IFA Talks

Fluid Matters - The nil by mouth (NPO) debate | TopMedTalk   Nov 28, 2018   This piece is taken from "The Great Fluid Debate", it's about changes in practice that have been implemented both in the UK and at various medical centres in the US. Hear how and why the old 'nil by mouth' or 'NPO' policy has changed in many instances. From water to carbohydrate drinks, to black coffee, the thinking has changed in many institutions but part of the battle is in educating patients and their well meaning friends and relatives. These pieces have been released to coincide with IFAD, the 7th International Fluid Academy Day. Make sure you subscribe to TopMedTalk to ensure you hear some of the pieces we recorded there. Chaired by Professor Monty Mythen and featuring; Dr Tim Miller, anesthsiologist from Duke University Medical Centre; Professor Mike Grocott, Professor of Anaesthesia and Critical Care at the University of Southampton; Professors Paul Wischmeyer and Stuart Grant, from the Department of Anesthesiology, Duke University and featuring questions from the audience. Join in the debate: [email protected]

Fluid Matters - 'The Great American Fluid Debate' | TopMedTalks   Nov 27, 2018   This is an excerpt from 'The Great American Fluid Debate' which was hosted at Duke University Medical Centre's "Controversies in Perioperative Medicine" conference of this year. These pieces have been released to coincide with IFAD, the 7th International Fluid Academy Day. Make sure you subscribe to TopMedTalk to ensure you hear some of the pieces we recorded there. The two pieces Monty mentions in the podcast, featuring Paul Myles, are found here: "THE RESULTS" https://www.topmedtalk.com/the-relief-trial-results/ "YOUR ESSENTIAL DEEP DIVE" https://www.topmedtalk.com/rcoa-11-the-relief-trial-your-essential-deep-dive-into-the-results/ And you can find the other piece here: "JOURNAL CLUB; BALANCED VERSUS SALINE" https://www.topmedtalk.com/journal-club-saline-solution/ Presented by Monty Mythen featuring; Mike Grocott, Professor of Anaesthesia and critical care at the University of Southampton; Professor Paul Wischmeyer from the Department of Anesthesiology, Duke University; Professor Stuart Grant, MB ChB, FRCA Director, Medical Student Education, Duke University School of medicine and Tim Miller, anaesthsiologist from Duke University Medical Centre.

Fluid Matters - Total body water and electrolytes | POQI   Nov 24, 2018   These pieces have been released to coincide with IFAD, the 7th International Fluid Academy Day. Make sure you subscribe to TopMedTalk to ensure you hear some of the pieces we recorded there. Coming from this summer's Peroperative Quality Initiative (POQI) hosted at Washington Duke University in Durham this podcast is presented by Monty Mythen and Henry Howe with their guests Tom Woodcock, an independent consultant in patient safety, medical law and ethics, and Manu Malbrain, Professor at Faculty of Medicine and Pharmacology Vrije University in Brussells. The website mentioned in this piece is here: https://www.fluidacademy.org/

Fluid Matters - Definite definitions, fluid physiology | POQI   Nov 23, 2018   This conversation was recorded on the morning of the second day of the Perioperative Quality Initiative (POQI) meeting hosted at Washington Duke University in Durham. These pieces have been released to coincide with IFAD, the 7th International Fluid Academy Day. Make sure you subscribe to TopMedTalk to ensure you hear some of the pieces we recorded there. Presented by Desiree Chappell with Professor Monty Mythen, Henry Howe and their guest Tim Miller, anaesthsiologist from Duke University Medical Centre and organiser of the POQI meeting.

The growing popularity of new media in medical education | IFAD   Nov 23, 2018   This piece is a chance to reflect upon the importance of new media within the sphere of medical education. As the run away success of TopMedTalk and other podcasts in this area shows people are hungry to use the unique potential of this medium. Also - how has social media, video casting and live streaming altered the way conferences are both organised, executed and received? Finally, our team of experts tackle the eternal question; where to next? Presented by Joff Lacey with his guests; David Lyness, Doctor in Anaesthetics and Intensive Care Medicine at Belfast Health and Social Care Trust, Segun Olusanyam Specialty Trainee in Intensive Care Medicine, Jamie Strachan, Intensive Care Medicine and Anaesthesia Registrar & Council Member of the Royal College of Anaesthetists and Dr Cian McDermott Consultant in Emergency Medicine at Mater Misericordiae University Hospital. -- Streamed live from the International Fluid Academy Day (IFAD) in Amsterdam on www.topmedtalk.com You can also join in with IFAD for free online https://www.fluidacademy.org/

Discussing The Paradigm Shift in Fluid Therapy | IFAD   Nov 23, 2018 This podcast is an exclusive discussion regarding the second session at The International Fluid Academy Day (IFAD) in Amsterdam. This in depth discussion is a reaction to the session at IFAD and contains insights into the following topics; 'Everything you need to know about fluid therapy', results from some of the most recent trials and 'How to set-up a fluid guideline'. The team also reflect a little more on the first session. Presented by Joff Lacey with Monty Mythen and Henry Howe. -- Streamed live from the International Fluid Academy Day (IFAD) in Amsterdam on www.topmedtalk.com You can also join in with IFAD for free online https://www.fluidacademy.org/

TopMedTalk at IFAD | Understanding Fluid Physiology Download this podcast for an exclusive discussion regarding the first session at The International Fluid Academy Day (IFAD) on Friday morning in Amsterdam. This in depth discussion is a reaction to the first session at IFAD and contains insights into the following topics; 'Everything you need to know about fluid physiology'; 'From Frank-Starling to Guyton-Hall'; 'Understanding edema formation' and 'Where does the albumin go?'. Presented by Joff Lacey with Monty Mythen and Henry Howe. -- Streamed live from the International Fluid Academy Day (IFAD) in Amsterdam on www.topmedtalk.com You can also join in with IFAD for free online https://www.fluidacademy.org/

Have you joined the International Fluid Academy yet?   Nov 23, 2018 Live from the International Fluid Academy Day (IFAD) in Amsterdam; the team explain how you can join in for free online https://www.fluidacademy.org/ and give us a bit of the history of the conference along with some of the discussion points you can expect to hear. Presented by Joff Lacey with Henry Howe, Monty Mythen and their guest Manu Malbrain, Professor at the Faculty of Medicine and Pharmacology Vrije University in Brussels and organiser of the conference.

