Fluid Balance and Weaning From Mechanical Ventilation.pptx

Fluid Balance and Weaning From Mechanical Ventilation

1. Fluid Balance and Weaning From Mechanical Ventilation By Dr. Mohamed Ramadan

2. Contents 1 4 2 5 3 6 7 Introduction Weaning from Mechanical Ventilation Weaning Failure Weaning-Induced Pulmonary Edema (WIPO) De-Resuscitation Fluid Responsiveness as a Physiologic Endpoint to Improve Successful Weaning Home messages

3. Introduction After resuscitation, it is frequent to find that patients received more fluid than required. A landmark trial by Rivers in 2001 in patients with septic shock, showed that 4.9 L of crystalloids were given in the first 6 h and 13.4 L in the first 72 h [ 1 ]. A decade later, the ProCESS , PROMISE and ARISE trials found similar results with, on average, between 3.7L and 5L being administered within the first 6 hours. A positive fluid balance is associated with increased morbidity and mortality in critically ill patients [ 2 , 3 ] and in patients with acute kidney injury [ 4 ], among other deleterious effects [ 5 , 6 ]. Conversely, achieving a negative fluid balance may increase survival in patients with septic shock and decrease the duration of the weaning process [ 7 ].

4. Weaning from Mechanical Ventilation From a hemodynamic perspective, weaning from mechanical ventilation could be seen as a cardiovascular stress test, equivalent to significant exercise [ 8 ]. This can induce both left and right ventricular dysfunction due to change in loading conditions, myocardial ischemia and, ultimately, cardiogenic pulmonary edema [ 9 ]. Switching from mechanical ventilation to spontaneous breathing, causes intrathoracic pressure to go from uniformly positive across the ventilatory cycle to markedly negative, promoting both an increase in venous return and possibly impeding left ventricular (LV) ejection secondary to increased transmural pressure [ 10 ]. All these events are significantly aggravated when fluid overload is present, as a preload-independent heart will not be able to handle the increased venous return [ 11 ].

5. Weaning Failure About 20% to 30% of mechanically ventilated patients are difficult to wean [ 12 ]. Weaning failure has been classically defined as the failure to pass an SBT or the need for reintubation within 48 h [ 13 ]. Cardiac failure is one of the leading causes of weaning failure.

6. Weaning-Induced Pulmonary Edema (WIPO) Weaning-induced pulmonary edema, was first described in 1988 [ 14 ]. Weaning-induced pulmonary oedema was defined in case of spontaneous breathing trial failure associated with at least one of the following two features:(1) echocardiographic diagnosis of pulmonary artery occlusion pressure elevation (E/A ratio above 0.95 and E/e’ ratio above 8.5 during the spontaneous breathing trial [ 15 ]) and/or (2) plasma protein concentration (5% increase in hemoglobin and/or plasma protein concentration) during the spontaneous breathing trial [ 16 , 17 ]. With the transition from positive pressure to spontaneous negative pressure breathing, preload and afterload both increase, leading to greater LV filling pressure, greater pulmonary artery occlusion pressure (PAOP), and greater transcapillary pressure. The progressively more edematous lungs lead to a greater work of breathing and subsequently greater myocardial oxygen consumption. Patients with previous chronic heart or lung conditions represent a group particularly sensitive [ 18 ].

7. De-Resuscitation The term de-resuscitation/de-escalation was first suggested in 2012 and finally shaped in 2014. It specifically refers to ‘Late Goal-Directed Fluid Removal’, which involves “aggressive and active fluid removal through diuretics and renal replacement therapy with net ultrafiltration”. Although there is wide consensus on the need to deplete critically ill patients once the resuscitation phase has been completed [ 2 , 19 ], there are no guidelines on how to de-resuscitate fluid overloaded patients [ 20 ]. Fluid removal and resulting hypovolemia may give rise to convective problems causing regional hypoperfusion, tissue hypoxia, metabolic and acid-base alterations. 5 steps of De-resuscitation/De-Escalation need to be kept in mind: (1) define a clinical endpoint (e.g., improvement in oxygenation); (2) set a fluid balance goal (e.g., 1 L negative balance in 24 h); (3) set perfusion and renal safety precautions (e.g., vasopressor need, 25% serum creatinine increase); (4) re-evaluate after 24 h unless safety limits reached; (5) adjust the plan accordingly.

8. Annals of Intensive Care   volume 2 , Article number: S15 (2012) Retrospective matched case-control study, included 114 mechanically ventilated (MV) patients with ALI. Comparing outcomes between a group of 57 patients receiving PAL-treatment (PAL group) and a matched control group, abstracted from a historical cohort. PAL-treatment combines high levels of positive end-expiratory pressure, small volume resuscitation with hyper oncotic albumin, and fluid removal with furosemide (Lasix®) or ultrafiltration. Effects on extravascular lung water index (EVLWI), intra-abdominal pressure (IAP), organ function, and vasopressor therapy were recorded during 1 week. The primary outcome parameter was 28-day mortality.

9. There is a lack of prospective studies looking for optimal clinical, physiological, biochemical, or organ-specific endpoints to guide the initiation and discontinuation of fluid removal strategies

10. BNP AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 186 2012 In a randomized controlled multicenter study, we allocated 304 patients to either a BNP-driven or physician-driven strategy of fluid management during ventilator weaning. To standardize the weaning process, patients in both groups were ventilated with an automatic computer-driven weaning system. The primary end point was time to successful extubation .

11. Fluid Responsiveness as a Physiologic Endpoint to Improve Successful Weaning Dynamic assessment of fluid responsiveness has been shown to improve patient-related outcomes. In mechanically ventilated patients, reaching a state of fluid responsiveness before starting a SBT will result in better outcomes when compared to the standard fluid balance approach.

12. CRITICAL CARE: ORIGINAL RESEARCH| VOLUME 158, ISSUE 4, P1431-1445, OCTOBER 2020 The Fresh trial A prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. They evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. Fewer patients required renal replacement therapy (5.1% vs 17.5%) or mechanical ventilation (17.7% vs 34.1%), and patients were more likely to be discharged home alive (63.9% compared with 43.9%).

13. Intensive Care Medicine volume 41, pages487–494 (2015) This study was conducted between June 2012 and September 2013. It included 30 patients after a first failed 1-h T-tube SBT who had a transpulmonary thermodilution already in place. Preload independence [no increase in the pulse contour analysis-derived cardiac index ≥ 10 % during passive leg raising (PLR)] was assessed before the second SBT. The occurrence of SBT failure related to cardiac dysfunction was predicted with a sensitivity of 97 % and specificity of 81 %.

14. Home massages

15. Thank you

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