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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 66-68

Beneficial effects of negative fluid balance in preventing global increased permeability syndrome of septic shock patient


1 Department of Anesthesiology and Intensive Care, Fatmawati Hospital, Jakarta Pusat, Indonesia
2 Trainee of Anesthesiology and Intensive Care Department, Faculty of Medicine, University of Indonesia, Jakarta Pusat, Indonesia

Date of Submission08-Jan-2020
Date of Decision28-Jan-2020
Date of Acceptance11-Feb-2020
Date of Web Publication11-May-2020

Correspondence Address:
Dr. Marilaeta Cindryani
Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya No. 5, Senen, Jakarta Pusat
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_3_20

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  Abstract 

Fluid is considered a successful tool for resuscitation based on the worldwide guideline for sepsis since 2001. However, recent publications have studied of a deleterious effect of overload in fluid resuscitation. Overload is suggested to contribute to many severe complications such as acute respiratory distress syndrome, acute kidney injury, and higher mortalities. About more than 10 years later, another theory emerged and successfully changing the whole paradigm. Sometimes we need to resuscitate, sometimes we need to hold, and sometimes we need to evacuate. Our patient had several advantages from a negative fluid balance to prevent deteriorating conditions.

Keywords: Fluid balance, fluid overload, resuscitation, sepsis


How to cite this article:
Taufik M A, Irawany V, Cindryani M. Beneficial effects of negative fluid balance in preventing global increased permeability syndrome of septic shock patient. Bali J Anaesthesiol 2020;4:66-8

How to cite this URL:
Taufik M A, Irawany V, Cindryani M. Beneficial effects of negative fluid balance in preventing global increased permeability syndrome of septic shock patient. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Jul 13];4:66-8. Available from: http://www.bjoaonline.com/text.asp?2020/4/2/66/284179


  Introduction Top


Rivers et al.[1] reported and recommended the early goal-directed therapy in 2001, we have been in full compliance of guidelines, which were made to compile and set up the management of sepsis and its complications. Almost 20 years, the art of giving fluid is still in good adherence to that protocol, not only in septic patients but also in every supposed to be in compromising hemodynamic status.

In 2017, Malbrain et al.[2] proposed a concept about resuscitation, optimization, stabilization, and evacuation, and the third-hit concept, which emphasized the roles of an intertwined and continuous process in the human body against sepsis natural history. They came up with the idea of evacuating fluids after a certain period of time. The main reason behind this is the increased permeability of the vascular system, caused by mediators and endotoxin released throughout the body. This will lead to global increased permeability syndrome (GIPS), in which the given fluid will leak out from the vascular and accumulate in interstitials.[2],[3],[4]


  Case Report Top


Our 64-year-old female patient, 55 kg, admitted to the intensive care unit (ICU) after decreased consciousness approximately 48 h postsurgery. She underwent laparotomy for fistulae repair after having surgery due to ovarium cancer. On presentation, we found her in a state of septic shock, acute respiratory distress syndrome, hypercoagulable state, and acute kidney injury (AKI).

Our yearly teachings taught us that fluid would be the first in mind and that was a crystalloid bolus 20–30 ml/kg/h. However, another question would arise, how much and how long would we give fluid bolus for this patient? Furthermore, she had then showed signs of AKI, with urine production of 10 ml/3 h. Rivers guideline instructed us to administer a certain volume of fluid based on hemodynamic status, without any limits, which could stop and tell us, the patient is already overloaded with fluid.


  Discussion Top


Our patient would have been in severe “catecholamine” storm. There were massive changes involving macrocirculation and microcirculation as well. Mediators would already be released and seriously affected hemodynamic and vascular systems. We could not only rely on clinical presentations but also on several parameters that need to be confirmed vice versa. We should need tailored de-catecholamine strategies to purify the blood, remove metabolites, mediators in replacing unresponsive kidney.[2],[3],[4]

Hemofiltration was chosen based on its ability to filter the patient's blood in swinging hemodynamic status. It also removes mediators continuously. The supposed-to-be-overload fluid that was given during the resuscitation period could be evacuated while restoring and maintaining the intravascular volume.[4],[5],[6]