Participants and Setting Jonny – Host/moderator, introducing the social media team at the International Fluid Academy (IFA) 2018 in Amsterdam. David – Social Media Chair for the conference. Catherine (Beni) – A new social media team member from Seattle, USA. Cian – Returning social media team member, participated in the previous year's IFA event. They discuss their roles within the conference's social media coverage, including how they prepare content (infographics, posts, and video segments), their personal journeys in social media, and the various platforms they use. Main Discussion Points 1. Newcomers to the Social Media Team Catherine's Preparations and Travels She traveled 9–13 hours from Seattle to Amsterdam. She was excited to see differences and similarities in how medicine is practiced in Europe compared to the US. Creating Infographics Catherine used Canva to design visually appealing and accurate graphics summarizing conference lectures. She prepared templates in advance and read through presentations/papers beforehand. Noted that a significant portion of her time was spent perfecting the infographic's look and content—sometimes losing progress and having to rebuild from screenshots. 2. Value of Visual Content in Education High Engagement with Graphics All participants agreed that infographics and visual media get more traction on social media (Twitter, Facebook) than plain text. People frequently save, print, and share these visuals in their departments. Online Tools and Analytics They mention using tools like "Pocket" to curate or bookmark interesting content for later reference. Social media metrics help identify which posts resonate most with their audiences. 3. Growth of Social Media in Medicine Conference Social Media Teams Cian describes how these roles evolved: reading abstracts in advance, posting content in real time, and engaging with audiences worldwide. The group also references other conferences (e.g., ultrasound/teaching courses in Melbourne, Montreal) that have embraced active social media coverage. Twitter, Facebook, and Instagram Twitter is favored for quick updates, "signposting" to deeper resources, and professional networking. Facebook can be better for detailed discussions or case-based sharing (e.g., surgical cases with peer input). It also reaches a large nursing audience. Instagram is increasingly popular, especially among medical students, and may suit visually oriented material like ultrasound clips. 4. Personal Journeys and Networking Cian and Catherine both note that Twitter opened doors to collaboration and learning, even without having many publications or lengthy CVs. WhatsApp Groups and Personal Learning Networks The team uses group messaging for real-time coordination, workshop planning, and educational exchanges. While beneficial, they joke about 15 notifications first thing in the morning. The Challenges of Recognizing People In Person Since many had only interacted online, they used Twitter photos to identify each other in a local bar. The speakers point out that having a recognizable profile picture (rather than an abstract image) helps colleagues connect at conferences. 5. Future Directions for Social Platforms Potential Shift Away from Twitter The group acknowledges that social media trends evolve quickly. Younger generations may prefer Instagram for visuals; educators and clinicians must adapt or risk "falling behind." They predict new platforms or versions might emerge with curated discussions or more advanced features. Ongoing Experimentation Some foresee ultrasound demonstrations flourishing on Instagram (short video clips). Others see Facebook as underutilized in certain specialties, given how it can host more in-depth discussions and large communities. Key Takeaways Preparation Yields High-Quality Content Reading presentations ahead of time and designing infographic templates in advance helps the social media team produce polished, accurate, visually appealing posts. Visual Media Drives Engagement Infographics and video clips resonate strongly, making it easier for conference attendees and global followers to digest complex medical information quickly. Platform Choice Matters Twitter excels at real-time coverage and networking. Facebook can offer more room for in-depth discussion (especially appealing to nurses, who represent a large segment of that user base). Instagram is popular among students and well-suited to short, highly visual medical content. Collaborations Transcend Borders Social media allows people with few publications or limited conference access to learn from global experts, join personal learning networks, and build professional communities. Adaptability is Crucial As social media evolves, clinicians and educators need to remain flexible—learning new platforms to continue sharing and accessing the best medical knowledge. Concluding Note This conversation highlights how the International Fluid Academy's social media team prepares conference coverage and leverages different platforms (Twitter, Facebook, Instagram) to reach broad audiences. They emphasize that carefully crafted visual content, proactive networking, and an openness to new technology can significantly enhance global medical education.

Participants and Setting Speakers: Dr. Catherine ("Beni") – A surgical resident posing detailed questions about fluid management. Dr. Johnny Wilkinson – An intensivist and physiology enthusiast, referencing research trials and discussing fluid strategies. Additional Colleagues (unnamed) – Intensivists, surgeons, or critical care professionals joining the discussion. They are at the International Fluid Academy 2018 in Amsterdam, where they discuss advanced fluid-management topics and reflect on conference sessions. Main Discussion Topics 1. The "Three-Day" Ebb and Flow Rule for Capillary Leak Traditional Teaching: Clinicians often cite a three-day period during which capillary permeability peaks (capillary leak), followed by a "closure" or "flow" phase. This is especially mentioned in sepsis and major surgical contexts. Open Abdomen & Repeated Surgeries: Dr. Benny wonders if this three-day timeline still applies to trauma patients returning multiple times to the operating room. Key Insight: Repeated insults (new surgeries, infections, "second hits") can prolong capillary leak well beyond three days. Individualized Response: The group explains that the "three-day rule" is, at best, a rough guide. Ongoing inflammation, sepsis, or major trauma can stretch the leak over weeks or months. The leak closes only when the underlying cause (e.g., infection, open abdomen) is controlled. 2. Phenotypes and Personalized Therapy Emerging Research: Recent studies identify multiple inflammatory phenotypes within conditions like sepsis (some cite five distinct subgroups). Each phenotype could respond differently to fluids, vasopressors, or adjunctive therapies (vitamin C, corticosteroids, albumin, etc.). Why Some Trials "Fail": Large RCTs often lump together heterogeneous patient groups, diluting possible benefits of certain treatments for specific phenotypes. Personalized (or "precision") medicine may be needed to target each subtype optimally. 3. Revisiting CVP (Central Venous Pressure) CVP Never Disappeared: Although many experts moved away from using CVP as a strict "target" (e.g., 8–12 cmH2O), surveys indicate a majority of ICUs still track it, at least as a data point. Utility vs. Pitfalls: CVP can offer trend information: a sudden jump from 8 to 40 likely indicates significant fluid accumulation or cardiac dysfunction. However, a single absolute CVP value is rarely instructive (e.g., "CVP 15 means fluid overload!"). It must be interpreted in context (cardiac function, vascular tone, changes over time, etc.). IVC Ultrasound Comparison: Measuring the IVC (inferior vena cava) via ultrasound is akin to looking at "CVP upside down," as both tools ultimately reflect central venous system pressures. The group lightly jokes that heated debates over CVP vs. IVC often obscure their shared physiologic underpinnings. 4. Albumin Use and Oncotic Pressure Persistent Controversies: Some clinicians routinely use albumin; others avoid it, citing cost, infection risk, or inconclusive evidence for mortality benefit. Trials and meta-analyses sometimes suggest fluid-sparing effects (i.e., patients may require less total fluid), but whether that translates into improved outcomes remains uncertain. Oncotic Pressure & Glycocalyx: The group mentions the glycocalyx and evolving views on how fluids distribute within the body. Traditional concepts of "oncotic pressure" have been challenged, as measuring it is difficult and the capillary barrier is more complex than once thought. They caution that lab-based findings on glycocalyx or oncotic pressure don't easily translate into everyday bedside decision-making. 5. Conference Highlights and Personal Takeaways Evolving Understanding: Dr. Beni appreciates learning that her own confusion reflects the field's genuine complexity; there is no universal formula for fluid management. The conversation reaffirms the value of building a "personal learning network" to share insights and questions with peers. Heated Debates: The group enjoys spirited disagreements among conference presenters (e.g., conflating ICU and elective surgery data). They praise the event for turning a "dry topic" like fluid therapy into dynamic, engaging discussions. Key Takeaways No Strict "Three-Day" Timeline The notion that capillary leak automatically resolves by day three is too simplistic—many variables, like persistent inflammation, repeated surgical interventions, and individual phenotypes, can prolong or alter this process. Precision Medicine in Fluid Therapy Different inflammatory phenotypes and patient contexts (e.g., sepsis vs. trauma) might require tailored therapies. This explains why broad clinical trials often produce mixed or inconclusive results. CVP: Still Relevant, but Context Matters Monitoring and trending CVP can offer valuable clues, yet it should not be used in isolation. It's best interpreted alongside clinical assessment, point-of-care ultrasound, and other hemodynamic data. Albumin Use is Nuanced Research is mixed about when albumin confers an advantage over crystalloids. Many clinicians do use it—often for fluid-sparing reasons—yet conclusive evidence for mortality or strong outcome benefits remains elusive. Cost, supply considerations, and possible infection risk also factor into decisions. Benefit of Open Debate The group appreciates conference sessions that stimulate robust arguments, recognizing it advances the conversation and highlights the complexity of fluid management. Concluding Note This transcript offers a window into current fluid-management debates, including capillary leak timelines, CVP's evolving role, and the uncertain but ongoing place of albumin in critical care. Above all, it underscores that individual patient factors—from genetic phenotypes to clinical context—drive decisions more reliably than any single guideline or laboratory concept.

