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Rational Fluid Therapy
23 Plays1 year ago
In this episode, Dr. Sergio Zanotti discusses rational fluid therapy. He is joined by Dr. Adrian Wong, a practicing intensive care medicine and anesthesia physician. Dr. Wong is a consultant and clinical lead at King’s College Hospital, London. He also serves as a committee member for the Intensive Care Society FUSIC, examiner for the European Diploma of Intensive Care Medicine, on the executive committee of the International Fluid Academy.
Additional resources:
Intravenous fluid therapy in the perioperative and critical care setting” Executive summary of the International Fluid Academy (IFA). Malbrain ML, et al. Ann. Intensive Care 2020: https://pubmed.ncbi.nlm.nih.gov/32449147/
Multidisciplinary expert panel report on fluid stewardship: perspectives and practice. Malbrain ML, et al. Annals of Intensive Care 2023: https://pubmed.ncbi.nlm.nih.gov/37747558/
The emerging concept of fluid tolerance: A position paper. Kattan E, et al. Journal of Critical Care 2022: https://pubmed.ncbi.nlm.nih.gov/35660844/
Everything you need to know about derescuscitation. Malbrain ML, et al. Intensive Care Med 2022: https://pubmed.ncbi.nlm.nih.gov/35932335/
Start with Why. TED Talk presented by Simon Sinek: https://simonsinek.com/videos/ted-talks/
Books mentioned in this episode:
Thinking Fast and Slow. By Daniel Kahneman: https://amzn.to/4hicUoj
Start with Why: How Great Leaders Inspire Everybody to Take Action. By Simon Sinek: https://bit.ly/42hzt8n
Recommended
Transcript
Introduction to Intravenous Fluids
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Fluid Therapy and the '4 Ds' Framework
00:00:33
Speaker
Administering intravenous fluids is one of the most common interventions in critically ill patients.
00:00:38
Speaker
Despite its frequency in our practice, there are significant gaps in our knowledge concerning best practices based on solid evidence.
00:00:44
Speaker
In today's podcast episode, we will discuss rational fluid therapy.
00:00:49
Speaker
Our guest is Dr. Adrian Wong, a practicing intensive care medicine and anesthesia physician.
00:00:53
Speaker
He's a consultant and clinical lead at King's College Hospital in London.
00:00:57
Speaker
Dr. Wong is a member of the Intensive Care Unit, Intensive Care Society, FUSA Committee, as an examiner of the European Diploma of Intensive Care Medicine.
00:01:06
Speaker
He was the ex-chair of the Social Media and Digital Content Committee of the European Society of Intensive Care Medicine and the course director of the Genius Ultrasound course.
00:01:16
Speaker
He's on the executive committee of the International Fluid Academy.
00:01:19
Speaker
A true pleasure to have him here today to discuss this important topic.
00:01:23
Speaker
Adrian, welcome to Critical Matters.
00:01:25
Speaker
Thank you very much for having me.
00:01:27
Speaker
I'm very excited.
00:01:28
Speaker
I would like to start with a big question.
00:01:31
Speaker
Why should intensivists care about this topic?
00:01:35
Speaker
Well, I think it is a fluid management, fluid prescription is ubiquitous across healthcare, be it intensive care, anesthesia, emergency medicine, all branches of medicine, intravenous fluid is involved.
00:01:52
Speaker
And especially for being on the intensive care unit, it's core practice, it's core business, it's what we do.
00:01:59
Speaker
We give fluids, we manage hemodynamics, that's what we do on the intensive care unit.
00:02:05
Speaker
And yet, as you alluded to in your introduction, I think there is a lot of variability.
00:02:11
Speaker
in terms of what actually happens on the shop floor.
00:02:15
Speaker
Now, straight bias declaration, I think that fluid therapy is given almost too easily.
00:02:23
Speaker
The patient's heart rate is up, we give fluid.
00:02:25
Speaker
The patient's urine output is down, we give fluid.
00:02:28
Speaker
The blood pressure is down, we give fluid.
Applying the '4 Ds' in Clinical Settings
00:02:30
Speaker
So I hope we can discuss some of these issues and hopefully provoke thought, reflection amongst all of us in the use of intravenous fluids.
00:02:41
Speaker
Perfect.
00:02:42
Speaker
You mentioned how easy it is to give fluids, almost like we say, a knee-jerk reflex many, many times during the day in our clinical practice.
00:02:52
Speaker
And maybe one way to start framing this conversation is to start thinking about fluids as true therapeutic agents, true medications.
00:03:02
Speaker
And I know that you've worked with some of your colleagues and others on this 4Ds.
00:03:08
Speaker
Could you give us a little bit of a more background on that?
00:03:13
Speaker
Absolutely.
00:03:13
Speaker
So I think if I said to you intravenous fluids are drugs, I don't think any of yourself or your colleagues would disagree with that.
00:03:21
Speaker
And like all drugs, they've got the correct indications and contraindications.
00:03:25
Speaker
So we started off with the four Ds, which is a term coined by Professor Malumal Brand, who's done a lot of work in all this.
00:03:32
Speaker
And the four Ds were initially, the first D is the drug.
00:03:36
Speaker
So what type of intravenous fluid you are going to prescribe?
00:03:41
Speaker
The second D was for dosing.
00:03:43
Speaker
So how much of the intravenous fluids you're going to give, over what period of time, and that's the duration.
00:03:50
Speaker
And finally, the fourth D, which is an element that's often seen as an afterthought and probably neglected, is de-escalation.
00:03:58
Speaker
Now, since the four Ds have been published, Professor Malbrainer has added a few more Ds.
00:04:04
Speaker
So rather than just drug dosing duration and de-escalation,
00:04:10
Speaker
He's added diagnosis.
00:04:12
Speaker
So what's the problem with the patient, the drug, the dosing, the duration, the de-escalation is still there, but now he's added documentation, diligence, and discussion education.
00:04:23
Speaker
And this all feeds into the whole concept of fluid stewardship, which I'm sure we'll come to.
00:04:29
Speaker
Absolutely.
00:04:30
Speaker
Could you give us maybe a quick example of how this would be applied at the clinical practice, at the bedside?
00:04:38
Speaker
So I think if you start with the first of the new these, the diagnosis, so what is wrong with the patient?
00:04:44
Speaker
So it's not just about the elevated heart rate.
00:04:48
Speaker
Is there a problem?
00:04:50
Speaker
What is the diagnosis?
00:04:51
Speaker
So it could be a community acquired pneumonia leading to septic shock.
00:04:55
Speaker
There is evidence of malperfusion for which I am going to administer fluids.
00:05:01
Speaker
So that's the diagnosis.
00:05:03
Speaker
The drug, in a sense, is this whole argument around what type of fluid you're going to give.
00:05:09
Speaker
So broadly speaking, again, is the whole discussion around crystalloids versus colloids.
00:05:15
Speaker
Certainly in the intensive care world and in my own practice, the only colloids we use these days are human albumin.
00:05:26
Speaker
So we don't have the gelatins, we don't have the starches, we don't have the dextranes.
