IFA Talks

Context and Setting

• John Downham is hosting a live webcast or social media feed from the International Fluid Academy 2018 conference. They are updating virtual attendees about streaming quality, ongoing conference events, and future content plans.

Main Discussion Points

1. Technical Setup and Streaming Quality

   • The speaker acknowledges that the video is "choppy" and they are adjusting recording settings on the fly to improve the streaming experience. They invite feedback from viewers via Facebook, Twitter, or Periscope regarding any ongoing technical issues.

2. Conference Updates and Agenda

   • The conference is currently on a coffee break after the morning sessions.

   • A live stream of the conference is available on the International Fluid Academy website, allowing viewers to watch all talks and post-session discussions in real time.

3. Plans for Speaker Interviews and Podcasts

   • The speaker is attempting to bring conference speakers up to the "social media hub" for interviews or informal chats.

   • All these conversations will eventually be produced as podcasts, extending the conference's educational content to a broader audience.

4. Social Media Hub Setup

   • The speaker refers to this space as the "social media hub," explaining that they're working to keep everyone informed in real time.

   • They mention juggling camera angles and positioning ("looking over my shoulder") to optimize the video setup.

Key Takeaways

1. Technical Issues Are Being Addressed: The host is transparently troubleshooting streaming problems and soliciting user feedback to improve the video feed's quality.

2. Multiple Access Points for Conference Content:

   • Live Streaming: Full sessions and Q&A segments can be viewed via the International Fluid Academy website.

   • Social Media: Viewers can follow updates on platforms like Facebook, Twitter, and Periscope.

   • Podcasts: Recorded interviews and session highlights will be released later in an audio format.

3. Engagement Encouraged: The host repeatedly asks the audience to report any streaming troubles and to follow along on social media, indicating a focus on interactive participation.

Closing Note

The transcript offers a behind-the-scenes glimpse of how the conference is being broadcast and the speaker's efforts to engage a virtual audience. By directing viewers to different platforms (website, social media, and future podcasts), they ensure maximum accessibility and help maintain an active community around the International Fluid Academy event.

Participants and Setting

1. Host/Interviewer (introduced as David Lyness, Social Media Chair)

2. Guest (introduced as Dr. John Mackenney) – An intensivist and self-described "physiology geek"

They are at an event called "five 2018" (likely another fluid-focused conference or session in 2018), discussing topics such as physiology, fluid management, and research trials. The exchange also references prior sessions on these subjects.

Main Discussion Themes 1. Previewing "the Next Session" and Conference Updates

• The transcript begins with a brief question: "What's the next session on?"

• The answer mentions "things... basically like in the meantime… updates"—suggesting that multiple sessions are covering new developments or "updates" in fluid management and critical care.

2. Introducing Speakers and Their Roles

• David Lyness introduces himself as the social media chair for the event, indicating he is responsible for engagement, possibly live-tweeting or sharing updates.

• Dr. John Mackenney is described as someone with a deep interest in physiology, aligning with the broader theme of how physiological principles guide real-world ICU decisions (e.g., fluid choices, monitoring strategies).

3. Guyton's Physiology and CVP—Challenges in Modern Practice

Although less detailed than in the first transcript, Dr. Mul Kenney still touches on:

• Misinterpretations of CVP (Central Venous Pressure): A single CVP value (e.g., 15 mmHg) doesn't necessarily distinguish between fluid overload, poor cardiac function, or other hemodynamic issues.

• Applying Classical Physiology: The conversation references translating Guyton's Model into pragmatic, modern-day critical care. This includes understanding the interplay of:

  • Venous return

  • Right atrial pressure

  • Cardiac output

  • Systemic vascular resistance

4. Randomized Controlled Trials vs. Practical Implementation

• The speakers briefly re-emphasize that relying solely on RCT data may not always give the full picture. Overly rigid trial designs sometimes fail to capture real-world nuances—particularly for dynamic interventions like point-of-care ultrasound (POCUS) or individualized fluid management.

• They note that negative trials can erode confidence in valuable tools (like POCUS) if those trials are underpowered or poorly designed.

5. Pulmonary Artery Catheter (PAC) Analogy

• As in other discussions from the same conference, there is a cautionary parallel to pulmonary artery catheter use. Decades ago, PACs were widely adopted, then fell out of favor after large RCTs showed no definitive survival benefits.

