kathryn maitland vs nick pigott: forget physiology- cautious fluids save lives

Forget physiology: cautious fluids save lives

Kathryn Maitland

Conflict of interest?

Not the only ‘sceptic’

Where is the physiological data?

Fluid resuscitation guidelines

Most animal modes: low cardiac output low perfusion – atypical

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)

Physiological and dose-finding studies

612121112125 4131516161611 498106106N =

Time(hrs)

4824126-841-20

CV

P (

cm H

2O)

12

10

8

6

4

2

0

-2

CVP low at admission

B

B=Bolus ~ 20-40mls/kgMaitland et al Pediatr Crit Care (2005)

Haemodynamic improvements….Pilot Studies

Oxygen Saturation: risk of mortality

Primary endpoint: 48 hour mortality

10.5%

7.3%

Shock reversal at one-hour&: does not predict benefit

&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

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

6.5

7

Cum

ulat

ive

inci

denc

e (%

)

0 4 8 12 16 20 24 28 32 36 40 44 48Hours 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

Slam dunk?

Forget physiology: cautious fluids save lives

Nick PigottAn Intensivist…

(not)

It’s about understanding physiology

The (African) elephant in the room…

An inconvenient truth….

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?

• 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

The golden hour…• When I was a trainee…

APLS – The seriously ill child…

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

CEC sepsis pathways

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

Physiology• How do we measure clinical response to acute

treatment?

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

Physiology• How do we measure fluid responsiveness?

Fluid responsiveness• General signs

+• SVC filling• ?Passive Leg Raise• Hepatic pressure(ie preload responsiveness)

Physiology• What happens to that fluid?

Physiology• It leaks straight out and doesn’t want to come

back• It destroys the glycocalyx

`

• 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%

On FEAST…

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…

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

Kath is wrong!

Thank you!

nick.pigott@health.nsw.gov.au

Rino• In ICU, no one dies without walking through

the forest of oedema

NSW fluid composition guidelines

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