00:05:32
Speaker
We only use crystalloids.
00:05:34
Speaker
And with regard to crystalloids, our practice has now swung towards more balanced solutions such as Hartman's or PlasmaLite as opposed to 0.9% saline or abnormal saline.
00:05:49
Speaker
With regard to the doses, I think we no longer give fluid because.
00:05:55
Speaker
10-hour bags, 12-hour bags, all these other things.
00:06:00
Speaker
Certainly in my practice, I try to reduce that.
00:06:03
Speaker
I think of fluids with regard to, is this fluid for resuscitation or is this fluid for
Types of Fluids: Crystalloids vs. Colloids
00:06:10
Speaker
maintenance?
00:06:10
Speaker
And that will decide the dose.
00:06:12
Speaker
So if it's more for resuscitated purposes, I would tend to go with fluid boluses or fluid challenges.
00:06:19
Speaker
And that will tie in nicely with the duration side of things.
00:06:23
Speaker
I think in my own clinical and research practice, the emphasis now, as continuously trying to evolve, is the concept of de-escalation.
00:06:34
Speaker
When is it time to start taking away fluid from the patients, diureasing them, or using renal replacement therapy to bring their fluid balance back down to neutral?
00:06:45
Speaker
So that's a brief overview of the Ds.
00:06:48
Speaker
You talked about giving fluids for resuscitation, giving fluids for maintenance.
00:06:53
Speaker
We also sometimes give them for replacement.
00:06:56
Speaker
But one aspect that I think we often forget at the bedside is what's called fluid creep.
00:07:01
Speaker
Could you talk a little bit about that and how it contributes to the overall fluid balance?
00:07:06
Speaker
Yep.
00:07:06
Speaker
And so this concept of fluid creep is the type, the fluids that we give that we don't necessarily clock.
00:07:13
Speaker
So, for example, if I prescribe a fluid bolus or a bag of maintenance fluid, be it heartmins, dextro saline, so on and so forth, we are generally speaking aware of it.
00:07:24
Speaker
Our nurses chart it on the fluid chart, on the intravenous therapy chart, so on and so forth.
00:07:30
Speaker
Fluid creep includes those drugs or fluid amounts that we give that we don't necessarily clock immediately.
00:07:38
Speaker
And the example I normally give is, for example, intravenous fluids.
00:07:42
Speaker
For example, in the intensive care unit, the sedative medications that we give, vasopressors that we give, all these drugs are given in a particular volume.
00:07:54
Speaker
And that volume...
00:07:56
Speaker
contributes to the total amount of fluids being administered.
00:08:00
Speaker
And so there was very nice study from Professor Van Riegel-Moltens based in Belgium, who accounted that actually fluid creep accounted for about 30-40% of all fluids administered to the critically ill patient on an IITU.
00:08:13
Speaker
So we need to be aware of it.
00:08:16
Speaker
We just don't think about it because it's not often the forefront of our clinical minds.
00:08:22
Speaker
So it's almost one of those givens in the ICU.
00:08:24
Speaker
I used to say, I think people are changing now, but I used to say that inevitably, yeah, drips for sedation would go up at night.
00:08:32
Speaker
And inevitably over time, people's fluid balance goes up no matter what we do, right?
00:08:37
Speaker
I completely agree with that.
00:08:39
Speaker
I think it's just too easy at times to put a bag up, a slow bag up because the patient is, you know, he's not drinking very much, not eating very much.
00:08:49
Speaker
We'll just hang a bag up for the overnight.
00:08:50
Speaker
Yeah, agreed.
00:08:52
Speaker
And I think this is going to be also an important aspect as we talk about fluid stewardship and de-escalation a little bit later.
00:08:59
Speaker
Now, you did mention, Adrian, the drug portion, right, and the types of fluids that we have available.
00:09:07
Speaker
And this has been an ongoing debate, but I do believe that in the last several years,
00:09:11
Speaker
We've had some important studies that maybe have inclined us to use one type of fluid over others more
Fluid Stewardship and Multidisciplinary Approaches
00:09:20
Speaker
commonly.
00:09:20
Speaker
Could you just give us a brief overview of the best type of fluid in general?
00:09:25
Speaker
So I'm interested in first balanced versus unbalanced crystalloids, and then crystalloids versus colloids, just kind of like your appreciation of where we stand today based on the available evidence.
00:09:37
Speaker
OK, I think let's start off with your second question, which is around the crystalloid and colloid question first.
00:09:44
Speaker
I think we all remember going to medical school, nursing school, and remember being told, you know, colloids are great.
00:09:51
Speaker
They expand the intravascular volume by three times.
00:09:55
Speaker
They stay in the circulation for longer, so on and so forth.
00:10:00
Speaker
However, you know, numerous trials which looked at the different types of colloids being used when compared to crystalloid solutions, they aren't as good as we thought they were.
00:10:14
Speaker
Certainly they don't expand the intravascular volume by three times.
00:10:19
Speaker
They do stay a bit longer in the circulation, but not that much longer.
00:10:26
Speaker
And like everything else in life, there are the benefits, but also the risks.
00:10:31
Speaker
And we started learning about the coagulopathic effects, the effects of some of these colloids on kidney perfusion and increased rates of kidney injury.
00:10:44
Speaker
So for a variety of different reasons, certainly in the UK,
00:10:48
Speaker
I remember when I started my anaesthetic intensive care training, we would use gelatin quite liberally, and that fell away quite rapidly with all these trials.
00:11:00
Speaker
And to this day, I think I struggle to think of the last time I prescribed a bag of gelatin in
00:11:07
Speaker
the dextrins have been removed from the European market completely.
00:11:12
Speaker
So I think that the discussion, arguments, debates around crystalloid and colloids have swung heavily in favour towards the crystalloid side such that I don't think many of us in the UK use colloids routinely now as a resuscitative fluid stroke drug.
00:11:35
Speaker
so on to the balanced crystalloids versus normal saline argument um that's more interesting there are lots of trials which examine them so the most recent of which i certainly clocked you've had the plus trial the basics trial the split trial the salt ed trial the smart trial and all of them seem to be much of a muchness but with a
00:12:03
Speaker
slight slant towards balanced solutions.
00:12:07
Speaker
Now, normal saline, I'm sure you all know, does not reflect the composition of plasma.
00:12:13
Speaker
There's too much sodium in it and definitely too much chloride in it.
00:12:20
Speaker
And this hypochloremic acidosis has been associated with worse kidney outcomes.
00:12:26
Speaker
So therefore, the logic of
00:12:29
Speaker
or the rationale for swinging towards more balanced crystalloid solution.
00:12:33
Speaker
If you take, for example, the PLUS trial, which was led by Simon Finfer and the ANZICS group.
00:12:39
Speaker
So it was comparison of balanced crystalloid versus normal saline, and there was no difference in 90-day mortality between the two groups.
00:12:48
Speaker
When you combined all the different trials together into a meta-analysis, it seems again to favor the balanced crystalloid group as opposed to the
00:12:59
Speaker
normal saline or any old joke amongst the fluid resuscitationist abnormal saline group.
