OK, thank you, Dr. Saparsky, for the introduction, and thank you all for being here. My section will be on the creep. We will be exploring the phenomenon of fluid creep and how it impacts our patients in the ICU. To start, I have no conflicts of interest to disclose. Our objectives will be to define fluid creep. We'll discuss the many factors that influence fluid creep, and then we'll go into strategies to both avoid and combat the creep. I wanted to just start with a quick review on fluids. You want to remember that fluids are medications, too. We have had many studies in recent years looking at both the right fluid to choose as well as the right dose to choose. The debate for colloids versus crystalloids was kind of settled with SAFE and LBOs, looking at albumin versus normal saline or other crystalloids, and establishing that there's no benefit to using albumin, which has landed crystalloids, as our initial resuscitation fluid of choice. And then the next controversy of balanced crystalloids versus normal saline was settled with SMART and SALTED. Those were looking at ICU and ED patients, respectively, using balanced crystalloids, either LR or plasmolyte, in comparison to normal saline, and found a benefit of using our balanced crystalloids. And then just a little bit on dosing. We are all very familiar with the surviving sepsis campaign and the dosing of 30 milliliters per kilogram of ideal body weight for our initial resuscitation volume. And then I just wanted to touch on really quickly the Parkland formula and burn shock. As you'll see in very near slides, we're going to talk about burn patients just really quickly. And that equation is 4 milliliters per kilogram of total body surface area burned. So what is the fluid creep? This term was initially defined in 2000 by Dr. Basil Pruitt. And this was in relation to the Parkland formula and noticing that patients were receiving fluids beyond what was suggested by the Parkland formula. There were several reasons that were suggested for why this may have been occurring. It was noted that specific patient populations, such as patients with inhalational injuries, high-voltage electrical injuries, larger body surface area burned were requiring more fluids than was required or suggested by the Parkland formula. Also, clinicians were not accounting for resuscitation that may have been received in the field prior to presentation to a hospital. And it was also noted that clinicians were slow to de-escalate by monitoring our patient's urine output were to be de-escalating or even discontinuing our fluids. But that wasn't really happening. And the original Parkland formula also did recommend colloid resuscitation after that initial 24 hours of crystalloids. And it was noted that that practice had been abandoned, leading to a much more crystalloid use given to these patients. But how can we expand that to all ICUs? So this term, fluid creep, has just been adapted to any patient that's receiving fluids beyond what's prescribed or what's being expected for our patients. So fluids can be split into two categories, discretionary fluids, which are those fluids where a specific volume is being ordered for our patients. And those would be things such as resuscitation fluids, maintenance fluids, and nutrition. And then these hidden or obligatory fluids, which are gonna be fluids that the patient's receiving that they have to be getting based on other therapies, but the volume of these fluids is not regulated or necessarily accounted for by clinicians. There have been a couple of study trying to estimate the amount of fluid creep that our patients are receiving. Bashir and colleagues looked specifically at that volume of hidden fluids that the patients were getting. So they had a prospective observational study looking at 24 hours of ICU care and the volume of the various types of fluids that patients were receiving. And they found a mean of about almost a liter of these hidden or obligatory fluids and a median of 645 milliliters. Now, Van Riegenmorder and colleagues also had a study looking at things beyond just our hidden fluids, but they did specifically look at what kinds of fluids the patients were being given and how much of that is from our IV medications or, again, fluids that we're not necessarily prescribing. And they found a very similar amount, a median of 645 milliliters per day. They noted that at least a quarter of a patient's mean total daily fluid volume was from fluid creep. And it was also noted that from day four onward of the ICU stay, the majority of the fluids that patients were receiving was due to fluid creep. This first chart is from Van Riegenmorder and colleagues. And this pie chart is just showing the overall volume of different types of fluids that the patients were receiving. And you can see the overall average was about a third of a patient's fluids during the day was because of fluid creep. And they broke that down to volume of fluids from electrolytes, from IV medications, and then that small amount of fluid that's used to keep the IV patent. I know this pie chart's a little bit hard to read is that it's in grayscale, but this is from the study by Bashir and colleagues. And they broke that down even further for what exactly which medications are contributing to fluid creep. And it might be difficult to see, but it's the 39% is due to antibiotics. And then the next highest percentages are gonna be due to our analgo sedation. That's about 16% total. Our vasopressors and then electrolytes will be following that. This is just a quick patient example to try to make everything a little bit more real for everybody. So let's