Thank you very much, Dr. Siparsky, for the introduction, and good morning to everyone. My talk is Maintaining ICU Patients in State of Dryness. It's kind of hard to have a state of dryness if we're raining every day recently, so we'll try our best. I have nothing to disclose that is related to this talk. I think fluid accumulation has been a problem, as well as fluid overload, which is being used interchangeably wherever you are. If you are in the PICU, NICU, medical ICU, SICU, OR, and ER, we are always using fluid for our treatment, and Albert Zeller's administration of fluid could lead to fluid accumulation and fluid overload. So we will just do a quick definition. Fluid overload is defined as more than 10% increase in weight from baseline, and there's a formula in the slides. And fluid accumulation syndrome is when the fluid accumulation occurs with a negative impact on end organ function, causing ARDS, causing AKI, and whatnot. And you might say, it's just fluid. However, a study by Dr. Casotakis in MGA showed that in adult blunt trauma injury, if you give more fluid, like in this case in the slides, more than 15 liters in resuscitation, which we usually do in trauma sometimes, now it's no longer relevant. But it increases the degree of ARDS, multiple organ failure, as well as abdominal compartment syndrome, as well as surgical site infection as well. And a study by Murphy showed that patients who received more fluids or had fluid accumulation on patients with septic shock and ARDS, the majority of them will probably perish or will have a higher mortality. And this is proven with the multiple meta-analysis done by Anna Mesmer. And our colleagues in Taiwan look at this long term as well, and it shows that mortality is higher even after beyond 12 months on patients who receive a lot of fluids. So I think this is very important. And Julie mentioned about a fluid creep a while ago, and I will not reiterate it again, but this is just what she mentioned earlier on. And during the 1970s and 2010s, we usually give them fluids, fluids and fluids, especially in the surgical ICU. And we have that mantra as well, to get well, right? However, that is passé anymore. We usually want to pee to be free. That's what the new mantra in the ICU. There's currently a study, this is just published recently, regarding conservative and liberal fluid. I don't want to contradict myself, but in this study, I just want to mention that they compare conservative versus liberal fluid. And they said that the mortality is actually not significant. However, if you will look at the details, they will say that in the area where in there are some conservative trial, that some of the fluid things are, the fluid randomizations are, the protocol is violated. So we cannot really put all our marbles in this study. However, I'd just like to mention that there's such point care and classic trial, showing that there's no statistical significance in the mortality. Our friend from Abu Dhabi mentioned about the pathophysiology of this fluid. And I think it's very important to know that venous conjection and a fluid overload causes organ and kidney failure. It prevent organ recovery and prevent patient recovery and survival. And it affects all the organs. It could cause cerebral edema. It could cause pulmonary edema, as we all know, myocardial edema, hepatic congestion, renal venous pressure, and renal interstitial edema, causing AKI, or even acute renal failure, as well as tissue edema that was mentioned earlier on regarding skin. And so how would we know that the patient had fluid overload? I think we had to measure. Checklist was mentioned earlier on. And typically, sometimes the I's and O's are sometimes omitted or not included in our checklist. I think it must be included. We should put it in one of those FASAGS BID. We had to make sure to pay attention in the urine output. Change in body weight is very important. Check the daily fluid balance. And use the point of care ultrasound. We could check for inferior vena cava collapsibility index. So we will know when to stop fluid resuscitation. Check the extravascular lung water index. And you could use that with the transpulmonary thermodilution. Check the intraabdominal pressure, if necessary or indicated. Check capillary leak index. You could use bioelectrical impedance analysis. And look at the usual chest x-ray that we usually order in our ICU patients. So we had to measure so we will know whether we have fluid imbalances, as well as fluid accumulation and fluid overload. So I think it's very important that we prevent this from occurring. And just like mentioned earlier on, I think fluid should be treated just like a drug. You know, we use the four D's. Is it the right drug or right fluid? Is it the right dose or right amount of fluid that we're giving? Is it the right duration? And we had to do the escalation as much as possible. Or as soon as possible. Because they could have this fluid creep that we mentioned earlier on. I think the four questions that we should ask is, when to start, when to stop, when to de-escalate or remove the fluid, and when to stop. It is also mentioned that, you