00:13:07
Speaker
And it's interesting, right?
00:13:08
Speaker
Because how names impact behavior is also interesting in terms that when people say normal saline, of course, it sounds like that's the right thing to give whenever I need to give something, right?
00:13:19
Speaker
And like you said, it has nothing normal in it.
00:13:22
Speaker
And I wonder how that name came up.
00:13:24
Speaker
It does make you think.
00:13:26
Speaker
Yeah, you're right.
00:13:27
Speaker
I don't know how normal saline became normal saline.
00:13:31
Speaker
Yeah, and I think it's important what we label things because I think it conditions our behavior.
00:13:37
Speaker
But like you said, I grew up training in medicine and in critical care background, and we were big on normal saline for everything, right?
00:13:46
Speaker
And slowly, I think...
00:13:49
Speaker
And we would almost like confirm our bias and decay.
00:13:53
Speaker
You would have hypercloremic, metabolic acidosis.
00:13:56
Speaker
You'd say, well, it's just a side effect.
00:13:58
Speaker
Or you would justify a lot of the things that you would see at the best side as collateral damage, right?
00:14:04
Speaker
And I think one of the things that we have learned is that there is a lot of damage that's not only collateral, but that probably impacts outcomes and that we should be paying attention to that.
00:14:14
Speaker
But definitely, it sounds like currently, not only we should be using more crystalloids, obviously, than colloids, like you said, but also when we're using crystalloids, the current evidence and our physiologic understanding would push us probably to preferentially use balanced crystalloids, which I think makes a lot of sense.
Fluid Responsiveness and Tolerance
00:14:37
Speaker
I think so.
00:14:37
Speaker
I think so.
00:14:39
Speaker
So let's talk about some new concepts, and maybe we can start by just an overall explanation of what's understood by fluid stewardship, and then dive a little bit deeper into some other terms that I think are common when we're talking about fluids.
00:14:59
Speaker
Okay, so fluid stewardship is a variant, draws a lot of parallels with the concept of antimicrobial stewardship.
00:15:09
Speaker
Put simply, it's the right fluid in the right patient for the right indication for the right duration.
00:15:18
Speaker
So I don't think any of us would disagree with that.
00:15:22
Speaker
But I think the extra layer of fluid stewardship, similar to antimicrobial stewardship, is that it is not just one step.
00:15:32
Speaker
It involves multiple steps.
00:15:35
Speaker
It involves multiple colleagues.
00:15:37
Speaker
So this is a multidisciplinary approach to ensuring that the right fluids get into the right patient for the right duration.
00:15:47
Speaker
And with that, there is an element of the clinical side.
00:15:51
Speaker
So what we talked about, the indications, the type of fluid, so on and so forth.
00:15:56
Speaker
But also other non-clinical aspects, such as is there an educational program involved
00:16:04
Speaker
for your team, not just the clinicians, but also the nurses, the pharmacists, so on and so forth.
00:16:10
Speaker
Is there an active governance audit data collection program to ensure that what's really happening is actually what's happening as opposed to what you think is happening?
00:16:23
Speaker
So right amount of fluid, right type of fluid to the right patient for the right time and all the various steps to ensure that happens.
00:16:34
Speaker
And it's interesting also, Adrian, that I'm sure you're aware that this year in the U.S., a series of big storms impacted what apparently we did not even know were some of the critical and few facilities that were manufacturing IV fluids.
00:16:53
Speaker
So all of a sudden, something that nobody bats an eye to give and that's considered to be abundant was scarves.
00:17:02
Speaker
And some hospitals got into a lot of trouble to the point of canceling elective surgery, which has real impacts for patients, right?
00:17:10
Speaker
And it just shows you also that we live under the impression, especially in many hospitals like the ones we practice in some parts of the world that are resource rich, that the resources are basically abundant and unlimited.
00:17:26
Speaker
But that is not true.
00:17:27
Speaker
Some of these resources can very easily under stress disappear and become very, very scarce.
00:17:34
Speaker
But I think what we've also learned during these months that we were tight on intravenous fluids is that maybe if you think about it, you don't have to use as much of it.
00:17:44
Speaker
No, agreed, agreed.
00:17:46
Speaker
I think sometimes we're both very lucky.
00:17:48
Speaker
We work in relatively resource-rich settings that I think we take things for granted until we no longer have it.
00:17:59
Speaker
I wouldn't wish the storm upon anyone, but it is emerging from it is that challenge to look at and review what we do
00:18:11
Speaker
how we practice with regard to intravenous fluids.
00:18:15
Speaker
Why do we prescribe intravenous fluids?
00:18:17
Speaker
Is it because?
00:18:19
Speaker
Why do we do things a certain way?
00:18:21
Speaker
Is it because it's always been that way?
00:18:24
Speaker
It's the way we've always done things?
00:18:26
Speaker
So when faced with such a dramatic challenge, it's an opportunity as well to re-evaluate what we actually do by the bedside.
00:18:36
Speaker
So the other terms that I wanted to hear a little bit more about are there's two terms that everybody uses at the bedside, fluid responsiveness and fluid tolerance.
00:18:47
Speaker
I'm sorry, and fluid overload.
00:18:50
Speaker
And in between is this emerging term of fluid tolerance.
00:18:53
Speaker
Could you kind of tell us what is fluid responsiveness?
00:18:59
Speaker
How do we use it?
00:19:00
Speaker
How do we misuse it?
00:19:02
Speaker
How would you think about fluid overload?
00:19:03
Speaker
And then go into fluid tolerance in more detail.
00:19:07
Speaker
Let's start off with fluid responsiveness first.
00:19:09
Speaker
So fluid responsiveness is put simply, and there are various different definitions out there, is a state where after the administration of fluids, your stroke volume goes up.
00:19:22
Speaker
And depending on which cut of use, so 10, 15%, generally speaking, is the cut of use in response to a fluid challenge.
00:19:30
Speaker
So after the administration of
00:19:34
Speaker
250 mils or 4 mils per kilogram of intravenous fluids, your cardiac output or stroke volume goes up by 10-15%.
00:19:41
Speaker
And we generally speaking, translates fluid responsiveness to improve tissue perfusion.
00:19:52
Speaker
Now, that is clearly not going to be the case anymore.
00:19:56
Speaker
under all circumstances.
00:19:59
Speaker
We tend to use fluid responsiveness, at least from a macro circulatory perspective, because it's something that we can measure, be it from the stroke volume calculator on an echocardiography, or if you've got some cardiac output monitors, such as the swan GANS, or less invasive devices.
00:20:18
Speaker
That's what we think fluid responsiveness is.
00:20:21
Speaker
And therefore we think if I make the, if I
00:20:25
Speaker
give fluids to this fluid-responsive patient, tissue perfusion will be better.
00:20:30
Speaker
It's obviously very difficult to measure tissue perfusion per se, and so we rely on surrogates, lactate, central venous saturations, capillary refill time, if you have time, we can discuss that later on.
00:20:45
Speaker
But just because you are fluid-responsive doesn't mean you need fluids.