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 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. 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. 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. 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 Technical Issues Are Being Addressed: The host is transparently troubleshooting streaming problems and soliciting user feedback to improve the video feed's quality. 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. 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 Host/Interviewer (introduced as David Lyness, Social Media Chair) 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 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. 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). 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. 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. 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 Dr. Catherine Benny – Surgery resident at the University of Washington in Seattle (USA). Dr. Johnny Wilkinson – Intensivist from Northampton, UK, and founder of Critical Care Northampton. 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: Ongoing blood loss (e.g., surgical bleeding or trauma) 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: Check for active bleeding (e.g., drains, wound sites, clinical stability). Review fluid input to see if it might have caused dilutional changes. Correlate with vital signs, ultrasound findings, and any advanced monitoring data. 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: Drug – Choose the right fluid: crystalloids, glucose, colloids, or blood. 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. Duration – Fluids shouldn't just continue indefinitely. 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

🎤 Live from IFAD – Catching Up with Johnny Wilkinson We're back again at IFAD, and I've got Johnny Wilkinson with me—who's been very busy this week. 🗣️ "Essentially, I'm doing a hell of a lot of podcasting. I've been wandering around like a bit of a roving lunatic with a microphone, catching people in the halls, at sessions, in workshops—basically anyone I can grab—to have short, sharp conversations about what's happening here at the meeting." Johnny and his team are on a mission to give listeners a snapshot of the full IFAD experience—from hands-on workshops to major plenaries, from big-name speakers to rising stars you might not have heard of yet. 🎧 Where can you listen? "We're uploading and editing as we go. All the podcasts will be available on the IFAD website, most likely under a section labelled 'Podcasts', and we may also host them on CriticalCareNorthampton.com and other partner sites." 💡 Whether you missed a session, want to catch some behind-the-scenes insight, or just love a good bit of #FOAMed content, be sure to tune in! Stay connected ➡️ #IFAD2017 #CriticalCare #Podcasting #FOAMed

🎥 Live from the International Fluid Academy Day 2017 Hi everyone, I'm Shagan Onasanya, and I'm here with Karen Browey, who just delivered a brilliant and succinct summary on the management of trauma-induced hyperglycemia and massive hemorrhage. 🩸 So, Karen, let's distill it down. Someone is exsanguinating on the floor—what's the one-word summary of what we should do? Karim: "Stop the bleeding. That's the first, second, third, and fourth priority. Press on the wound, apply a tourniquet, do something—get them to surgery. In the meantime, do as little as possible, and what you do should focus solely on keeping the patient alive: Maintain coronary perfusion Support the ability to clot Don't dilute them with unnecessary fluids Avoid exacerbating the inflammatory response And treat any existing coagulopathy" ✅ A clear, focused, and life-saving message. 🎙️ "Fantastic—thank you very much, Karen!" 📍 Stay tuned for more insights from #IFAD2017 #TraumaCare #MassiveHemorrhage #FluidTherapy #FOAMed #CriticalCare

🎙️ Live from IFAD – Friday Afternoon We caught up with Dr. Jan just after his session on a crucial—yet often overlooked—topic: the dangers of de-resuscitation. 🗣️ "Yes, I spoke about de-resuscitation, or what's also called fluid de-escalation or fluid removal. The first thing we need to do is really understand what it is—and why it's important. It typically comes at the very end of resuscitation, which might be why it doesn't always get the attention it deserves." While many clinicians rely on cumulative fluid balance numbers, biomarkers, and hemodynamic indices, Jan emphasizes a critical point: 👀 "Look at the patient. Don't just rely on numbers. Look for clinical signs of fluid overload and even fluid toxicity. Before you start removing fluid, make sure you have a clear clinical reason—such as unresolved respiratory failure or acute kidney injury that could be linked to fluid accumulation." So how does Jan decide when to start de-resuscitation? 🤔 "It's difficult. There's no biomarker for it. You need to make a clinical judgment. Many people wait for the patient to become hemodynamically stable or to be off vasopressors—but actually, in my experience, fluid removal can often be tolerated even with low-dose vasopressors. That shouldn't be seen as an absolute barrier." ✅ Key takeaway: There's no one-size-fits-all solution. The decision to de-resuscitate should be based on the full clinical picture, not just fluid balance sheets. 👏 Thanks to Jan for sharing these important insights! 📍 Stay tuned for more from #IFAD2017 #FluidTherapy #DeResuscitation #CriticalCare #FOAMed

