again, I draw your attention to we don't really know how to dose and optimize the dosing strategies for some of those diuretics in our ICU patients with different comorbidities or contraindications, AKI, et cetera. So some key takeaways just in the last brief moment. The ROSE model and the four rights construct collectively help you become a fluid steward. Maintenance IV fluids are most always administered but not always prescribed, so we're giving them regardless. It's just a matter of finding those other ways to identify that the patients are receiving them, quantifying them, and knowing that those are contributing to what should be next is our evacuation phase. And I would encourage everyone to hopefully use some of the principles we're going to hear in just a few minutes to be proactive about the evacuation phase, set goals, routinely evaluate and reevaluate those goals to help you achieve such. And when I saw the title of this session, Stopping the Salinity, the first thing that came to my mind, this is my dog standing at the ocean. And it takes her one sip from that water to realize that she is not meant to have maintenance fluids that are purely saltwater. And so with that, I thank you.

fluid management

ICU

individualized treatment goals

fluid creep

evaluate and reevaluate