00:20:51
Speaker
So you and I sitting here having our chat, we may not have had a drink of water, a cup of tea in the last hour or so, and if we did any fluid responsiveness tests on either of us, I'm sure we're going to be fluid responsive.
00:21:06
Speaker
However, if we then look at markers of tissue perfusion, our markers of kidney injury, our lactates, so on and so forth, I'm pretty sure we are okay, Sergio.
00:21:19
Speaker
We're going to be okay.
00:21:21
Speaker
So just because you're fluid responsive doesn't mean you need fluids.
00:21:26
Speaker
I've mentioned cardiac output as sort of the benchmark in terms of assessing fluid responsiveness.
00:21:34
Speaker
But there are other parameters that we could use.
00:21:36
Speaker
Some people have used this diameter of the inferior vena cava.
00:21:41
Speaker
I think it's probably incorrect to use mean arterial pressure, urine output, although that's easily done by the bedside, because strictly speaking, we're looking at how the heart responds, how the circulation responds to that fluid challenge.
00:21:57
Speaker
Does that make sense?
00:21:58
Speaker
It does, and I think that the point you made, which is an important one, is to reemphasize is that just because you're fluid responsive doesn't mean that you require or that we should be giving you fluid, right?
00:22:11
Speaker
I think that has been, I think the two things that I have noticed in practice is that first, a lot of times people are not measuring for fluid responsiveness, which is
00:22:21
Speaker
It's another story.
00:22:22
Speaker
But when they use a dynamic hemodynamic measurement to look for it, they immediately equate that with more fluid.
00:22:29
Speaker
And we spend a lot of time thinking of a kind of upstream, right?
00:22:35
Speaker
Upstream impact or effects.
00:22:38
Speaker
But we don't really think about what's happening downstream, which is where the harm's being done.
00:22:43
Speaker
And we need to be more balanced in our approach.
00:22:50
Speaker
So with regard to fluid overload, now all of us probably, it's been drilled into us since day one medical school.
00:22:56
Speaker
If you give too much fluids, you're facing a patient who acutely becomes short of breath in full-blown primary edema.
00:23:02
Speaker
That's obviously one, the extreme end of what might happen.
00:23:07
Speaker
We know there are numerous studies out there that if you are in positive fluid balance after 48 hours on the intensive care unit, your outcomes are poorer.
00:23:18
Speaker
and outcomes include mortality, but also morbidity.
00:23:23
Speaker
So you spend more time on a ventilator, you spend more time on the intensive care unit, you have a higher incidence of complications, so on and so forth.
00:23:33
Speaker
But we know too much fluids is a bad thing.
00:23:35
Speaker
It's not just the lungs, it's all the other organ systems as well.
00:23:41
Speaker
So it's the liver, the gut, the brain, so on and so forth.
00:23:45
Speaker
So it is not just a cardiovascular system that sees the impact of too much fluid.
00:23:54
Speaker
The term fluid tolerance is a relatively new one.
00:23:59
Speaker
And essentially, it is the degree at which the body can handle the fluid without having
00:24:09
Speaker
organ dysfunction becoming evident.
00:24:12
Speaker
So in the same way as palmar edema is a measure of how the lungs are not coping, fluid tolerance just expands that concept to the other organ systems, the kidneys, the gut.
00:24:27
Speaker
Again, declaration of interest.
00:24:29
Speaker
I have a clinical research interest in the kidney, so that's the focus of
00:24:34
Speaker
my clinical practice at this moment in time and my research practice time.
00:24:38
Speaker
But simplistically, fluid tolerance is the degree at which the system, the body, copes with fluids without any evidence of organ dysfunction.
00:24:49
Speaker
And it is interesting how we've evolved over the last decades, right?
00:24:54
Speaker
I mean, I still remember practice long enough where you would almost think that peripheral lower extremity edema was just basically collateral damage.
00:25:05
Speaker
That's what you see in these patients in the ICU.
00:25:07
Speaker
If they got into pulmonary edema, a lot of times if they're still sick, you would just say, okay, that's an indication for intubation to keep giving fluids, right?
00:25:20
Speaker
And that we really did not see what was going on underneath the skin.
00:25:24
Speaker
You talk about the kidney, but obviously we've learned a lot about it.
00:25:28
Speaker
intra-abdominal hypertension and compartment syndrome and how that can also impact the kidney and impact other structures, even to the point where I think we've all recognized that we've had patients in the ICU for a long time who were quite encephalopathic and not waking up.
00:25:46
Speaker
And once you start diuresing them, all of a sudden, I mean, they...
00:25:51
Speaker
start waking up, right?
00:25:52
Speaker
So even at the CNS level, I think we've seen these effects.
00:25:55
Speaker
And I think that's really what we're trying to prevent, right?
00:25:59
Speaker
To use the concept of fluid tolerance to try to manage patients in a way that we don't get to those kind of very advanced organ failures that were precipitated by the overuse of this drug of intravenous fluids.
00:26:14
Speaker
So
The ROSE Framework for Fluid Management
00:26:15
Speaker
as we dive a little bit deeper into fluid tolerance, Adrian, can you tell me a little bit about how you think of the determinants of fluid tolerance?
00:26:23
Speaker
So I think the way I use it on a daily basis in my clinical practice is to think about fluid tolerance both from the palmary perspective and then the systemic perspective.
00:26:36
Speaker
The palmary perspective, because that's more or less drilled into us, you know, too much fluid, palm reedema.
00:26:43
Speaker
Okay.
00:26:43
Speaker
Okay.
00:26:44
Speaker
With regard to the other organ systems, the systemic side of things, I think my practice has evolved tremendously with the evolution of point of care ultrasound.
00:26:54
Speaker
So in my practice, I scan patients a lot, not just the heart.
00:27:01
Speaker
as can the lungs and more recently the abdomen and the venous circulation.
00:27:05
Speaker
So if we start with the lung first, we know that lung ultrasonography is superior to clinical examination and chest radiograph when it comes to detecting palm edema, consolidation, plurifusion.
00:27:21
Speaker
It's a relatively quick, non-invasive examination.
00:27:25
Speaker
So I use that to give me an idea of how wet the lungs are in the correct clinical context.
00:27:32
Speaker
With regard to the other organ systems, those of us who practice ultrasound would have undoubtedly heard of the VEXA score that was published two, three years ago now by colleagues in Canada.
00:27:49
Speaker
And the principle of the VEXA score is to quantify or examine the venous side of the circulation.
00:27:56
Speaker
For too long now, we generally speaking have just been focusing on the arterial side of circulation.
00:28:01
Speaker
What's the mean arterial pressure?
00:28:02
Speaker
What's the systolic blood pressure?
00:28:05
Speaker
And really with the venous side, we tend to be restricted by the fact that we've just got the CVP.
00:28:11
Speaker
But William and colleagues basically use ultrasound.
00:28:16
Speaker
And by performing Doppler analysis of the hepatic portal infrarrenal vein, in combination with the inferior vena cava, they tried to quantify and score the degree of venous congestion.