• The speakers suggest the same pattern could happen with POCUS or other monitoring tools if studies fail to capture nuanced clinical application or are misinterpreted.

6. Importance of Contextual Clinical Judgment

• Both participants stress that physiology must be integrated with clinical reasoning:

  • A high or low CVP reading must be considered alongside a patient's cardiac function, vascular tone, and overall fluid status.

  • Similarly, POCUS should be applied by trained clinicians who can interpret ultrasound findings within the broader clinical scenario.

7. Closing Remarks

• The transcript ends with the host wrapping up and hinting at returning to the ongoing conference sessions. There's also a lighthearted question: "Can my mom see this?", implying the content might be posted or streamed online.

Key Takeaways

1. Continued Emphasis on Multifaceted Assessment

   • Just like the previous transcript, this discussion reinforces that no single number (e.g., CVP) can dictate fluid management. Context and trends are paramount.

2. RCTs vs. Real-World Nuance

   • Large trials are vital but not always definitive in fluid therapy or advanced monitoring. Understanding why a trial might fail—poor design, low recruitment, heterogeneity—prevents discarding potentially useful tools (e.g., POCUS).

3. Value of Bedside Tools, Used Wisely

   • Pulmonary artery catheters, point-of-care ultrasound, and advanced hemodynamic monitors can be immensely helpful when used in the right clinical context, rather than merely following protocol-driven thresholds.

4. Physiology Remains Foundational

   • The conversation underscores that knowledge of Guyton's principles—venous return, vascular tone, stressed vs. unstressed volume—remains crucial for understanding CVP (and other parameters) in a critically ill patient.

5. Ongoing Need for Balanced Communication

   • Conferences and social media chairs (like the host) can bridge the gap between research, clinical practice, and real-world updates so that important nuances (e.g., how to interpret negative trial results) aren't lost.

Concluding Note

This dialogue reiterates the significance of integrating classical physiology with modern technology and evidence. While new trials, devices, and protocols proliferate, the speakers caution against one-size-fits-all interpretations of CVP or "negative" study results. The overarching theme remains: to optimize fluid management and critical care decisions, clinicians should combine robust physiological understanding with contextual, patient-specific assessment—rather than relying on any single metric or study alone.

Participants

1. Dr. Catherine Benny – Surgery resident at the University of Washington in Seattle (USA).

2. Dr. Johnny Wilkinson – Intensivist from Northampton, UK, and founder of Critical Care Northampton.

3. Dr. Manu Malbrain – Intensivist from Brussels, Belgium, and founder of International Fluid Academy Days.

They are at the 2018 International Fluid Academy Day in Amsterdam, discussing challenging topics in fluid management and perioperative care.

Main Discussion Points 1. Interpreting Declining Hemoglobin Values

• Context After major surgery (or in an ICU setting), clinicians often track hemoglobin or hematocrit levels to detect potential bleeding. However, a drop in hemoglobin can stem from two main causes:

  1. Ongoing blood loss (e.g., surgical bleeding or trauma)

  2. Hemodilution (from fluid administration)

• What the speakers say

  • Dr. Malbrain points out that relying on a single hemoglobin value to diagnose bleeding versus dilution is unreliable. In stable dialysis patients, you can sometimes interpret hemoconcentration or dilution from hematocrit because the fluid shifts are more controlled. But in surgical or trauma patients—especially those receiving rapid fluids or who might be actively bleeding—hemoglobin alone does not give a clear picture.

  • Multiple Parameters: He suggests correlating hemoglobin trends with:

    • Hemodynamic parameters (heart rate, blood pressure, mean arterial pressure)

    • Volumetric measures of preload (for example, advanced hemodynamic monitoring)

    • Point-of-care ultrasound

    • Bioelectrical impedance analysis (to look at total body water and fluid distribution)

  • Dr. Wilkinson reiterates that you want to look at trends rather than a single measurement. A sudden drop could indeed be concerning for active bleeding, but slow changes might just reflect fluid shifts, sampling frequency, or lab variation.