As seen in the kidney function curve [Figure 1], the ureum level was increased around 24–48 h after the incident, but the creatinine level was not reassuring. Electrolyte profiles [Figure 2] were also not convincing in the early phase, which could suggest high efforts from the patient to maintain her acid-base equilibrium, even in a shocking state.
Figure 1: Kidney function curve

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Figure 2: Electrolyte profile

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We started the hemofiltration technique using continuous veno-venous hemofiltration (CVVH) postdilution method and adsorbent. At first, we were targeting for removing overload interstitial fluid without significant hemodynamic perturbation [Figure 3]. At least 50 ml/h of periodic fluid removal was recorded. The highest level was around 80 ml/h, and the process was continued for the next 24–48 h [Figure 4].
Figure 3: Clinical presentation

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{Figure 4}

She showed signs of progression in the following 12 h. We continued the periodic fluid removal using CVVH, and we increased it to 180–200 ml/h [Figure 5]. The next day, we were maintaining similar modes and periodic fluid removal to get 100–180 ml/h, and the hemodynamic status showed more progressions [Figure 6]. On the 4th day, we were getting aggressive with approximately 2500 ml was evacuated and then suggesting that the organ functions were resolved, we were discontinuing the CVVH on the 5th day of treatment [Figure 7] and [Figure 8].
Figure 5: Continuous veno-venous hemofiltration day 2

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Figure 6: Continuous veno-venous hemofiltration day 3

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Figure 7: Continuous veno-venous hemofiltration day 4

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Figure 8: Continuous veno-venous hemofiltration day 5

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Overall crude status monitoring of daily fluid could also be seen from the daily body weight records [Figure 9]. Our ICU beds are equipped with the bodyweight estimated calculator, which could predict the body weight status in daily observation in the ICU. The patient started to gain weight of about 4 kg after she was treated in ICU. Fluid overload is considered whenever there is a weight gain for more than 10% of baseline body weight, and it was quite dangerous not to do any interventions to return it to the baseline level. Considering limited oral supplementation in the ICU based on patient sedated condition, it was reasonable to assume that weight gain was caused by overload.[3],[5],[6]
Figure 9: Daily body weight curve

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Fluid therapy is considered a two-sided blade and by blindly giving resuscitation fluid in a septic patient with compromised kidney function could only lead to worsening the problems. GIPS might not be apparent in our patient, but she already suffered from vascular leakage and permeability disturbances added with circulating pro-inflammatory mediators. These problems need to be solved first to reduce the hyperdynamic and hypercatabolic virtues and maintain vital filtrating organ to regain its function.


  Conclusion Top


The extracorporeal filtration technique would not play its role at its best without evacuative protocol aimed to reach a negative fluid balance. Further insights and developments should be sought related to evacuation and negative balance limitations and targets; nevertheless, the negative balance process is not a harmful concept but rather an option to be considered to take in patients with vascular compromising status.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgement

We obtained consent from the patient for the possibility of future publications regarding her case, as long as we do not reveal any identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.  Back to cited text no. 1
    
2.
Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: A systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 2014;46:361-80.  Back to cited text no. 2
    
3.
Malbrain ML, van Regenmortel N, Saugel B, de Tavernier B, van Gaal PJ, Joannes-Boyau O, et al. Principles of fluid management and stewardship in septic shock: It is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care 2018;8:66.  Back to cited text no. 3
    
4.
Duchesne JC, Kaplan LJ, Balogh ZJ, Malbrain ML. Role of permissive hypotension, hypertonic resuscitation and the global increased permeability syndrome in patients with severe hemorrhage: Adjuncts to damage control resuscitation to prevent intra-abdominal hypertension. Anaesthesiol Intensive Ther 2015;47:143-55.  Back to cited text no. 4
    
5.
O'Connor ME, Prowle JR. Fluid Overload. Crit Care Clin 2015;31:803-21.  Back to cited text no. 5
    
6.
Benes J, Kirov M, Kuzkov V, Lainscak M, Molnar Z, Voga G, et al. Fluid therapy: Double-edged sword during critical care? Biomed Res Int 2015;2015:729075.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 1], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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