🎉 Good morning from IFAD! We're really excited as the first day of the conference kicks off—and the opening plenary session is starting in just one minute! We just wanted to say a quick hello 👋 🎤 Kean, what are you most excited about today? 🗣️ "I'm really looking forward to diving into the heart of the conference—meeting all the delegates and hearing the keynote presentations. I'm especially excited for the sepsis debate and the hot topics session this afternoon. There'll be plenty of lively back-and-forth on some of the most controversial issues we face in critical care. Definitely my highlight of the day!" 👏 Sounds like a packed and thought-provoking schedule ahead. Don't miss a beat—follow us on Twitter (as we know you already are 😉) and stay tuned for more live updates throughout the day! 📍 #IFAD2017 #FOAMed #CriticalCare #SepsisDebate

🎙️ Welcome back to the iFAD Live Vodcasts! It's Friday afternoon here at IFAD, and we're joined by Jade and Eve, two fantastic research nurses from Cardiff ICU. 🩺 So, what brought you to IFAD? Jade: "One of our colleagues was presenting a poster, and we helped collect the data for it. But more than that, we really wanted to see how research is impacting clinical care across different centers." Eve: "Yeah—it's a great opportunity to collaborate, to share what we're doing, and also learn what others are working on so we can take new ideas back to our own unit." 📍 Do you do a lot of research back in Cardiff? Both: "We do! We're involved in a wide range of studies—both commercial and non-commercial—and we actually run 24/7 recruitment." ⏰ 24/7? That's quite rare, isn't it? Eve: "It is! But we've found it's the most effective way to maximize recruitment. Most of our patients are recruited outside of standard hours—because that's when people are admitted, that's when their conditions deteriorate. ICU doesn't run on a 9-to-5 schedule, so neither can we." Jade: "If you're only recruiting during office hours, you're missing a significant portion of your ICU population, and that can seriously bias your study outcomes. Running a full-time recruitment model allows us to serve all eligible patients and strengthens the validity of the research we're involved in." 🧪 A big thank you to Jade and Eve for joining us and for the incredible work you're doing in advancing intensive care research. 💬 This is what IFAD is all about—collaboration, real-world impact, and pushing the boundaries of critical care. 📍 #IFAD2017 #ICUResearch #FOAMed #NursingExcellence #CriticalCareResearch

🎤 Live from IFAD 2017 in Antwerp, Belgium! We're joined now by two local attendees, Sim and Tom, who've come to the conference from nearby. 👋 "We're from Brussels," they tell us. "I work in Bruges," says Sim, "and Tom works at the University Hospital in Brussels." 🗣️ So why did they come to IFAD? "We know about the conference because our new Head of the Intensive Care Department is Professor Malbrain," Tom explains. "He invited us, and even though I'm a trainee in internal medicine and Sim's more in nuclear medicine, it's a great opportunity to learn about fluid and critical care—areas we don't get exposed to much." When asked about highlights from the day, Sim says: 🧠 "There's been a lot of really good information—I've picked up so many take-home points, I can't even choose one specific thing." Tom adds: 💡 "One of the most interesting presentations for me was about the choice of maintenance fluids—both in pediatrics and stable adult patients. It really made me reflect on the importance of tailoring fluids to the individual patient, rather than just following routine practice." And they both agree: 💬 "Fluids should be considered a medicine, not just an afterthought or a standard protocol. That perspective really stood out to us." 👏 Thank you to Tom and Sim for sharing your reflections! 🎥 This has been your live update from IFAD 2017—stay tuned for more conversations and insights from the floor. 📍 #IFAD2017 #FOAMed #FluidTherapy

🎥 Live from IFAD! I'm here with the ever-energetic David Lyness from Propofology.com and @gas_craic on Twitter. So, David—what are you up to at IFAD? 🗣️ "I'm herding cattle and cats—basically trying to rally the social media troops! I'm helping to run the social media campaign, getting content online, pushing Twitter hard, and broadcasting as much of the conference to the #FOAMed community as humanly possible. Also, I'm being very militant about hashtags." We appreciate the dedication! And just to be clear—what's the official hashtag? 🟦 #IFAD2017 – for anyone following the action. So aside from the tweeting frenzy, what else is going on? 🗣️ "I've teamed up with Johnny Wilkinson from CriticalCareNorthampton.com, and we've created a joint fluid protocol flowchart. You can download it on Propofology.com or Johnny's site. We're launching it during the conference to get feedback and promote safer, smarter fluid prescribing—it's a quality improvement tool and a fluid stewardship initiative all in one." That's awesome. A big thank you for pushing the digital boundaries and bringing IFAD to a global audience! 💻 Check out the protocol ➡️ Propofology.com 💬 Follow the conversation ➡️ #IFAD2017

🎬 Lunchtime update from IFAD! We've just wrapped up a fantastic morning of the Critical and Acute Care Ultrasound (CACU) course, and it's been really popular! I'm here in my classic white IFAD t-shirt, soaking up the atmosphere—and now, we're bringing you some top ultrasound tips straight from our amazing faculty. 🎉 🎤 Cian: "When I teach ultrasound, I always wear jeans—and here's why. On your right-hand side, there's that little jeans pocket. If you're struggling with rib shadows, line up your probe and twist it like you're sliding it into that pocket. Works every time!" 🎤 Segun: "Having trouble getting a good four-chamber view of the heart? Start with a parasternal short axis view and trace it down to where you see the twist at the apex—that shows you the heart's direction. Then switch to the left side and point the probe where the apex was. Boom! A beautiful four-chamber view, 99% of the time." 🎤 Adrian: "In a peri-arrest patient, the subcostal two-chamber view is often the only view you'll get. Just rotate the probe so the marker faces up and angle it toward the left ventricle. It gives you a view similar to the parasternal short axis—super useful in emergencies." 🎤 Justin: "When you're learning, and your mentor takes your hand to guide the probe—don't let go. Grip tighter. Feel how they move the probe, relate that to what you see on the screen, and you'll learn so much faster." 🎤 Aidan: "Movement is everything. Remember the three key probe motions: slide, rotate, and tilt/fan. And as for grip, think of it like holding a screwdriver—or applying lipstick (your choice!). #iFAD2017" 🎤 Johnny Wilkinson: "No talk about lipstick or grabbing probes from me. Just this: practice, practice, practice. Learn what's normal—then you'll recognize what's not. Especially if you're being mentored by me. 😉" 🎥 That's it from us (for now!)—some top tips from some of the best educators in ultrasound. Stay tuned, because there's more to come throughout the day. Thanks for tuning in! 💬 #iFAD2017 #POCUS #UltrasoundTips

