"What you do now—you cut it through." As you do, you'll see a tiny portion of the anterior mitral leaflet, particularly the A2 segment, and just behind it, a glimpse of the posterior leaflet. This is one of the foundational skills we teach in the Point-of-Care Ultrasound (POCUS) Beginners Course at the IFAD Fluid Academy Meeting.

I am Adrian Wong from UK, and I am the course director for this POCUS course, which I helped organize to include both didactic lectures and hands-on sessions. The goal is to give novices a solid introduction to bedside ultrasound—scanning the heart, lungs, abdomen, and vascular system—essential tools in modern critical care.

And yes—Kuma Rinrich! I finally had the pleasure of meeting you here in Europe!

Most of today’s attendees are complete beginners in point-of-care ultrasound. Many are from Belgium, and they’ve come to develop a skill that is rapidly becoming essential in daily clinical practice. We're helping them build confidence through structured teaching, followed by interactive scanning sessions where they get to apply the concepts in real time.

One key concept we emphasize is the phenomenon of foreshortening—something as simple as rotating the probe just slightly can dramatically alter the image and lead to misinterpretation. That’s why both technique and anatomical understanding are crucial.

I believe this is a very important congress. While the word "fluid" is in the title, the IFAD meeting is about much more than fluid therapy—it brings together experts across the spectrum of critical care medicine. Still, fluid remains one of the cornerstones of critical care, and this event provides a platform to debate and dissect its use in real-world clinical practice.

Fluid management has always been controversial—what type of fluid should we give, how much, when, and when should we take it off? These are basic yet vital questions. And because fluid administration is one of the most common interventions in medicine, it often doesn’t receive the scrutiny it deserves. That’s why meetings like IFAD are so valuable. They provide space not only to review the evidence but also to debate our practices, challenge assumptions, and improve patient care.

Hi, I am Mervyn Singer from UK. There’s been a lot of hype in the literature lately—claims that sepsis incidence is rising, but at the same time, mortality is declining. That sounds like good news, but it’s worth taking a closer look.

In my talk, I explored the impact of the Sepsis-3 definitions, which were introduced in February 2016. Now, with more than 20 months of clinical experience and research using these new criteria, we’re starting to see how they’ve influenced clinical practice, research design, and epidemiological reporting.

One of the key drivers of change—particularly in the United States—is incentivization. There’s a financial motivation to code patients as having sepsis rather than, say, pneumonia, because sepsis often brings higher reimbursement rates. This naturally has implications for how cases are classified and reported.

But to me, the most important contribution of Sepsis-3 lies in the consistency it provides. Finally, we have a shared language. Before Sepsis-3, the definitions were vague and inconsistent. Terms like “severe sepsis” or “septic shock” were often interpreted differently across institutions and even individual clinicians. This lack of standardization led to wide variation in reported incidence and mortality—making it difficult to compare data or draw meaningful conclusions.

Now, with the newer criteria, we’re seeing much greater homogeneity. Mortality rates reported from different countries are strikingly similar, which suggests we’re finally capturing more accurate and comparable data. That’s a solid foundation from which to build future research and clinical strategies.

I am Daniel Lichtenstein from France. Which ultrasound equipment do we recommend? Actually—none. Every doctor tends to be happy with their own device. If you prefer a laptop-based system, go for it. Personally, since 1992, I’ve been using a simple, reliable machine with a universal probe—a single transducer capable of scanning the entire body. And that’s more than enough.

Today's lecture was particularly fascinating for me. I'm typically invited to speak about lung ultrasound, especially the BLUE protocol. But this time, I had the chance to explore the broader application of ultrasound in the management of ARDS and sepsis.

Of course, I talked about the lung, using the BLUE protocol. But I also covered septic shock, focusing on the FALLS protocol, especially the round FALLS protocol. This comprehensive approach allows you to scan the entire body, helping identify septic foci and enabling the earliest possible diagnosis.

I also addressed the therapeutic applications of the FALLS protocol—specifically how lung ultrasound can guide fluid management, helping clinicians decide when to give fluids and when to stop. This integration of diagnostic and therapeutic guidance is what makes critical care ultrasound so powerful.

Take, for example, the C-profile. It's simply the detection of lung consolidation on the anterior chest wall. Yet this simple sign can provide vital information.

If I could share one key message, it would be this: Use the simplest equipment—that same magic universal probe—and scanning the whole body becomes incredibly easy. In fact, you’ll find that critical care ultrasound becomes more accessible and intuitive when using a minimalistic approach.

The BLUE protocol also asks you to examine the veins. You’ll quickly rule out venous thrombosis. Then, returning to the posterior lung fields, you complete the assessment—rapidly and effectively.

I travel a lot and have attended many congresses around the world. I can confidently say that this is a high-level event, bringing together world-class experts. My sincere congratulations to Manuel Brun for organizing such a strong meeting. Being among these experts gives me the wonderful feeling of being part of the family.

This project is still very much in its conceptual stage—what one might call in the mind of God. But we've had a chance to explore a potentially game-changing idea: using renal signals to assess our volemic status. In other words, letting the kidney “judge” whether the patient is adequately filled or not.