00:28:34
Speaker
And that led to the development of something called the Vexus score.
00:28:39
Speaker
An increasing VEXIS score is associated with poorer kidney outcomes in that original patient population, which was the post-cardiac surgery population.
00:28:49
Speaker
But the evidence base for the use of VEXIS is rapidly expanding.
00:28:57
Speaker
It's a tool that's out there.
00:28:58
Speaker
I don't think we know when the best time to use this tool, how to use this tool quite yet, but it's a rapidly evolving field, so keep an eye on it.
00:29:09
Speaker
And in terms of a, of a tolerance, I think that one, one of the, the, the issues, right.
00:29:16
Speaker
Is that we don't think about a lot of the duration and deescalation timing.
00:29:22
Speaker
Right.
00:29:22
Speaker
And this hopefully helps you, helps you limit that, that, that, that timeframe and initiate that, that phase a little bit quicker.
00:29:31
Speaker
Is that how you use it at the bedside when you think about this?
00:29:35
Speaker
I've reached a stage in my career where I constantly think about the fact if there's a bag of fluid hanging up there, I ask myself and the team, why is it up there?
00:29:46
Speaker
Because if you buy into the principle that intravenous fluids are drugs, and all drugs have got their side effects, first do no harm.
00:29:55
Speaker
So I constantly find myself asking, why is that bag of fluid out there?
00:30:00
Speaker
Is there too much fluid on board?
00:30:02
Speaker
So asking myself that question, and only by asking myself that question do I start thinking about possible solutions.
00:30:11
Speaker
Is it time now to take fluid away, be it from using diuretics, so LASIK furuzumide?
00:30:19
Speaker
Or if this patient is on renal replacement therapy, should I be setting fluid balance targets towards the negative side now?
00:30:29
Speaker
One of the frameworks that has been popularized in this context of people who obviously are doing the research and talking about this is the ROSE framework.
00:30:40
Speaker
I think there's others similar, but I think the concept is
00:30:44
Speaker
is the same.
00:30:46
Speaker
And the idea of really incorporating these four Ds into an algorithm for practice that's easy to remember.
00:30:54
Speaker
So could you talk about that in detail and kind of walk us through each phase?
00:30:59
Speaker
What does ROES signify?
00:31:00
Speaker
But then also talk to us in terms of not only how do we do it, what the best practice says, but how do you do it and how do you implement this at the bedside?
00:31:10
Speaker
Okay.
00:31:10
Speaker
So ROES stands for R for resuscitation.
00:31:14
Speaker
O for optimization, S for stabilization, and E for evacuation or de-escalation.
00:31:24
Speaker
The way I use it is that whenever I see a patient at the bedside on the ward in the emergency department, I ask myself, okay, where is this patient with regard to these different phases?
00:31:37
Speaker
Is it in the resuscitation optimization phase?
00:31:40
Speaker
Or if this patient has been on the intensive care unit for a number of days, is this patient towards the evacuation end of that spectrum?
00:31:48
Speaker
So if I start off with resuscitation
00:31:52
Speaker
So resuscitation is the life-saving phase.
00:31:55
Speaker
You're trying to rescue the patient.
00:31:57
Speaker
So early, adequate fluid management needs to be given.
00:32:01
Speaker
So, for example, if you have the surviving sepsis guidelines, they recommend 30 meals per kilo in the first hour or multiple fluid boluses.
00:32:11
Speaker
Four meals per kilo tends to be the standard fluid bolus given in across five to ten minutes or so.
00:32:19
Speaker
to use fluid boluses more so small aliquots of fluids given give reassess give more reassess so your triggers to starting this phase sort of this is a patient in shock essentially so you've got a mean arterial pressure that's barely recordable you get a patient who's drowsy and if you've got any test of
00:32:43
Speaker
fluid responsiveness, there will be fluid responsiveness.
00:32:45
Speaker
You've got evidence of malperfusion, so the lactate is up, the central venous saturations are down, your cardiac index and cardiac output is down, so on and so forth.
00:32:54
Speaker
So that's a resuscitation phase, so this is a patient really sick, you need to rescue them.
00:33:02
Speaker
Once you've administered some fluids and you've
00:33:06
Speaker
bought yourself a bit of time, then it becomes optimization.
00:33:10
Speaker
And this is about trying to rescue the organs and avoiding fluid overload.
00:33:17
Speaker
So this is a time where your advanced cardiac output monitoring goes in, your
00:33:22
Speaker
echocardiography comes in, your various different tests of perfusion, be it biochemical or physiological, so your lactate, your cardiac index, your pulse pressure variation, you've hopefully cited arterial lining.
00:33:39
Speaker
So that's the optimization phase.
00:33:42
Speaker
Now, the stabilization phase is this is when the patient is getting better.
00:33:48
Speaker
You know, you've got them to a state where their blood pressure and their organ perfusion are all reasonable.
00:33:57
Speaker
This is the phase that I think that most people are saying to themselves, well done team, we've managed to save this one.
00:34:04
Speaker
They're slowly on the mend.
00:34:06
Speaker
So the antibodies are kicking in, they're recovering post-operatively or whatever it may be.
00:34:11
Speaker
But this is, I think, is the phase where if you are complacent, you take your eyes off the ball, you start letting the fluid creep happen.
00:34:21
Speaker
The positive fluid balance that was, you know, 500 mils here and there suddenly becomes three, four liters over the couple of days before you realize it.
00:34:29
Speaker
So this is the phase, I think.
00:34:31
Speaker
certainly for me, is the one I lose sight of and I try to remind myself, okay, are we approaching the E phase, the evacuation phase, where now you think actually we're reaching the stage where the positive fluid balance is starting to have a detrimental effect on the patient.
Complexities of Fluid Management
00:34:50
Speaker
And I should be thinking about resolving the fluid overload in order to improve the
00:34:57
Speaker
organ perfusion, and that is by achieving negative fluid balance in whatever form that you want to think of, whatever means you're thinking of and available to you.
00:35:07
Speaker
So diuretics or renal replacement therapy.
00:35:12
Speaker
So let's dive a little bit deeper in some of these.
00:35:13
Speaker
I'll ask you some questions, but that was a great, great overview, Adrian.
00:35:18
Speaker
And when we're thinking of the resuscitation phase, right, I think you mentioned that a lot of times clinically, it's very easy or very likely that we can predict if someone's going to be fluid responsive, right?
00:35:30
Speaker
When you meet a patient,
00:35:32
Speaker
who is hypotensive, tachycardic, presents to the ED or to the ICU briefly with a raging infection, septic shock, we know that if you give them fluid, they're going to be fluid responsive.
00:35:45
Speaker
Now, if we were to measure fluid responsiveness, like you said, it doesn't mean that being fluid responsive means that you need fluid, but at that stage,
00:35:54
Speaker
which might be creeping into the optimization stage.
00:35:57
Speaker
If we were to measure at one point flu responsiveness and they're not flu responsiveness, that should be a sign to pause, right?
00:36:05
Speaker
And think a little bit what we're doing because I think that people sometimes still get fluid.