2. IVC Collapsibility and Fluid Responsiveness

• Context Point-of-care ultrasound (POCUS) is commonly used to assess volume status by looking at the inferior vena cava (IVC)—specifically, how it changes with respiration. In spontaneously breathing patients, IVC collapsibility (or distensibility) can be an indicator of fluid responsiveness. However, this can be heavily confounded by factors like:

  • Mechanical ventilation

  • High PEEP (positive end-expiratory pressure)

  • Low tidal volumes

  • Right heart failure

  • Increased intra-abdominal pressure

• What the speakers say

  • Dr. Wilkinson emphasizes that in the presence of high PEEP, altered lung mechanics, or increased abdominal pressure, IVC measurements become "entirely useless," at least as a sole measure of fluid responsiveness. He warns against focusing on just one parameter (e.g., IVC diameter) when multiple physiologic and machine-related factors can distort the reading.

  • The takeaway: IVC ultrasound can still be helpful in relatively stable or spontaneously breathing patients, but in a complex ICU scenario with mechanical ventilation and high PEEP, it should not be used on its own to guide fluid management.

3. The Importance of a "Holistic" View

• Both Dr. Malbrain and Dr. Wilkinson keep coming back to the point that a single value—whether it's hemoglobin, hematocrit, or IVC measurement—cannot reliably guide fluid or transfusion decisions in isolation.

• A patient's fluid status and/or bleeding risk should be inferred from multiple data points, including clinical exam (heart rate, blood pressure, capillary refill, etc.), continuous monitoring (CVP or advanced hemodynamic monitoring), imaging (POCUS, chest X-ray if needed), and laboratory trends (serial hemoglobin measurements, lactate, base deficit, etc.).

4. Practical Application

• For a patient who is post-op in the ICU and has a dropping hemoglobin, the clinicians would:

  1. Check for active bleeding (e.g., drains, wound sites, clinical stability).

  2. Review fluid input to see if it might have caused dilutional changes.

  3. Correlate with vital signs, ultrasound findings, and any advanced monitoring data.

  4. Look at sequential trends in hemoglobin/hematocrit rather than making a decision based on a single-point drop.

Brief Summary

In this short exchange, Drs. Benny, Wilkinson, and Malbrain highlight the pitfalls of relying on one-dimensional measures—like hemoglobin trends or IVC ultrasound—to guide fluid and transfusion decisions. They emphasize:

• The need for trend analysis (multiple data points over time) rather than single-point values.

• The value of combining parameters from clinical assessment, ultrasound, hemodynamic monitors, and advanced measurements (e.g., bioimpedance) to accurately gauge whether a patient is bleeding or simply experiencing fluid-induced hemodilution.

• The limitations of IVC collapsibility in mechanically ventilated patients, especially with high PEEP or other complicating factors (right heart failure, increased abdominal pressure).

Ultimately, the conversation stresses an integrated, multimodal approach to patient assessment in critical care and perioperative settings, rather than placing too much faith in any single measurement tool.

🎤 Live from IFAD 2017 – A Conversation with Dr. Xavier Monnet

We caught up with Dr. Xavier Monnet, who delivered a compelling session today on fluid challenges in critically ill patients.

🗣️ Xavier, what was the key message of your talk?

*"I spoke about the importance of testing for preload responsiveness—especially in complex patients like those with sepsis. Before administering fluids, we need to assess whether they will actually be effective.

The traditional fluid challenge has a major flaw—it inherently induces fluid overload. So instead of fluid challenges, we should be performing preload challenges using tools like the passive leg raising test."*

💡 It's a shift in mindset—from "give and see what happens" to "test before you treat."

🧠 Why don't more clinicians apply this approach?

"Doctors tend to be conservative. It's often easier to just give fluids than to evaluate responsiveness. But with complex patients, we really need to be more thoughtful, and focus on the physiology. They deserve a more precise approach."

🙌 Thanks to Dr. Monnet for sharing his insights—and for encouraging us to practice smarter fluid therapy.

📍 #IFAD2017 #FluidTherapy #PassiveLegRaising #CriticalCare #FOAMed

🎤 Live from IFAD 2017 – Talking Fluid Physiology with Dr. Tom Woodcock

Hi again! We're still going strong at IFAD, and I'm here with Dr. Tom Woodcock, who's been diving deep into fluid dynamics and stirring some healthy debate.