Everything in this discussion revolves around fluid management—fluid physiology, fluid therapy—one of the oldest and most persistent challenges in intensive care medicine.

If there’s one key message to take from this journey through fluid management, it’s this: Be a doctor first, not just a follower of computer-driven protocols.

You need to understand the underlying physiology to tailor therapy to each individual patient, avoid exposing them to unnecessary risk, and ultimately apply common sense in your decision-making.

Contrary to popular belief, I don’t think 80% of ICU patients have true kidney problems. However, the use of mechanical ventilation with positive pressure almost inevitably leads to fluid retention. The clinical challenge during this time is not to overdo fluid administration, but to find the right balance—a reasonable compromise.

Some degree of fluid retention is unavoidable. Like many things in medicine, both extremes—too much or too little—can be harmful. So again, the message is clear: be a doctor, use your brain, and apply common sense.

As for congresses like this one—I believe they’re incredibly valuable. Often, what we label a “keynote failure” is not a failure at all; it’s actually the keynote working, challenging us to rethink our assumptions.

A good congress doesn’t just deliver answers—it sparks new questions and rekindles curiosity. And I believe this is one of those congresses. A strong faculty, a genuinely engaged audience, and a carefully curated selection of topics make this an excellent forum for learning and exchange.

I am Lui Forni from UK. As a nephrologist, I can tell you with confidence: sodium is bad for you. If you look at the Yanomami Indians in South America, who have one of the lowest sodium intakes in the world, you’ll notice something fascinating. Their systolic blood pressure rarely exceeds 80 mmHg, hypertension is virtually nonexistent, and they almost never die from coronary artery disease.

Recently, I was invited to speak about the rationale behind blood purification technologies and techniques—a topic that spans traditional modalities like CVVH (Continuous Veno-Venous Hemofiltration) and CVVHD (Continuous Veno-Venous Hemodialysis), as well as newer, more targeted approaches such as endotoxin-absorbing polymers. It was intended as a broad overview of potential strategies for managing septic shock in critically ill patients.

A key area I covered—one that’s particularly close to my own clinical interests—involved blood purification in sepsis. The most important takeaway? Understanding this field requires a framework I refer to as the Johari Window, a concept that might sound familiar from Donald Rumsfeld’s “known knowns” and “unknown unknowns” speech.

Here’s how it applies:

• The known knowns: We know that sepsis and septic shock are highly complex, dysregulated inflammatory conditions.

• The known unknowns: We don’t yet know which patients will truly benefit from blood purification, when to initiate therapy, or how long to continue it.

• The unknown unknowns: These are the gaps in our understanding we haven’t even identified yet—and that’s precisely why ongoing research is so essential.

Currently, we have what I believe to be the most comprehensive meta-analysis available on this topic—but I can assure you, with recent developments like the EUPHRATES trial, many more studies will be published in the next 6 to 12 months.

This is my first time attending the International Fluid Academy Congress, and I have to say—it’s a fantastic experience. The atmosphere is interactive, friendly, and intellectually stimulating. Unlike those massive congresses with 6,000 or 7,000 participants, where you often feel like just another face in the crowd, this meeting—with around 500 attendees—makes you feel like a valued member of a vibrant community. It’s a great place to connect, collaborate, and discuss cutting-edge science.

We need better classifications for ARDS. Definitions must always reflect underlying pathophysiology and, importantly, they should guide our treatment decisions. Unfortunately, the current definitions often fall short in this regard. However, incorporating parameters like extravascular lung water might help bridge that gap.

It’s also essential to remember that fluids are drugs—they come with indications, contraindications, and potential adverse effects. It's not just about the type of fluid; we must also consider the dose. Giving too much or too little can be harmful. Next is the duration—if a patient is no longer fluid responsive, we must stop administering fluids.

The final step is de-escalation. That doesn’t just mean stopping fluid administration, but in some cases, it involves active, even aggressive, fluid removal. These principles form the Four Ds of fluid therapy: Drug, Dose, Duration, and De-escalation.

Over the years, the International Fluid Academy Days (IFAD) have grown into a key event, unique in its comprehensive focus. It's the only meeting that brings together experts on fluid therapy and hemodynamic monitoring in a single platform.

Thank you so much, Rob, for this outstanding talk. You’ve highlighted some truly important points that we should keep in mind when drafting protocols for future research.

When it comes to fluid therapy, the number four appears again and again:

• There are four key questions to answer.

• We need to understand the four phases of shock.

• Think of the four main indications for fluid therapy.

• Fluids are drugs, and we must respect the four Ds of fluid management.

• There are four body fluid compartments.

• And don’t forget the four phases of fluid therapy: resuscitation, optimization, stabilization, and evacuation.

For accurate assessment, ideally, the patient should be in a supine position. If they’re standing, gravity redistributes fluids, especially in methods like bioimpedance analysis. That’s why I don’t trust those fitness center machines where you just stand and touch electrodes—they’re not reliable.