🎙️ Hello from the Fluid Academy! We're back again—and this time, I'm joined by Brendan Riardan, who might just be the furthest-traveled member of our faculty. Brendan, where have you come from? 🗺️ "I've come from Seattle in the US—but I did spend a bit of time traveling through the Netherlands before arriving here, so technically I've only just come from The Hague by train!" So maybe not quite in the last 24 hours—but still impressive! 🚨 Don't forget—we've got an exciting Social Media Workshop happening this afternoon! 📍 Hope Room 🕓 4:10 PM (local time) We'll be discussing how to: 📲 Use social media to support your research and education 🌍 Disseminate your work and ideas to a global audience 💡 Share what matters to you in medicine, in real time Whether you're a social media pro or just getting started, come join us for a practical and engaging session!

When you walk into an ICU, you often see patients who look very much alike. Regardless of the original insult—be it trauma, infection, or another trigger—they're all receiving mechanical ventilation, hemodynamic support, renal replacement therapy, artificial feeding, and more. That's because any localized insult can trigger a systemic host response—transforming a regional issue into a body-wide disease. I had the opportunity to give two lectures at this congress. One focused on cytokine removal in septic shock patients, and the other addressed fluid therapy—specifically, crystalloids versus colloids—and their impact on hemodynamics. Let me bring the pathophysiology a little closer to home. Over the past few years, I've stumbled upon what I like to call an analogy between sepsis and love. What is love, from a pathophysiological perspective? It's a systemic inflammatory response provoked by somebody. Now, back to clinical practice: In patients with severe sepsis and high risk of death, we often see multiple organ dysfunction and a cytokine storm. My recommendation is to monitor this inflammatory surge using procalcitonin kinetics. If it's rising significantly, consider implementing cytokine removal therapies as part of the treatment plan. Regarding fluid therapy, our data suggests that as long as hemodynamic stability is maintained using a multimodal, individualized approach, it doesn't matter much whether you use crystalloids or colloids in terms of microcirculatory outcomes. That said, we still believe that in the early resuscitation phase, colloids may have an advantage—they tend to restore circulation faster than crystalloids. And finally, a word on antioxidants: If you consume too many, you'll simply excrete most of them. The only antioxidant I confidently recommend? Hungarian red wine. This was my first time attending IFAD, and I must say, it's been one of the best conference experiences I've had. The environment is friendly and relaxed, the audience is highly motivated, and the speakers are truly world-class. It's been a fantastic experience, and I look forward to returning.

One of the more technical yet fascinating aspects I discussed was freeze substitution, a technique performed at -90°C, where water remains mobile, but larger molecules are immobilized. During this process, we introduce acridine orange and uranyl acetate, which results in a "fluffy" structural visualization—a revealing view into the delicate architecture we're studying. What I want the audience to understand is the crucial role of the glycocalyx—not just as an isolated structure, but as a dynamic, functional layer of the cell surface. It plays a vital role in cell behavior, communication, and vascular integrity, and its condition changes dramatically between health and disease. My personal focus is on the impact of diabetes. In diabetic patients, the glycocalyx becomes disrupted, which contributes to a host of microcirculatory problems—in the kidneys, retina, and lower limbs. These complications are common and devastating, and they correlate strongly with glycocalyx degradation. We believe the glycocalyx is a key player in diabetic vascular complications, and our hope is to one day restore or rebuild a healthy glycocalyx, which could help reestablish proper endothelial function and ultimately preserve vascular health. This research opens a door not just for better understanding, but for potential therapeutic interventions—aiming to consolidate the vasculature and mitigate the progression of diabetes-related organ damage.

In extracorporeal support systems like ECMO, understanding pressure dynamics is key. For example, internal pressure refers to the pressure after the pump head but before the oxygenator. By comparing this with the arterial pressure, we calculate the pressure gradient (delta P) across the oxygenator—a critical metric for assessing oxygenator function and circuit performance. Our mission today is to bring clinicians closer to advanced therapies like ECMO, including not only how to initiate them but also how to monitor the system and the patient holistically. ECMO remains a complex and high-risk therapy, and our goal is to demystify it, making it more accessible and manageable for those facing critically ill patients. In practice, we've opted to keep circuit connections consistent—for instance, connecting venous to venous (phenocyte to phenocyte) and arterial to arterial (arterioscite to arterioscite)—to reduce the risk of complications and standardize care protocols. Fluid dynamics, in this context, is all about measuring and knowing. It allows us to adapt therapy in real time, track patient evolution, and predict clinical course. By understanding where a patient came from, where they are today, and what trends are unfolding, we can tailor our treatment for tomorrow. This kind of monitoring isn't optional—it's essential to optimizing outcomes. Once you've performed pressure zeroing inside the Cardiop system, you're ready to prime the circuit—a critical step before initiating support. But beyond the technical aspects, there's a deeper message here: If we have an opportunity to educate healthcare professionals, we must take it—and we must do it consistently. New regulations highlight the need for structured, recurring training—every two years, for example—to maintain safe and effective practice. At the end of the day, the best patient outcome is what drives us. And that's why we come together—to share knowledge, refine our techniques, and learn from each other. That, in many ways, is what makes IFAD such a valuable and collaborative community.

Over the years, the trend in fluid therapy has been clear: we're using fluids less and less. But if we project that trend too far into the future, we might imagine a time when we stop using fluids altogether—and I simply don't see that happening. There has to be a balance point—a place where we can appreciate both the benefits and the risks of fluids, and use them wisely. That's the real challenge: finding that middle ground. The importance of this conference is considerable, because many doctors are still confused about fluid therapy. On the one hand, fluids are the cornerstone of resuscitation. No matter what type of shock a patient presents with, our instinctive first move is usually to give fluids. But at the same time, we face a number of uncertainties: How much fluid should we give? What type of fluid is best? What endpoints should we target? How do we know when to stop? So while fluid therapy is common practice, it's also a source of common confusion. That's why meetings like this one are so important. They help us clear the fog, consolidate the latest evidence, and define clear, practical goals that clinicians can apply at the bedside.