00:36:11
Speaker
So I think you're absolutely right.
00:36:13
Speaker
I think the first thing I would say is that all the fancy tests that we do or have up our sleeves, it doesn't replace your clinical examination and your clinical acumen.
00:36:26
Speaker
So as a practitioner of ultrasound, I say to myself more often than not, don't treat the image, treat the patient.
00:36:34
Speaker
That's the first thing I would say.
00:36:36
Speaker
I think the next thing I would say with regard to giving fluids in those situations is that
00:36:48
Speaker
fluid responsive you give fluids and nothing happens don't keep giving fluids I see it quite a lot in my years of training that okay I've given 250 500 mils of a fluid challenge nothing happens so I'm going to get more and I keep going I keep going I keep going I think it's if something hasn't gone according to plan or what isn't what you expect it to happen then I think it's a reminder to just stop think and
00:37:17
Speaker
Have you got the right diagnosis?
00:37:21
Speaker
Have you got the right treatment?
00:37:24
Speaker
Am I causing harm?
00:37:26
Speaker
So those are the things that crossed my head if I was faced in that scenario.
00:37:30
Speaker
And there's also this concept, obviously, of ebb and flow, right?
00:37:34
Speaker
And it's not like you are an R and all of a sudden you're an O and you remain an O because patients have ongoing inflammation with many of these diseases, right?
00:37:45
Speaker
So you might get to a point where you don't need additional fluids, but 24 hours later, 12 hours later, for many reasons, that patient might need an additional fluid and just recognizing-
00:37:58
Speaker
recognizing that that that it's kind of like it's not like a clear cut right we kind of are can you talk a little bit more about that concept i think i think one of the thing great things i enjoy about intensive care medicine is that it's such a dynamic place patients change hour by hour day to day and i think that when you see the patient just because the strategy worked
00:38:25
Speaker
an hour, two hours ago or a day ago.
00:38:27
Speaker
It doesn't mean that it's still going to work.
00:38:30
Speaker
So this constant
00:38:32
Speaker
going to the bedside, examining a patient, evaluating the patient, making a plan, and after you've done what you think was the right thing to do, vasopressors or fluid or whatnot, go back and reassess.
00:38:44
Speaker
I think sometimes when we prescribe, coming back to the core topic around fluid, we give fluids and when we walk away, well, and by the time you come back, it may be a couple of hours,
00:38:56
Speaker
You know, that fluid bolus that you gave, that fluid you've administered, you've lost sight of what it actually did.
00:39:04
Speaker
So you're completely right in the sense that things change with the patient day by day, hour by hour.
00:39:11
Speaker
And the take-home message is go back and reassess, go back and reassess.
00:39:16
Speaker
Do something, make a decision, go back and reassess.
00:39:20
Speaker
Has it worked?
00:39:20
Speaker
Has it not worked?
00:39:21
Speaker
Is it beneficial or has it caused harm?
00:39:25
Speaker
The other aspect that I was thinking and wanted to ask you about, Adrian, is there is a point where giving fluid will still help raise the blood pressure, but you're probably at an inflection point where it also will start causing harm.
00:39:40
Speaker
How do you think about that?
00:39:42
Speaker
I mean, the fact that even it gives you the physiologic effect that you are looking, I think raising the blood pressure would just be maybe a surrogate for...
00:39:53
Speaker
for fluid responsiveness, but there's a point maybe where you're seeing signs of harm or considering the fluid tolerance concept that probably, even though it might help your hemodynamics, the right answer at that point is not giving
Tools for Assessing Fluid Tolerance
00:40:08
Speaker
more fluid.
00:40:08
Speaker
Can you talk a little bit about that?
00:40:11
Speaker
Yeah, and I think this is where the concept of fluid tolerance that's emerged over the last couple of years has really made me sit up and think a lot more because we tend to think of...
00:40:23
Speaker
fluid tolerance and fluid responsiveness as one as a start point all the way to the other end of fluid unresponsiveness and fluid intolerance almost like it's almost like a straight line but um more so
00:40:41
Speaker
So we think about fluid tolerance and fluid responsiveness on one side, and then all the way to the other side, fluid intolerant and fluid unresponsive, almost like a straight line joining up between these two dots, if you will.
00:40:55
Speaker
But there is reasonably good evidence emerging, certainly from colleagues such as Glenn Hernandez of the Andromeda trial, and then other South American colleagues, for example, Munez, who's talked about the fact that you can be...
00:41:11
Speaker
fluid intolerant and yet be fluid responsive and you can also be fluid tolerant and also fluid unresponsive.
00:41:22
Speaker
So now you've got four phenotypes, if you will.
00:41:26
Speaker
The tolerant-responsive and the intolerant-unresponsive are obviously the ones that seem obvious to everyone.
00:41:35
Speaker
And then what's emerging now is that the other two states.
00:41:39
Speaker
So
00:41:40
Speaker
fluid-responsive and yet fluid-intolerant, and fluid-unresponsive and fluid-tolerant.
00:41:51
Speaker
And I think that just reflects the complexity of the circulation hemodynamics and what we thought we understood about it.
00:41:59
Speaker
So it's the field that's gradually emerging.
00:42:02
Speaker
The evidence and studies are only starting to emerge, but you are right.
00:42:06
Speaker
The way I tend to work it is, okay,
00:42:10
Speaker
This patient may be fluid responsive using whatever test I choose to use, but yet on my assessment of fluid tolerance, the risk benefit now swings towards the side of the degree of harm is a much more real possibility.
00:42:30
Speaker
So perhaps in this patient, I am not going to give any more fluids.
00:42:36
Speaker
I'm going to stick with vasopressors or a wait and see or whatnot.
00:42:40
Speaker
I hope that makes sense.
00:42:42
Speaker
Yeah.
00:42:42
Speaker
And I think it's a great illustration of the complexities of this topic, but of any topic related to critical care in medicine.
00:42:53
Speaker
And I think it...
00:42:56
Speaker
it really invites us to be a lot more humble, right?
00:43:00
Speaker
And to really appreciate that we really understand very little of what we do and how these complex systems such as a biological system interact.
00:43:11
Speaker
are are things that we're just basically understanding i think the very very surface of it but but but i like this i love this discussion adrian because i think that a lot of clinicians would assume that ivy fluids is just a it's an easy topic it's just something we just do right but when you start really peeling the layers of this onion it starts getting really really interesting
00:43:35
Speaker
You know, I am old enough to remember when I graduated from medical school that in terms of fluid balance and fluid strategies, you gave two litres of normal saline and one litre of dextrose.
00:43:49
Speaker
You know, it's a balance of sweet and salty and you change it up in between.
00:43:53
Speaker
And the more I progressed in my career, the more I realised how little I knew then and how little I know now about something as...
00:44:03
Speaker
core, as fundamental as fluids.
00:44:05
Speaker
So since we graduated from medical school, you could prescribe fluids.
00:44:09
Speaker
You couldn't do the same for chemotherapy agents or anything like that.
00:44:13
Speaker
But fluids, go knock yourself out.