It’s truly incredible that the sixth IFAD meeting was attended by over 500 delegates from more than 45 countries worldwide. The Fluid Academy, alongside researchers like Niels, has produced impactful work—his contributions, including the MIHMOSA study, have been incredibly valuable.

By supporting open-access research, the Fluid Academy has created a global platform for knowledge sharing. IFAD-supported studies have been downloaded tens of thousands of times. Additionally, our social media team plays a critical role in amplifying our message, promoting #FOAMed (Free Open Access Medical Education) content, and ensuring our research reaches a worldwide audience.

When he looked at the need for renal replacement therapy, he again found a clear relationship: patients with a positive fluid balance had a higher likelihood of requiring RRT in critical care settings.

My name is Djillaili Annane, and I work in Paris at the University of Versailles. This is my fourth time attending the IFAD meeting in Antwerp, where I usually contribute by discussing the role of colloid solutions—and that was once again the focus of my presentation today.

This time, I had the opportunity to share new and unpublished data from a subgroup analysis of the large CRISTAL trial, specifically looking at surgical patients—a group comprising nearly 800 individuals. These data had not been presented before, and today was the first time they were shared publicly.

What we found is quite relevant:

• There were no significant differences in major clinical outcomes—such as mortality, organ dysfunction, or serious adverse events—between patients resuscitated with colloids versus crystalloids.

• However, colloids were associated with a higher likelihood of achieving resuscitation goals more quickly in the immediate post-operative period.

I believe the IFAD meeting is truly one of a kind—a unique congress entirely dedicated to fluid therapy in both the ICU and operating room settings. It brings together a community of clinicians deeply involved in fluid resuscitation, and it has rightfully earned its place as a standard reference meeting for those focused on fluid management in critically ill patients.

I am Niels Van Regenmortel, internist-intensivist and co-organizer of the IFAD meeting from ZNA Stuivenberg in Antwerp, Belgium. participated in the Pro-Con debate on balanced solutions, and I took the "Can" side.

My key message was that, while the evidence supporting balanced solutions may not be as definitive as some believe, these fluids are still perfectly safe—and likely better for kidney function compared to 0.9% saline. So, my advice is: if you can afford to implement balanced solutions economically, then absolutely go for it.

What makes the IFAD meeting so important is that it shines a spotlight on a topic that has been neglected for far too long—fluid therapy. Every clinician gives fluids—often daily—and yet we rarely question what kind, how much, or when to stop.

This congress is the first, and arguably the most important and largest, dedicated event that brings global experts together to discuss fluids, fluid monitoring, and clinical outcomes. It fills a crucial gap in our medical education and practice.

My name is Dr. Sherif Nasr, and I’m from the United States of America. This is our fourth time attending the IFAD meeting—we’ve only missed one—and it’s always a pleasure to be here.

I really enjoy the venue, the quality of the program, and the speakers, many of whom I now know personally. Of course, being doctors, our dinner conversations tend to drift into work—two doctors at dinner? Forget it! But that’s part of what makes this gathering special: we’re passionate about what we do.

What makes IFAD truly unique is that no other conference is so dedicated to fluids and fluid monitoring. We often discuss many topics in medicine, but fluid therapy and hemodynamic monitoring are central to our daily clinical practice, and yet they rarely receive focused attention. This was the first conference to dedicate itself entirely to these subjects, and it remains the only one of its kind.

I come here to see where the rest of the world stands, and to compare that with our practice in the U.S.. It's always insightful to exchange perspectives and learn from our international colleagues.

One of the things that strikes me most is how, in Europe, clinical decision-making seems to be driven more by science and physiology. In the U.S., unfortunately, we often find ourselves practicing defensive medicine—guided not only by clinical evidence, but by concern over legal scrutiny. We think about how our documentation or treatment decisions might be interpreted in a courtroom, not just by peers or through the lens of scientific merit.

In contrast, here in Europe, there’s more freedom for scientific thought, individualized care, and principle-based application of therapies. It’s refreshing—and one of the reasons I keep coming back to IFAD.

Let’s try not to swing the pendulum too far in the other direction—risking another form of high mortality. Instead, let’s aim to find the sweet spot.

I am Inneke De laet , Intensivist from ZNA in ANtwerep, Belgium. My lecture focused on de-resuscitation in the critically ill—and whether this could be the key to solving the problem of fluid overload. As we’ve seen, aggressive fluid administration may save lives in the early phases of shock, but excess fluids later on can be harmful, and managing this balance is critical to improving outcomes.

One of the great strengths of the IFAD Congress is that, unlike broader ICU meetings where a wide range of topics are only briefly touched on, here we can focus deeply on one essential area: fluid therapy. This narrow focus allows for in-depth presentations, richer discussions, and more meaningful exchanges between experts.

I believe it’s also important to highlight the value of collegial interaction at meetings like this. While randomized controlled trials (RCTs) remain essential, we are increasingly recognizing the importance of understanding how to translate those results into clinical practice. And that’s something you can only refine by sharing real-world experiences and perspectives with your peers.

This congress provides exactly that kind of environment—specialized, collaborative, and clinically relevant.