This is the environment I feel most comfortable in. Put me in a general practice setting—sitting in a quiet room with a patient—and I get nervous. My hands sweat, my heart races. But in the complex, high-stakes environment of intensive care, I feel completely at home. I am Matthew Morgan and I just delivered a talk that partially explored the history of intensive care medicine, which dates back to the 1953 polio epidemic in Copenhagen. From those early days, I traced how the specialty has evolved over the decades, and how far we've come in our ability to support critically ill patients. But my real message to the audience was about something even more important: the need to engage with the public. We must do a better job of explaining what intensive care medicine actually is, the uncertainties we face, and the delicate balance between what we can do and what we should do. They say it takes 10,000 hours to become an expert—but I tried, in just 15 to 30 seconds, to share my approach to intensive care: it's about teamwork, humanity, and curiosity, as much as it is about science and technology. I'm proud to be here not just as a speaker, but as part of a research team from Cardiff. And not just physician researchers. I've travelled here with two research nurses, who do the real heavy lifting—recruiting patients, coordinating protocols, ensuring the work actually gets done. I'm also joined by an academic foundation doctor, whose enthusiasm and insight keep our team fresh and forward-looking. Because the reality is this: Research in medicine is a team game. And coming to conferences like this—not just as individuals, but as a team—is hugely beneficial for learning, for collaboration, and for building the future of our specialty.

The sodium conundrum. A conundrum is a riddle, a brain teaser, an enigma. So perhaps a better title for my talk would be: "The Riddle of Salts." I am Niels Van Regenmortel from Antwerp in Belgium and what I'm most passionate about in fluid management today is this: We should be doing much more to avoid excessive sodium administration in hospitalized patients. Why? Because sodium—not just fluid—is a major contributor to fluid overload in our patients. This issue goes beyond the volume of fluids we give—it's also about the sodium content of those fluids. So how can we reduce sodium overload? There are two key strategies: Use hypotonic maintenance solutions. We should avoid routine use of isotonic maintenance fluids, except in very specific cases, such as patients with brain edema, where sodium balance is critical. Avoid "fluid creep" and "salt creep." These are the hidden sources of sodium that come in through medications, flushes, and infusion carriers. They often go unnoticed but can significantly contribute to daily sodium load. Let's also remember that potassium often gets an unfair reputation. The normal dietary intake of potassium ranges from 40 to 120 mmol per day. People panic when serum potassium rises slightly above 5 mmol/L, but that's just what's circulating in the blood. In reality, our bodies are well adapted to much higher potassium intake. For example, a single glass of orange juice contains about 120 mmol of potassium. Finally, I'd like to emphasize the importance of this Congress. It fills a critical gap—because no other meeting is dedicated solely to fluids. And yet, fluid management is central to the care of every hospitalized patient. Every clinician, in every specialty, should be thinking carefully about how fluids—and particularly sodium—are being managed.

I am Mike Smet from Antwerp in Belgium. When I'm teaching echocardiography, I always remind my students that there are really just three basic probe movements: You either rotate the probe, Slide the probe along the body, Or tilt it to change your angle of view. These simple techniques form the foundation of ultrasound scanning—and once understood, they empower clinicians to begin exploring visual medicine. This is a beginner's course, designed to spark interest in both basic and more advanced ultrasound applications. Point-of-care ultrasound is truly a revolution in bedside medicine—it allows for faster and more accurate diagnoses. For example, if a patient presents with shortness of breath, a basic lung or cardiac ultrasound can lead you to the correct diagnosis within minutes. One of the key diagnostic distinctions we teach is how to tell the difference between pleural and pericardial fluid: If the fluid lies behind the heart and behind the aorta, it's pleural fluid. If it lies in front of the aorta, it's pericardial fluid. Our hands-on training sessions are particularly valuable for those who have never used ultrasound before. They provide a chance to view the basic cardiac and abdominal scans, helping participants become familiar with a form of medical imaging once reserved for radiologists. But ultrasound is rapidly expanding—it's no longer confined to imaging departments. It's coming to every floor: the emergency department, the ICU, and even the general wards. It's becoming an essential tool for clinicians everywhere. We encourage learners to start with big, sweeping motions—like battleships—as they navigate their first scans. And soon, they'll begin to recognize the structures and signs that lead to confident, bedside diagnosis.

Atrial fibrillation (AF) is likely the most frequent supraventricular arrhythmia encountered in clinical practice—and in the ICU, it's also a leading cause of diastolic heart failure. I am Martin Balik from Czech republic and in my lecture, I focused on the potential role of short-acting beta-blockers, particularly landiolol and esmolol, in the management of atrial fibrillation in critically ill patients. These agents offer unique advantages due to their short half-lives and rapid titratability, making them ideal for the dynamic environment of the ICU. In this setting, it's crucial to optimize preload, taper catecholamines, and consider early rhythm control, especially for the prevention of heart failure. My approach is grounded in cardiovascular stabilization, rather than simply rate control. However, this kind of therapy requires a complex and individualized approach to monitoring. The decision to use short-acting beta-blockers should be based on advanced hemodynamic assessment, ideally supported by echocardiography. This allows us to identify a select group of patients who are likely to benefit from this therapy without compromising cardiac output or perfusion. What I appreciate most about this congress is that it's not just a platform to lecture— I also have the opportunity to organize echo workshops, contribute to the main program, and most importantly, learn from other prominent speakers from around the globe. The International Fluid Academy Days (IFAD) brings together world-class experts, offering cutting-edge education and discussion on topics that are highly relevant to real-life critical care. It's a privilege to be part of it.

What is the effect of renal replacement therapy (RRT) modality on renal recovery in critically ill patients? I am Hilde De Geus from The Netherlands and that was the focus of my lecture—looking specifically at whether the choice between hemofiltration and dialysis impacts renal outcomes. There's a common myth in intensive care that hemofiltration is somehow superior for renal recovery. However, the literature I presented clearly shows that there is no significant difference between hemofiltration and hemodialysis in terms of their impact on renal recovery. While convective therapies like hemofiltration may provide more efficient clearance of large molecules, this does not translate into improved renal outcomes. On the other hand, dialysis offers more favorable technical characteristics: Lower blood flow requirements Lower filtration fraction These make it more practical and sustainable in critically ill patients. So, the main takeaway is this: There is no clear advantage of hemofiltration over dialysis in terms of renal recovery, and based on technical simplicity and physiological tolerance, continuous hemodialysis may be the more logical choice in many ICU settings. As for the broader question—does RRT influence renal recovery at all?—the evidence suggests that the modality itself is not the determining factor. This is an area where more nuanced understanding is needed, but we should be cautious about assigning undue benefit to one approach over another without clear evidence. This congress is truly well-educated and evidence-based. The level of discussion is state-of-the-art, and it's an honor for me to be here as a speaker. I would strongly encourage others to attend—because if you want to stay up to date with the latest, most reliable evidence in fluid and renal care, this is the place to be.