🗣️ Tom, what did you talk about this morning?

"I introduced the audience to the Steady-State Starling Principle, a new way of thinking about fluid therapy—especially why fluids sometimes don't behave the way we expect them to. It's a shift from traditional textbook physiology to something more consistent with what we actually see in practice."

🥪 And after a solid scientific session?

"A lovely European lunch!"

🌍 Is this your first time at IFAD in Antwerp?

"Yes! I've visited Antwerp before but never managed to attend the meeting—so I'm really glad I finally made it this year."

💬 You mentioned on Twitter that not everyone in the audience was convinced?

"Yes—I had a bit of a heckler who didn't believe in the Steady-State Starling Principle and said it was dangerous to discuss it. I eventually gave up trying to convince him on the spot."

So, for everyone watching online—can you explain, in a sentence, why it matters?

🧠 Tom:

"It's real because if you read the larger randomized controlled trials and look at how patients actually respond to fluid therapy, those responses align with the Steady-State Starling Principle—not with the outdated physiology still taught in many medical schools. So if you're planning fluid therapy, use the paradigm that matches reality—because your patients will respond accordingly. It's really that simple."

👏 Thanks so much, Tom—and for those curious to learn more, stay tuned throughout the day and be sure to check out his work online.

📍 #IFAD2017 #FluidTherapy #StarlingPrinciple #CriticalCare #FOAMed

🎤 Live from IFAD 2017 – ECMO Insights with Tamas

We caught up with Tamas, who made quite the journey to get here—from Wales, by motorbike, no less!

🏍️ "It was about 400 miles, but luckily it stayed dry the whole way," he said with a smile.

So what's been the highlight so far?

🩺 "I attended the Beginners ECMO Course this morning. It's designed for people either starting an ECMO service or wanting to understand the basics. I've referred many patients for ECMO in the past, so I wanted to better understand what actually happens on the other side."

🧠 The morning sessions covered:

• Basic ECMO concepts: how it works, different modalities

• Fluid management in ECMO: still a field largely guided by clinical judgment due to limited data

• A fascinating point on sedation: "I didn't know that ECMO significantly increases drug clearance—you often need to up the doses to maintain adequate sedation. That was completely new to me." While some centers are exploring awake ECMO, it's still quite rare.

🔧 Hands-on practice?

"Yes! We had a cannulation session this morning and there's more to come this afternoon. We're working with actual ECMO machines from a couple of supporting companies. It's great to get familiar with the different systems and setups."

👏 Thanks to Tamas for sharing your experience—and for going the extra mile (or 400!) to be here.

📍 Follow more updates from #IFAD2017 #ECMO #CriticalCare #FOAMed #HandsOnLearning #FluidAcademy

🎤 Live from IFAD 2017 – Interview with Dr. Ruth Kleinpell, President of the Society of Critical Care Medicine (SCCM)

We had the pleasure of catching up with Dr. Ruth Kleinpell, who just delivered a talk at IFAD 2017 on a topic that resonates across ICUs worldwide: appropriate lab testing in critical care.

🧪 Ruth, what was the focus of your presentation?

"My talk was centered on the need to rethink routine practices in the ICU—particularly daily lab testing and daily chest X-rays, which are often ordered out of habit rather than necessity."

Dr. Kleinpell highlighted the Choosing Wisely campaign, launched in 2012, which encourages medical societies to identify tests or procedures that may be overused. In response, the Critical Care Societies Collaborative—including the American Thoracic Society, CHEST, SCCM, and the American Association of Critical-Care Nurses—developed a list of five key practices to reconsider in ICU care.

🚨 At the top of that list?

"The routine use of inappropriate lab testing—daily blood draws that don't always contribute meaningfully to patient care."

She noted that post-op order sets often default to daily labs without individual clinical justification.

🩻 What about chest X-rays?

"There are still facilities routinely performing daily chest radiographs, even when they may not be necessary. It's not just about reducing patient exposure to radiation—it's also about cost-conscious, evidence-based care."

🧠 The takeaway message? It's time for critical care teams to reassess automatic orders and move toward more thoughtful, patient-centered testing.

