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Fluid resuscitation is more a cause rather than a help of ACS. This is not right!

Fluid resuscitation is more a cause rather than a help of ACS. This is not right!. Michael Parr University of New South Wales ICU, Liverpool Hospital, Sydney International Trauma Care (ITACCS).

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Fluid resuscitation is more a cause rather than a help of ACS. This is not right!

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  1. Fluid resuscitation is more a cause rather than a help of ACS. This is not right! Michael Parr University of New South Wales ICU, Liverpool Hospital, Sydney International Trauma Care (ITACCS)

  2. Balogh, Z et al.Abdominal Compartment Syndrome: The Cause or Effect of Postinjury Multiple Organ Failure. Shock 2003;20:483-492 • Patients have a pulmonary artery catheter and gastric tonometer placed and are resuscitated according to a protocol to achieve a specified oxygen delivery index (DO2I) goal for 24 h. • Interventions: • 1) PRBC transfusions if Hb <10 g/dL, • 2) crystalloid boluses to increase PCWP >=15 mmHg if DO2I < goal • 3) Starling curve generation with successive 500 mL crystalloid boluses to optimize CI-PCWP relationship if Hb >=10 g/dL, PCWP >=15 mmHg, and DO2I < goal • 4) inotrope if CI-PCWP has been optimized and DO2I < goal • 5) vasopressor if mean arterial pressure <65 mmHg

  3. At the inception of the protocol, DO2I >= 600 mL/min/m2 was the goal of the protocol process. This goal was chosen by review of the published literature and local consensus opinion. • After 2 years, based on consensus groups concerns over the large volume of crystalloid being administered (a mere 13 litres in 24 hours) and publication of the most recent trial by Shoemaker and colleagues which failed to demonstrate improvement in survival in trauma patients with a similar protocol process with a DO2 >= 600 goal, we decreased the DO2I goal in patients to 500 mL/min/m2

  4. Conclusions: Attempts to boost the cardiac index and systemic oxygen delivery failed to improve the outcome in this heterogeneous group of critically ill patients. Contrary to what might have been expected, our results suggest that in some cases aggressive efforts to increase oxygen consumption may have been detrimental.

  5. What fluid? How much?

  6. Malbrain ML et al. Intensive Care Medicine 2004;30:822-9. • DESIGN: A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries • Enrolled 97 patients • The prevalence of: • IAH (IAP 12 mm Hg or more) was 50.5% • ACS (IAP 20 mm Hg or more) 8.2% • The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance.

  7. Fluid resuscitation is not a cause of ACS. • It’s not the fluid! • Some patients because of their illness or injury are destined to get IAH and ACS and can be identified early by IAP measurement • It’s the clinicians and their resuscitation protocols!

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