Why are we still giving fluids to test fluid responsiveness? Today, we have methods to predict fluid responsiveness without administering a single drop of fluid. I'm referring, of course, to the passive leg raising (PLR) test, which functions as a reversible fluid challenge. I am Xavier Monnet from Paris in France and in my lecture today, I focused on the concept of fluid challenges—or more precisely, preload challenges. What we really need is not a fluid challenge that risks overloading the patient, but rather a safe and reversible preload test to determine whether the patient is preload responsive. That's why I advocate for using passive leg raising. It's a dynamic and physiological way to test the patient's position on the Frank-Starling curve—at the bedside, in real time. If cardiac output increases during PLR, you can reasonably assume that it would also increase after giving a real fluid bolus—without actually needing to give one. This helps avoid unnecessary fluid administration and the risks that come with it. It's important to recognize that fluid challenges inherently risk fluid overload, especially if repeated. This is why we should shift toward preload challenges without fluids, using PLR as a safer and more effective alternative. I've been attending this congress since its very first edition, and I can honestly say it's a wonderful event. What makes it unique is its dedication to fluids, not just from a clinical angle but starting with foundational physiology and extending all the way to practical bedside tools like cardiac ultrasound. The faculty list is outstanding, and what really stands out is the quality of the attendees—these are people with a genuine interest in hemodynamics, people with a strong hemodynamic culture. Conversations here are always stimulating, meaningful, and clinically relevant. This congress truly ranks among the most interesting and high-value meetings in critical care across Europe.

I am Jan Poelaert from Brussels, Belgium and it's undeniably difficult to distinguish between lung tissue and thrombus on ultrasound, especially in certain patient populations. During the CACU (Critical and Acute Care Ultrasound) workshops, I spoke about some of these challenges, particularly in our newer patient populations, such as those with obesity, where cardiovascular structures are harder to visualize. This issue becomes even more pronounced in cervical patients, where access and image quality can be significantly compromised. One of the most critical parameters to assess in ICU and perioperative care is left ventricular (LV) function. It plays a central role in evaluating hemodynamic stability in critically ill, intraoperative, and postoperative patients. In this context, transesophageal echocardiography (TEE) serves as a valuable hemodynamic monitoring tool, both intraoperatively and in the ICU. However, it's not without limitations. For example, in cases of abdominal surgery, introducing a transesophageal probe may be contraindicated, and the risks and benefits must be carefully weighed before proceeding. What sets this congress apart is its specific focus on fluid management. It's a concise, two-day symposium that covers the entire spectrum of fluid-related issues in a highly structured and informative way. Despite its brevity, the content is rich and to the point, making it a very important and worthwhile event for anyone working in critical care.

I am Rob Wise and in South Africa, we normally maintain a supply of about two to three days' worth of emergency blood. But recently, we were down to just 0.7 days. That's not a warning sign—it's a national crisis. A severe shortage of blood products is placing enormous strain on healthcare services. My lecture focused on the use of fluids in resource-limited countries. One of the most important messages I wanted to convey is that the developing world faces challenges that many in high-income countries simply do not encounter. The reality on the ground can be drastically different. The fluid research currently being conducted is incredibly valuable, and I applaud the progress being made. However, it's crucial that we include resource-limited settings in both the research and the solutions. Otherwise, the recommendations won't be applicable or helpful for those who need them most. When clinicians have no choice at all—for example, only one fluid available—the outcome is dissatisfaction and frustration. When there are too many choices, the decision becomes overwhelming. Interestingly, offering just the right amount of choice—around six options—leads to the greatest satisfaction. This metaphor captures the complexity of decision-making in both resource-rich and resource-poor environments. This is my first time attending IFAD, and I'm truly enjoying the experience. It's fantastic to meet so many people from around the world and to share experiences and challenges. This meeting has been both educational and inspiring, and I look forward to being a part of it again.

One of the key advantages of colloid fluids in the operating room is their ability to provide a pronounced and stable plasma volume expansion. Unlike crystalloids—where most of the fluid tends to disappear from the vascular space within 30 minutes—colloids remain longer, offering more sustained intravascular support. I am Robert Hahn from Sweden and I've had a long-standing interest in fluid therapy, and at this meeting, I'm giving a lecture on the kinetic modeling of fluids—a powerful tool that helps us understand how different types of fluids behave in the body, and how we can use this knowledge to optimize fluid management in clinical practice. Over the decades, one of the most concerning observations I've made is that we tend to overlook the patients at both extremes—the ones who are being desiccated and those who are being drowned to death by fluid overload. This is where we need to sharpen our focus. My goal is to ensure that clinicians become more familiar with the basic science behind the fluids they use every day. It's important to understand how these fluids distribute, how quickly they are eliminated, and how they interact with the body's physiology. With that knowledge, clinicians can make more informed decisions and avoid both under- and over-resuscitation.

We need technology to help us—not necessarily to work harder, but to work smarter. I am Yazine Mahjoub from France. Yesterday, I had the opportunity to give a lecture on the right ventricle and how to evaluate right ventricular function using Doppler echocardiography. I emphasized to attendees that while this technique is relatively easy to perform, it does require practice and training, especially in the intensive care setting, where such evaluations are often crucial. My main take-home message was this: In any ICU patient in shock, we must always consider acute cor pulmonale as part of our differential diagnosis. Doppler echocardiography is an extremely useful and accessible tool for assessing right heart function in these situations and can guide important clinical decisions. This congress is especially important because it brings together experts from all over the world, creating a space to exchange diverse perspectives on some of the most serious and complex topics in critical care. These conversations help us broaden our thinking, challenge our assumptions, and ultimately improve how we care for our patients.

I am the Scientific Chairman of the Society of Cardiac Anesthesiologists of Thailand, and I've been traveling across Asia to promote fluid therapy and goal-directed therapy throughout the region. I must say, I found this meeting to be truly outstanding. It offers a global update on the latest data and practices in fluid management, all presented in an accessible and engaging format. While this may not be one of the largest meetings, it is certainly one of the most valuable. The quality of the content, the depth of discussion, and the opportunity to interact with international experts make it a very, very good meeting. Next year, I will actively promote this event across Asia and encourage more colleagues to attend. I strongly believe that many physicians from our region would benefit tremendously from being part of this growing community.