🙏 Thank you, Dr. Kleinpell, for sharing this important message with the IFAD community.

📍 Follow more from #IFAD2017 #CriticalCare #ChoosingWisely #SCCM #HighValueCare #FOAMed

🎥 Live from the International Fluid Academy Days (IFAD) 2017! Welcome to the IFAD Live Stream, where we'll be bringing you interviews, conversations, and behind-the-scenes moments with some of the incredible faculty and delegates joining us here in Antwerp.

Joining me now is the always engaging Ross Fisher, who's speaking later today.

🗣️ Ross, what will you be talking about?

Ross Fisher:

"As ever, I'll be talking about presentation skills. There's very little I can add to the core clinical science of the International Fluid Academy—except to say that salt water is for cooking pasta!

But seriously, my goal is to help some of the incredibly clever people here understand that great ideas need great delivery. It's not enough to just give a talk that ends when the slides do—your message needs to live beyond the room. And that's where presentation skills come in."

🎯 Well said. We've already seen some amazing presentations—some memorable for their brilliance, and others... let's just say, memorable for different reasons. But that's part of the learning curve, right?

Ross:

"Diplomatic." 😉

👏 If you've got suggestions for who you'd like to see on this live stream, send them our way via Twitter!

📱 Follow the conversation with #iFAD2017 📡 Stay tuned—more live moments coming your way soon.

🎤 Still going strong at IFAD 2017! I caught up with Matt Rowland to see what he's most excited about today.

🗣️ Matt:

"I'm really looking forward to Ross Fisher's 'Talk Like TED' workshop this afternoon. I think it's going to be absolutely brilliant."

🎤 Are you speaking today?

Matt:

"Nope, not this time—I'm here purely as a delegate, just soaking up all the knowledge. And honestly, it's been fantastic to finally put Twitter handles to real-life faces!"

🧠 That's what IFAD is all about—learning, connecting, and sharing ideas beyond the screen.

📍 Stay tuned for more updates from #IFAD2017 #FOAMed #MedicalEducation #TalkLikeTED #CriticalCare

🎤 Live from IFAD 2017 – Interview with Conference Organizer Prof. Manu Malbrain

🎬 "Okay, ready? Three, two, one..."

Hi everyone! We're here live at the International Fluid Academy Day 2017, and I'm joined by the conference organizer himself, Prof. Manu Malbrain.

🗣️ So Manu, what's the key message from the conference this year?

Manu:

"The core message is simple but powerful: Fluids should be treated as drugs. Just like antibiotics, we must think about fluids in terms of indication, type, dose, duration, and eventually, de-escalation."

💉 He draws a parallel with the Four D's of antibiotic therapy:

1. Drug – Choose the right fluid: crystalloids, glucose, colloids, or blood.

2. Dose – It depends on the context:

   • For resuscitation, you might give 30 ml/kg in 3 hours (per Surviving Sepsis Campaign), though that may be too much or too little depending on the patient.

   • For maintenance, the dose is often around 1 ml/kg/h, equaling 20–25 ml/kg/day.

3. Duration – Fluids shouldn't just continue indefinitely.

4. De-escalation – Just as you reduce antibiotics when appropriate, fluids need stopping or active removal when no longer needed.

🌟 Manu adds that we also need to consider the Four Indications for fluid therapy:

• Resuscitation

• Maintenance

• Replacement (e.g., for losses via vomiting or diarrhea)

• Nutrition – "We often forget that nutrition is also a fluid!"

🎓 This year, IFAD has successfully brought together fluid experts, nutritionists, and stewardship advocates. In addition to workshops on antibiotic stewardship, there's now a strong push for fluid stewardship—the idea that every ICU should have a dedicated steward overseeing fluid therapy.

"And maybe in the future, we'll also see sepsis management stewardship too."

🗓️ So Manu, what are you most looking forward to today?

Manu:

"Well, it's Friday—so definitely the gala dinner tonight! And I'm looking forward to meeting the Mayor of Antwerp. He might even show up for a selfie—he's quite the character. Look him up!"

🎉 Thank you, Manu, for your time and all the work you've done to make IFAD 2017 such a fantastic event.

📍 #IFAD2017 | #FluidStewardship | #CriticalCare | #FOAMed