say that we have a 70 kilogram patient that's presenting to the ICU in septic shock. They gave initial fluid bolus of two liters of balanced crystalloids. Antibiotics were initiated using vancomycin, cefepime, and metronidazole dosed for normal renal function. And vasopressors were initiated with norepinephrine and vasopressin. The concentrations at my institution are listed. So based on the fluid bolus that was received as well as the fluids from their antibiotics and vasopressors, approximately what volume of fluid will this patient actually be getting? And I'm not wanting everybody to do some real quick math. I'll give you the answer. But it's almost four liters of fluid that this patient actually received. It's about 3.9 liters. And it's not necessarily to say, don't get that initial fluid bolus. Obviously we know that our patients need that initial resuscitation. But it's just to show that in a fairly typical ICU patient, they're gonna be receiving a large amount of volume that we're not really prescribing for them necessarily. So how do we combat the creep? Some strategies that we can use to help avoid would be to minimize maintenance infusions. We can try to account for some of these continuous IV medications that our patients are receiving and use that to either decrease our maintenance infusions or discontinue them completely. We can transition some intermittent IV infusions to IV push. There has been an increasing amount of safety evidence showing that certain medications, rather than being in a piggyback of maybe 100 or more milliliters, can actually be administered either slightly diluted or undiluted as IV push. A lot of these medications are certain antibiotics, antibiotics, some vitamins. So those are some medications that we can be switching from hundreds of mLs per day down to tens of mLs per day. Lots of institutions also employ IV to pre-O protocols. This is a protocol that allows the pharmacist to automatically make changes from certain medications from IV to PO. These are typically medications that are one-to-one in their bioavailability. The patients are already tolerating either enteral nutrition and or other enteral medications, and that allows them to decrease the amount of volume we're receiving that way. In my practice, sometimes I will transition to enteral sedation medications when I'm getting ready to transition patients off of the continuous IV. This is usually for patients who have been on a large amount of IV sedation for several days. At one point, I'm gonna be worried for withdrawal when I'm getting ready to extubate and starting to initiate some of these enteral medications that will help us to decrease the volume that they're receiving IV and then also to help us prepare for extubation. Then a very common question we get as pharmacists is can I concentrate this drip? We actually have some recommendations from the American Society of Health System Pharmacists as well as the Institute for Safe Medication Practices that both recommend standard concentrations from many of our IV medications. This is to decrease our risk. Whenever we're compounding medications, there's always a risk of error. And actually when we have multiple concentrations available for certain medications, we have a risk of error at every single step of delivery of the medication to the patient from ordering by the provider, verification by the pharmacist, preparation in the pharmacy, and then finally administration. So we're gonna use some of our more standard concentrations that are also commercially available so that we also decrease that compounding risk to help to decrease the risk of many of these medications are high-risk medications. Sometimes, though, fluids are unavoidable. My patient is strict NPO. I can't be making any of these changes. They have to be on continuous sedation. They have to be on continuous vasopressors. I gave them a lot of fluid. Now what do I do? So we can actually employ de-resuscitation, which would be the active removal of fluid off of our patients. This is using either a loop diuretics or dialysis as whatever is appropriate for our patient. The optimal timing for de-resuscitation has been explored in a couple of studies and looking at about day three of our patient's ICU stay, that initial resuscitation phase should be complete and we should have a little bit more of our stability with our patient and that would be an appropriate time to start pulling fluid off aggressively. And then lastly, I'm sure we all employ a bunch of different checklists to make sure that we're getting through all of the appropriate steps for our patients. A common checklist that we use is the Fasthugs, Fasthugs BID. While it's not always helpful to make these longer, I think an easy step would be just adding fluids into the F section, feeding and fluids tend to go together. So that's looking at, am I giving a maintenance infusion, do they still need it? Am I giving IV fluids through medications? Can I make a transition to something else? If not wanting to add this to the F section, it could also be considered in the drug de-escalation section. As I mentioned, fluids are medications too. So can we be de-escalating any of these medications to enteral or just taking them off completely? So in summary, fluid creep occurs due to unintentional fluid administration and can be hard to avoid. Common causes of fluid creep include our antibiotics, vasopressors and sedation. And we can employ those strategies that we just discussed to help to avoid and also combat the creep when it occurs. And thank you very much.

fluid creep

ICU patients

fluid management

de-resuscitation

patient care