What are we talking about?

De-resuscitation is defined as active fluid removal in patients with GIPS (global incresaed permeability syndrome) or a positive cumulative fluid balance (fluid overload defined as 10% increase in body water). It can be done with diuretics or RRT with ultrafiltration. But the best option is to avoid it! Below is a list of potential parameters or monitoring tools that could help to assess fludi overload and how to guide and monitor the de-resuscitation phase.

Clinical parameters

• Body weight
• Fluid balance
• Cumulative FB
• Pitting edema
• 2nd and 3rd space fluid accumulation (orthopnee)
• JVP and HJR
• Capillary refill

Biochemical parameters

• AKI, urinanalysis
• Urine albumin/creat ratio
• Dilutional anemia
• Low albumin, protein
• Infection, inflammation
• Increased CLI (CRP/alb)
• Low osmol, COP
• BNP and NT-pro-BNP

Imaging

• Cardiomegaly, congestive hili, Kerley B-lines, pleural effusions, lung edema
• Ascites
• E/e’, LVOT VTI
• IVVCI (IVC > 2.5cm)
• LA volume >34ml/m2
• B-lines, comet-tail

Hemodynamic monitoring

• MAP, HR
• High CVP, PAOP
• High GEF/GEDVI
• High RVEF/RVEDVI
• Absence of FR
• Low PPV, SVV
• Negative PLR
• Negative EEO

Organ function monitoring

• EVLWI/PVPI
• P/F ratio
• ORI
• GIPS
• ICP, CPP (=MAP-ICP)
• IAP, APP (=MAP-IAP)
• AKI: biomarkers (N-GAL, cystatin C), CARS

Other techniques

• V/Q match
• TBW
• ECW/ICW ratio
• Volume excess
• IVF vs EVF
• Total CBV (technetium albumin)
• BVI

In this lecture given by @manu_malbrain during the 38th #ISICEM18 meeting held in Brussels the above mentioned concepts are explained and discussed.

Why wait, just start with fluid stewardship now avoiding fluid overload and GIPS:

Go to Video

Suggested Reading

Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N: Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 2014, 46(5):361-380.