know, we should probably be thinking about permissive oliguria, especially in the operating room. I am a surgeon. And during major surgery, the patient is under a physiologic antidiuretic state. And typically, you know, after the operation, we could actually look and see that sometimes there are fluid accumulation after surgery. So sometimes we had to think about, should we just do a permissive oliguria on this patient? Is 0.3 mL per kilogram per hour output? Is the new 0.5? Because we usually use 0.5, right? So probably we have to rethink on some of these things that happen in the operating room. The other thing that I'd just like to mention as well is what we call direct peritoneal resuscitation. This is an idea that was really popularized by Dr. Smith from the University of Louisville. And they use dialysis peritoneal fluid to put into the abdomen, especially in the patient with an open abdomen, patient with a catastrophic abdomen, patient with open abdomen. And this is to resuscitate the patient. And apparently, we want the immune response. It increases the chance of fascial closure. It increases the chance of avoiding intra-abdominal complications, as well as preventing hernia. So most of the patients that we resuscitate during 20 or 10 years ago, they usually end up with an open abdomen and a hernia. So use of direct peritoneal resuscitation may be a novel way of preventing over-resuscitation on this patient. I actually would like to mention as well the role of hypertonic saline solution. So instead of giving them a lot of fluid, why can't we just concentrate that and give them 3% hypertonic saline solution? A study showed by Han here showed that they compared 3% with 7.5% and LRS, or lactated ringers. And it showed that in 7.5%, there's usually tachycardia. So I don't think it's recommended to use the 7.5% hypertonic saline solution. However, with the lactated ringer solution, the chance of acute renal failure, pulmonary edema, and anaphylaxis, and that coagulopathy is higher on those patients. And there is a report that fascial closure will be faster on those who were resuscitated by hypertonic saline solution. However, one of our members, Tyler Loftus, studied this, and they showed no difference whatsoever if you do hypertonic. So I know I'm contradicting myself here, but I would like to make sure we present both data. And the last recent meta-analysis showed that's really no benefit of hypertonic saline solution. And the last study about this, which was just released a few days ago, they did a double-blinded randomized study comparing hypertonic saline solution and non-hypertonic saline solution, and it showed that hypertonic saline infusion does not improve the chance of primary fascial closure. So we have to probably weigh in. I think the truth may be in the middle that there may be a role, but I think looking at different protocols and appropriate protocols must be looked into whether this is really important or helpful for our patients. So for the treatment, I think we already mentioned this earlier on. I think we had to use protocol. There's these rows, not desert rows, but we usually start with resuscitation, optimization, stabilization, but most importantly, we had to do the evacuation phase or the de-escalation process. So now they're saying about, you know, hashtag the resuscitation. It started in 2014, and I think it's catching fire. We all know the perils of resuscitation on fluid overload, and I think we had to be mindful of doing active de-resuscitation. And this is just a management of fluid overload that we had to stop the fluid as soon as we don't need it. So typically, if my patient is already eating and had a return of bowel functions, all fluid stops. I tried to concentrate safely what needs to be concentrated. I started diuretic if I knew the patient had the fluid overload. And the presence of pressors itself does not limit or absolute contradiction for diuretic treatment. So bear that in mind. And liberal use of vasopressors probably is necessary to decrease fluid overload. So in conclusion, before, it's well to get well. Now we had to pee to be free in the ICU. We had to measure, measure, and measure so we could diagnose fluid overload. We had to treat fluid as a drug, you know. We should be a fluid steward. We had to probably think about permissive oliguria and its role. In clinical therapy, like direct peritoneal resuscitation, I put in there a question mark for hypertonic saline solution. I know a lot of people has been using that. But however, we had to be careful not to cause hyperanathremia, not to cause arrhythmia on those patients. And we should probably start initiating our dead resuscitation protocol. Coming up, I think there's a study coming in, and it will be completed in December 2024. It's called the CONFIDENCE trial. And they're using lung ultrasound guided fluid resuscitation on the duration of ventilation in the ICU patients. So probably next year in Orlando, we may have a report for you on the CONFIDENCE trial. That's it. Thank you very much. Thank you.

fluid management

ICU patients

fluid overload

conservative fluid management

CONFIDENCE trial