Kathryn Maitland vs Nick Pigott - Forget Physiology: Cautious Fluids Save Lives

1. Forget physiology: cautious fluids
save lives
Kathryn Maitland

2. Conflict of interest?

3. Not the only ‘sceptic’

4. Where is the physiological
data?

5. Fluid resuscitation guidelines

6. Most animal modes: low cardiac output low perfusion – atypical

7. Paediatric Recommendations:
Dellinger 2012
‘…… blood pressure alone is not a reliable endpoint for assessing the
adequacy of resuscitation. However, once hypotension occurs,
cardiovascular collapse may soon follow. Thus, fluid resuscitation is
recommended for both normotensive and hypotensive children in
hypovolemic shock [542–554]’’.
4 dengue paper, 1 malaria systematic review; implementation
(before after study designs) one small RCT (India)

8. Physiological and dose-finding studies
612121112125 4131516161611 498106106N =
Time(hrs)
4824126-841-20
CVP(cmH2O)
12
10
8
6
4
2
0
-2
CVP low at admission
B
B=Bolus ~ 20-40mls/kg
Maitland et al Pediatr Crit Care (2005)

9. Haemodynamic improvements….
Pilot Studies

12. Oxygen Saturation: risk of mortality

14. Primary endpoint: 48 hour mortality
10.5%
7.3%

15. Shock reversal at one-hour&:
does not predict benefit
Bolus combined No Bolus Total
¥
Relative risk*
No shock at
one hour 43/876 (5%) 8/323 (2%) 51/1198 (4%)
1.98
(0.94-4.17)
Continued
shock at one
hour 141/1180(12%) 50/701 (7%) 191/1881(10%)
1.67
(1.23-2.28)
&One-hour time point chosen since no difference in deaths in
bolus vs control arms ie result not influenced by survivorship bias
*p-value for heterogeneity between the two relative risks. = 0.68

16. 1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
Cumulativeincidence(%)
0 4 8 12 16 20 24 28 32 36 40 44 48
Hours until death
Cardiogenic (Bolus)
Cardiogenic (No Bolus)
Neurological (Bolus)
Neurological (No Bolus)
Respiratory (Bolus)
Respiratory (No Bolus)
Unknown/Other (Bolus)
Unknown/Other (No Bolus)
Percentage of death in Bolus (B) vs Control (C) with Terminal Clinical Event attributed to:
 Cardiogenic/shock: 4.6%(n=96) B vs 2.6%(n=27) C [Ratio 1.79 (1.17-2.74) p=0.008]
 Neurological: 2.1%(n=44) B vs 1.8%(n=19) C [Ratio 1.15 (0.67-1.98); p=0.6]
 Respiratory: 2.2%(n=47) B vs 1.3%(n=14) C [Ratio 1.68 (0.93-3.06); p=0.09]
‘Terminal Clinical Event’:
Cumulative incidence of mortality for bolus & control arms

17. Slam dunk?

19. Forget physiology: cautious fluids
save lives
Nick Pigott
An Intensivist…
(not)

20. It’s about understanding physiology

21. The (African) elephant in the room…

22. An inconvenient truth….

23. FEAST
• Why did they die?
• What excuses have we made?
• Do any of them hold up?
• Are our patients different enough to permit us
to ignore this?

24. • Deaths were not from fluid
overload
• Regardless of the type of ‘terminal
clinical event’, there was a
significant difference between
those who had boluses and those
who did not

25. The golden hour…
• When I was a trainee…

27. APLS – The seriously ill child…

28. Clinical Excellence Commission (CEC)
of NSW – ‘Between the Flags’

29. CEC sepsis pathways

32. Basically…
• Fill them up until they sound wet!
• Then add inotrope

33. Physiology
• How do we measure clinical response to acute
treatment?

34. Signs of response to therapy…
• CR
• Improving perfusion
• Falling pulse rate
• Urine production
• Falling lactate (?!)
• Improving conscious level

35. Physiology
• How do we measure fluid responsiveness?

36. Fluid responsiveness
• General signs
+
• SVC filling
• ?Passive Leg Raise
• Hepatic pressure
(ie preload responsiveness)

37. Physiology
• What happens to that fluid?

38. Physiology
• It leaks straight out and doesn’t want to come
back
• It destroys the glycocalyx

39. `

42. • Prospectively looked at 200 children accepted for
admission to 17 PICUs with sepsis or suspected sepsis
• 34 deaths (17%)
• Children defined as shocked received more fluid
• OR for death in shocked patients was 3.8 (p=0.008)
• 2002 ACCM-PALS guideline was not followed in 62%

44. On FEAST…

45. In closing…
• I have seen hundreds of children recover from shock
apparently as a result of aggressive management
strategies including lots of fluid
• I believe the results of the FEAST study are very
relevant to ‘our’ patients – I just don’t know how…

46. Summary
• We need to UNDERSTAND the physiology of shock
• We should not change our practice without understanding
what we are actually doing
• We should be wary of undermining years of work towards
consistent, timely practice without more complete data

47. Kath is wrong!

48. Thank you!
nick.pigott@health.nsw.gov.au

50. Rino
• In ICU, no one dies without walking through
the forest of oedema

51. NSW fluid composition guidelines

52. • We should not change our practice in shock
without understanding what we are actually
doing