00:44:15
Speaker
Everyone, knock yourself out.
00:44:19
Speaker
So we used to say, I mean, when you finish medical school, you're 007, right?
00:44:24
Speaker
License to kill.
00:44:26
Speaker
And maybe the most accessible tool was fluids at that time.
00:44:31
Speaker
Yeah, but it just, I think when you reach the stage where you realize that you don't know everything and you may have caused harm with what your practice is, it's truly a time to reflect on what you know.
00:44:45
Speaker
And I think more importantly, what you don't know.
00:44:46
Speaker
And there's a lot we don't know in medicine and intensive care.
00:44:49
Speaker
For sure.
00:44:50
Speaker
And one of the themes that keeps coming up over and over again on the podcast as I speak with colleagues and experts from around the world is that at the end of the day in medicine,
00:45:00
Speaker
there is probably more value in having the right questions than having the right answers, right?
00:45:06
Speaker
And really thinking at the bedside and asking the questions.
00:45:08
Speaker
And the question I want to dive in right now is, at what point do you say, okay, it's time to de-escalate and to de-resuscitate or to get into that evacuation phase?
00:45:20
Speaker
And how do you proceed then?
00:45:23
Speaker
Okay, so I think this is a fascinating one, and I've been trying to answer that question in my own practice for the last couple of years.
00:45:28
Speaker
There was a very fascinating study by colleagues in Belfast, Jonathan Silversides, who essentially surveyed clinicians, presented scenarios, the fluid overloaded, fluid access patients.
00:45:42
Speaker
What would they do?
00:45:43
Speaker
And the take-home message across all the various parameters and questions given was that there is huge amount of variability in terms of what clinicians would do, in terms of what indicators they would use, what parameters they would use to indicate, I'm going to start taking fluid off.
00:46:00
Speaker
And then subsequently, a lot of variability in terms of how you would achieve that negative fluid balance.
00:46:05
Speaker
So a bolus of LASIK, an intravenous infusion of LASIK.
00:46:10
Speaker
You put them on renal replacement therapy, so on and so forth.
00:46:14
Speaker
I wish I could say to you that if you did de-resuscitation, your patients will do better.
00:46:19
Speaker
The trials just aren't out there.
00:46:23
Speaker
A recent systematic review by colleagues based in Switzerland have basically shown that.
00:46:28
Speaker
However, in all the trials that looked at de-resuscitation versus conventional therapy,
00:46:34
Speaker
the intervention arm and the control arm, there was never really a significant separation between the groups in terms of the fluid balance.
00:46:44
Speaker
Hence, that might be why we didn't see the outcome that we would have liked to have seen.
00:46:50
Speaker
So putting it all together, what I do in my practice, I ask myself, okay, is this patient appropriately resuscitated?
00:46:59
Speaker
Is there any evidence of organ malperfusion?
00:47:04
Speaker
Is there any evidence of fluid access?
00:47:10
Speaker
Is there any signs of venous congestion?
00:47:15
Speaker
If the answer, I work through that in a sort of like a checklist fashion, and the answer is yes, the patient is appropriate resuscitation.
00:47:22
Speaker
There's no evidence of organ dysfunction at this moment in time.
00:47:27
Speaker
No, yes, there's starting to be evidence of fluid access, be it
00:47:32
Speaker
In the lungs, in the tissues, in the kidneys, yes, there is evidence of venous congestion on, say, ultrasound.
00:47:41
Speaker
And if the patient has no ongoing vasoactive drug requirement or significant vasoactive drug requirement, then I would think about de-resuscitating them.
00:47:54
Speaker
So that, generally speaking, is my approach to it.
00:47:58
Speaker
Some colleagues would advocate if they're no longer fluid responsive, you could start de-resuscitating them then.
00:48:06
Speaker
My personal opinion is that there are tools, easily available tools out there to give you that extra layer of security just beyond the question, is this patient fluid unresponsive responsive?
00:48:19
Speaker
But there's also probably a role for implementing dynamic measures as you resuscitate them, right?
00:48:26
Speaker
Could you use them in the reverse way to say, okay, I'm getting to a point where there's a good point?
00:48:31
Speaker
Can you talk about that a little bit?
00:48:33
Speaker
Yeah, so one of the strategies that they put forward is that generally speaking, well, the traditional speaking, as we talked about earlier, was that these patients who are fluid intolerant are going to be fluid unresponsive.
00:48:47
Speaker
So if you de-resuscitate them to the point, you know, they become fluid responsive,
00:48:53
Speaker
regardless of what your parameters you use.
00:48:56
Speaker
So that's one way of gauging how much you can de-resuscitate.
00:49:02
Speaker
The other way, which I think is a nicer way of doing it, is with using the VEXA score, which we briefly talked about.
00:49:09
Speaker
So we know there are several studies out there that show us that in patients who have a high VEXA score, so multiple sites of venous congenital
00:49:21
Speaker
a de-resuscitation strategy, these scores will track.
00:49:27
Speaker
In the same way as we know from colleagues in mostly from the nephrology, but also in critical care world, if you have a wet set of lungs on ultrasound and you start de-resuscitating, evacuating them, you can assess them again and track their lungs going from a wet state to a dry state.
00:49:49
Speaker
So yes, there are other tools available out there to help you fine tune how much fluid to remove or what period of time.
Reflections on Clinical Practice
00:49:57
Speaker
Perfect.
00:49:57
Speaker
As we close the clinical discussion, Adrian, are there any major pitfalls and pearls that you could share with us?
00:50:06
Speaker
I've already said my number one take-home message was just because you're fluid responsive doesn't mean you need fluids.
00:50:11
Speaker
That's the first thing.
00:50:12
Speaker
Definitely is my one take-home message from this.
00:50:15
Speaker
I suppose the other pearl is to keep
00:50:19
Speaker
Your eyes, ears, peel for the evolving evidence base, certainly when it comes to fluid tolerance.
00:50:28
Speaker
I think the concept of fluid responsiveness is more or less established now across critical care and acute specialties, but I think the concept of fluid tolerance is less well established.
00:50:37
Speaker
And my sincere hope over the next couple of years, both in terms of the clinical side of things and the research side of things, is that that concept of fluid tolerance, the degree of harm, becomes more widespread and it becomes part and parcel of our daily discussions by the bedside.
00:50:57
Speaker
Excellent.
00:50:57
Speaker
And I think that as pitfalls, obviously, it would be the converse of your number one message, which is don't give fluid just because they're fluid tolerant and they're fluid and responsive, right?
00:51:09
Speaker
That would be kind of like the pitfall that we obviously see.
00:51:12
Speaker
Is there anything in particular that you're really, I mean, I think you mentioned some of the things that seems that you're quite excited about the evolving research and studies on the concept of fluid tolerance and how to apply this at the bedside.
00:51:26
Speaker
But are there other large clinical trials that we should be paying attention to coming up in the upcoming year?
