HOW DO I MANAGE FLUID OVERLOAD;

PHARMACOLOGICAL DE-RESUSCITATION

Yohanes George
WHEN SHOULD DE-RESUSCITATION BEGIN?
• DE-RESUSCITATION SHOULD BE CONSIDERED WHEN FLUID OVERLOAD AND FLUID
ACCUMULATION NEGATIVELY IMPACT END-ORGAN FUNCTION.
• DE-RESUSCITATION IS MANDATORY IN A CASE OF A POSITIVE CUMULATIVE FLUID
BALANCE IN COMBINATION WITH:
• POOR OXYGENATION (P/F RATIO < 200),
• INCREASED CAPILLARY LEAK (HIGH PVPI > 2.5 AND EVLWI > 12 ML KG-1 PBW),
• INCREASED IAP (> 15 MM HG) AND HIGH CLI
WHEN SHOULD DE-RESUSCITATION BEGIN?
 EBB PHASE: AFTER RESUSCITATION
FLUID OVERLOAD
Lung Edema: PaO2/FiO2, prolong weaning
ACS: Abd Compartment Syndrome

KDIGO 3 OR UNSTABLE HEMODYNAMIC, KDIGO 1-2 AND STABLE

HYPERKALEMIA, UREMIA AND ACIDOSIS HEMODYNAMIC

DIURESIS RESPONSIVENESS:
FUROSEMIDE STRESS TEST; BOLUS LASIX 1-1.5/Kg

+ if urine >200ml/2 Hours

DERESUSCITATION DERESUSCITATION
NON-PHARMACOLOGY (HD-CRRT) PHARMACOLOGY (DIURETIC)

FLOW PHASE:
FLUID MOBILISATION:
Creatinin , Diuresis 
Edema resolution
Weaning ventilation
 DOKUMEN ACUTE DIALYSIS QUALITY INITIATIVE
(ADQI) XII TAHUN 2014
Protokol deresusitasi yang aman dengan mengunakan:
1. Target endpoint physiology
1. target klinis (resolusi edema, perbaikan oksigenasi paru)
2. Target fluid balans 24 jam – 1 Liter (20%)
2. Target safety perfusion.
1. lactate darah
2. Target fungsi ginjal, peningkatan ureum dan creatinin <25% dan
3. Target perubahan Na < 4 mmol/L.
Sebagai contoh jika target klinis dan fluid balance belum tercapai namun
target keamanan perfusi dan ginjal masih dalam batas aman maka
deresusitasi di lanjutkan, namun jika target klinis dan fluid balance belum
tercapai namun target kemanan perfusi atau fungsi ginjal mulai di lewati
maka deresusitasi di stop.

S. Goldstein, S. Bagshaw, M. Cecconi, M. Okusa, H. Wang, J. Kellum, M. Mythen and A. D. Shaw for the ADQI XII Investigators
Group. Pharmacological management of fluid overload. British Journal of Anaesthesia 113 (5): 756–63 (2014).
Target balance negatif belum tercapai, Lasik  RRT
masih edema, oksigenasi masih buruk

Lactate > 1, Creatinin naik >25%,

Na naik > 4 mmol/L
Stop lasik 
fluid terapi?
CASES STUDIES;
 Dry is
better?

Day 4 ICU Day 7 ICU

Day 1 ED

A Novel strategy of
resuscitation for
severe capillary
leakage
syndrome??Severe
Dengue
haemorrhagic fever.

1.Resuscitation
phase (12 hours):
Blood components +
500 ml of alb 5%.

2.Conservative fluid
removal 2nd day,
furosemide drip with
target %FO<10%.

3.No hyperoncotic alb

has been given,
albumiin level as a
marker of index
permeability will
recover when
permeability was
improved. Is the
negative fluid balance
improve the
permability?
ICU RSPI – PRE-ELIMINARY
DE-RESUSCITATION STRATEGY TARGETING LOW CENTRAL VENOUS
PRESSURE IN POST LAPAROSCOPIC APPENDECTOMY WITH SEVERE
SEPSIS AND FLUID OVERLOAD
Forty six-years old patient admitted to the Emergency Department with severe sepsis ec
intra abdominal infection due to acute appendicitis complicated with acute kidney
injury and disseminated intravascular coagulopathy (DIC). After receiving significant
fluid resuscitation and antibiotic (meropenem 3x2 gram and metronidazole 2x1
gram), he underwent laparoscopic appendectomy and admitted to ICU.
On arrival, he was sedated and ventilated, with signs of tissue hypoperfusion (anuria,
lactate was 8.3 mmol/l). Circulation was supported by noradrenaline (0.12
μg/kg/minute) and dobutamine (5 μg/kg/minute). The patient had a low dynamic
compliance of the respiratory system (CRS value) 28 ml/cmH2O with a PaO2/FIO2
ratio up to 160, dilated IVC and significant B-lines. His cumulative fluid balance prior
to ICU admission was positive, up to 2700 ml.
Furosemide infusion was started 2 hours later, aiming to achieve a negative fluid
balance of up to 1000-2000 ml/24 h and CVP 0-2mmHg. Sustained low-efficiency
dialysis (SLED) was also initiated due to increasing sCr and Ur. SLED and furosemide
infusion continued up to full stabilization of the renal function in the patient. The
patient was discharged to the ward on 5th day
CVP
Active de-resuscitation strategy applied to four patients, was targeted to achieve CVP of
0-2 mmHg.

• Pt A, 46 yo man post laparatomy due to app perforation with

severe intraabdominal infection with AKIN 1-2
• Pt B, 58 yo man post cardiogenic shock due to anterior MI with
AKIN 3 complicated sepsis pneumonia
• Pt C, 12 yo kid post laparatomy exp due to app perforation with
AKIN 1-2.
• Pt D, 10 yo kid post resusitation from Dengue Shock Syndrome
complicated sepsis pneumonia with AKIN 1-2.

Lowering CVP with furosemide drip infusion 0.1 mg/kg/hr will increase venous return
by increasing the gradient pressure between CVP and MCFP.
 CONCLUSION
• The dosage and timing of pharmacological fluid measures may depend upon the
relative level of Fluid Overload, the targeted and actual rates of active fluid
removal and underlying kidney function.
• In a patient fully resuscitated from septic shock with intact kidney function,
urine output may be adequate to allow early tapering or discontinuation of
pharmacological measures.
• In urgency case, the rate of fluid removal, prompting clinicians to plan a more
rapid fluid removal trajectory, perhaps with the use of extracorporeal therapy.
• An active pharmacological de-resuscitation strategy based on the achievement
of negative fluid balance is a safe and effective procedure that resulted in
improvement in hemodynamics, serum lactate, renal function and also systemic
oxygenation