00:51:34
Speaker
I think I'm aware of certainly looking at, there are a few trials looking at a more conservative fluid strategy when it comes to various different clinical conditions, but also more specifically when it comes to more conservative fluid strategies, the use of
00:51:52
Speaker
tools to assess the venous side of the circulation, ultrasound being the most obvious ones, is starting to be part of the newer clinical trials.
00:52:00
Speaker
So, for example, if I'm going to de-resuscitate someone, more often than not, it's just a urine output, weight-based outcome or guide.
00:52:11
Speaker
But now we're seeing trials being published or methodologies of trials being published where they are looking at more of
00:52:19
Speaker
dynamic parameters assessments of to guide the research station.
00:52:24
Speaker
So that's quite exciting.
00:52:26
Speaker
Excellent.
00:52:27
Speaker
So we'd like to close the podcast, Adrian, with a couple of questions that are unrelated to the clinical topic.
00:52:33
Speaker
Would that be okay?
00:52:35
Speaker
Yeah.
00:52:36
Speaker
The first question relates to books.
00:52:38
Speaker
Are there any, a book or books that have influenced you significantly or books that you have gifted often to other people?
00:52:46
Speaker
Okay, so there are two books.
00:52:49
Speaker
So the first book is, I expect most of your listeners will have heard about it, is Daniel Kahneman's Thinking Fast, Thinking Slow.
00:52:56
Speaker
And the reason why I love this book is because over the years, I've been fascinated by decisions.
00:53:06
Speaker
In other words, why healthcare professionals do the things that they do?
00:53:13
Speaker
For example, if you go back to the initial topic of fluid, why do you give fluid?
00:53:18
Speaker
What made you give the fluid?
00:53:21
Speaker
Is it more often than not, it's pattern recognition, it's the way we've done things, it's our bias.
00:53:27
Speaker
And I find Dan Economan's book, Thinking of Artings, so fascinating to help me answer that question.
00:53:33
Speaker
The second book I'm going to recommend is aligned with my interest with regard to fluid stewardship.
00:53:42
Speaker
And that is Simon Sinek's Start With The Why.
00:53:46
Speaker
How do you get a team working together with a common goal?
00:53:53
Speaker
And I find this book really, really insightful in terms of the slanty of the human mind.
00:54:01
Speaker
How do you get teams to work as a team?
00:54:05
Speaker
that unified sense of purpose, that unified goal.
00:54:09
Speaker
So, yep.
00:54:10
Speaker
So those two books are the ones I probably mentioned and influenced me the most in the last couple of years.
00:54:17
Speaker
Awesome.
00:54:17
Speaker
And we definitely will include those in the show notes, links to those books, and both are excellent reads.
00:54:24
Speaker
I think Thinking Fast and Thinking Slow, like you said, really an amazing book, giving us insights into cognition, right, and how we think and how we make decisions.
00:54:36
Speaker
Yeah.
00:54:37
Speaker
We do all the time in the ICU, but we're never metacognition.
00:54:41
Speaker
There's no metacognition thinking about how we think, right?
00:54:44
Speaker
So I think this is perfect.
00:54:45
Speaker
And definitely Simon Sinek, I think, is a very gifted communicator.
00:54:50
Speaker
And the golden circles and the start with white concept, I think, is a great framework to apply to patients.
00:54:56
Speaker
to everything, right?
00:54:57
Speaker
I mean, even to your own life, you could say, I mean, what is my why?
00:55:01
Speaker
And we'll definitely include those.
00:55:02
Speaker
And I encourage our listeners, if you have not read these books, absolutely, you should, because you're not going to regret it.
00:55:10
Speaker
The second question, it relates to, I think that the greatest sign of intelligence is when we can change our minds, right?
00:55:18
Speaker
When we can admit that we were wrong and move on and learn.
00:55:23
Speaker
So could you share something you changed your mind about over the last couple of years?
00:55:28
Speaker
So I have recently just come back from spending a week in Milan talking about patient safety in a fellowship organized by the European Society of Intensive Care Medicine.
00:55:39
Speaker
And over the years, aligned with my interest in healthcare decisions is the concept of clinical governance.
00:55:46
Speaker
So how do we get colleagues or how do we encourage colleagues to do the right thing?
00:55:54
Speaker
And when I started my training, my intensive care career, I remember thinking that clinical governance is just one of those tick box exercise.
00:56:05
Speaker
It's a bureaucratic paperwork.
00:56:08
Speaker
It's there to stop me being the clinician that I can be.
00:56:13
Speaker
And over the last few years, since I became a consultant, I think the importance of clinical governance has been underlined
00:56:22
Speaker
So many times through either a patient adverse safety event or clinical audits or service evaluation, how do we build a framework such that healthcare practitioners who go to turn up for work and want to do the right thing can do the right thing in order to achieve the best possible outcome for our patients?
00:56:44
Speaker
So from seeing this clinical governance as a negative bureaucratic thing,
00:56:51
Speaker
I'm not saying that it's definitely a positive thing.
00:56:54
Speaker
I've recognised now the importance of it and how we operationalise the term clinical governance and how important it is to delivering the best possible care for our patients.
00:57:07
Speaker
I think that's a very important point and definitely something that a lot of times, unfortunately, because of how it's structured, has a negative connotation for our colleagues.
00:57:19
Speaker
But you're right.
00:57:21
Speaker
It serves a very important why.
00:57:23
Speaker
And the question is, how do we make it work towards that why?
00:57:27
Speaker
And also as an enhancement of our practice.
00:57:29
Speaker
Agreed.
00:57:30
Speaker
100% agree.
00:57:32
Speaker
The final question, Adrian, is what would you want every listener to know?
00:57:36
Speaker
It could be a parting thought, fact, a quote, anything you want to leave our audience with to think about.
00:57:44
Speaker
So when I first got into critical care practice, one of my wise professors said, sat us all of the new trainees fellows down, sat us all of us down and said, ladies and gentlemen, just because you can doesn't mean you should.
00:58:04
Speaker
And he followed up this
00:58:07
Speaker
immortal line with a quote from Professor Dunstan, who is a professor of theology and moral ethics from the University of London, and it reads, The success of intensive care is not, therefore, to be measured only by the statistics of survival, as though each death were a medical failure.
00:58:28
Speaker
It is to be measured by the quality of life preserved or restored, and by the quality of the dying of those in whose interest it is to die.
00:58:37
Speaker
and by the quality of human relations involved in each death.
00:58:42
Speaker
So I have this sort of pinned in multiple notebooks around the place just to remind myself of the why, if you will.
00:58:52
Speaker
Adrian, that's a good death can be a good outcome.
00:58:54
Speaker
Absolutely.
00:58:55
Speaker
And I think that is something that we should all think about and is a perfect place to stop.
Closing Remarks and Call to Action
00:59:03
Speaker
I really appreciate you taking the time to share your expertise with us.
00:59:08
Speaker
Learned a lot and look forward to having you back on the podcast soon.
00:59:14
Speaker
Thank you very much.
00:59:14
Speaker
It's been a real pleasure.
00:59:17
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:59:20
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:59:26
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:59:31
Speaker
To learn more, visit www.soundphysicians.com.