As we previously published, the Mortality Prediction Model version II appears to be the most accurate tool for predicting maternal mortality in obstetric populations, particularly in low- and middle-income countries such as Colombia and others in Latin America. Our presentation focused on the use of severity of illness scores in pregnant patients. We evaluated several general severity indices and assessed how effectively they measure the clinical condition of obstetric patients. After completing our analysis, we concluded that the Mortality Prediction Model II outperformed other models in predicting maternal mortality within our specific patient population in Colombia. One interesting observation during our study was seeing age listed as the first variable—something that's rarely emphasized in European models. It sparked some fascinating discussion, as this may reflect unique demographic or clinical realities in different regions, and certainly warrants further exploration. This meeting has been an incredible experience. I was genuinely surprised—and inspired—by the diversity of participants, coming from all over the world. The exchange of experiences, especially around fluid management, has been extremely enriching. What makes this congress special is that it doesn't focus solely on the critically ill adult population, but also includes discussions around surgical, obstetric, pediatric, and neonatal patients. That breadth makes it truly unique—and a valuable learning opportunity for all of us.

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. 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.

Simplicity is key. We need to keep things simple—because even experts often struggle to interpret complex data. That's why it's crucial to ensure that data are not only easy to access, but also easy to understand and act upon. My name is Geert Creemers, and I'm the CEO and founder of Argon Measuring Solutions. I'm probably one of the few, if not the only, non-medically trained professionals attending this conference. I come from the industrial sector, where we specialize in high-precision 3D measurement technologies. In a conversation with Prof. Manu Malbrain, the organizer of this congress, we discovered some fascinating parallels between the medical and industrial worlds. While our sectors may seem different on the surface, we face similar challenges—particularly around data usability, decision-making, and real-time feedback. Over the past five to ten years, our industry has learned some important lessons—lessons that, I believe, could be highly relevant to the medical profession: Keep systems simple Deliver data quickly to the right people, whether that's an engineer or a doctor, an operator or a nurse As a company, we're now exploring opportunities to adapt some of the platforms and solutions we've developed for industry to meet the needs of the medical field. We believe that cross-sector collaboration like this could bring real value—especially in an era where precision, speed, and clarity are more important than ever.

Hi I am Annika Reintam Blaser from Estonia and when we talk about enteral nutrition, it's important to clarify that it can be administered via gastric, jejunal, or even transgastric routes—and each of these approaches matters. They are not interchangeable, and the route of administration can have a significant impact on tolerance and outcomes. In my lecture, I presented the European guidelines on early enteral nutrition in critically ill patients. These guidelines represent a substantial collaborative effort, and we developed them with a clear goal: to make them practical and applicable at the bedside, supporting clinicians in their daily decision-making. However, it is equally important to recognize the limitations of our current knowledge. The evidence base is weak, and as a result, all of our recommendations are conditional. That transparency is essential. We don't want to oversell certainty where it doesn't exist. Another critical point I want the audience to remember is this: Even when early enteral nutrition is indicated, it should always be initiated slowly and carefully. Critically ill patients are vulnerable, and nutrition must be introduced in a way that supports recovery without causing harm. In summary: There are meaningful differences in route of delivery. The current guidelines are practical, but the evidence is limited. And regardless of indication, early enteral nutrition must be started with caution.

I am Fabio Taccone from Brussels, Belgium. When you look at real patients—and not just models—undergoing CPH (continuous purification therapies) and measured for antibiotic concentrations, what you find is striking: there is huge variability in how these drugs behave. I was invited to speak about the association between fluids and fluid overload, specifically in relation to pharmacokinetics—the study of how drug concentrations change over time in the body. I shared two key messages with the audience: Pharmacokinetics in critically ill patients is highly unpredictable. In the ICU, we often administer therapies without fully understanding how these drugs are processed. Critical illness alters drug behavior—absorption, distribution, metabolism, and clearance—and we cannot always predict how much of the drug will reach its target. Fluid therapy can significantly alter drug concentrations. When we administer fluids, we're not just "filling the tank"—we're expanding the volume of distribution for many drugs. This can dilute plasma concentrations and, in some cases, increase drug clearance. In other words, fluid management directly affects the effectiveness of antibiotic therapy and other medications. The big takeaway is this: when we measure drug concentrations in actual ICU patients—outside of pharmacokinetic models—the variability is enormous. You cannot rely on standard dosing or one-size-fits-all assumptions. What works in theory or in stable patients may not work at all in critically ill individuals. This highlights the importance of Therapeutic Drug Monitoring (TDM) in the ICU. If we truly want to personalize therapy and improve outcomes, we must measure and adjust based on real-time pharmacokinetics, not outdated models. This meeting has been a great platform for these kinds of discussions. It's a focused congress—dedicated entirely to fluids—allowing us to explore specific aspects of fluid management that often get overlooked in larger general conferences. It's also a fantastic opportunity to network, meet colleagues and friends, and hear the latest research and thinking in this evolving field. The meeting is clearly growing in participation, the organization is excellent, and the location is ideal. It's a pleasure to be part of it.

Hi, I am Jan De Waele from Ghent, Belgium. At this meeting, fluid therapy has rightly taken center stage—with many presentations and discussions focused on when and how to give fluids. But far fewer have tackled the other side of the coin: fluid removal. In my talk, I addressed a topic that's gaining attention yet remains understudied: the dangers of fluid de-escalation. While it's a common intervention, we still have limited understanding of the potential risks involved. These risks are closely tied to both the methods and the rate at which fluids are removed. I provided an overview of the different aspects of de-escalation—its role, clinical rationale, and, most importantly, how to apply it safely at the bedside. Of course, the best-case scenario is to avoid excessive fluid administration in the first place. That's a no-brainer. Prevention is always better than cure. A good place to start is by carefully monitoring the cumulative fluid balance from the beginning of treatment. But when de-escalation is needed, it's crucial to understand that it can come with significant risks—not only in the short term, but potentially with long-term consequences as well. Simply looking at fluid balances and lab values isn't enough. Effective de-escalation demands clinical judgment, careful patient evaluation, and a keen sense of timing. One of the biggest challenges is identifying the turning points—those critical moments when the patient is truly ready for fluid removal. Get it wrong, and you may cause more harm than good. This is not my first time at this meeting, and I've been excited to see how it continues to grow with every edition. It's clear that fluid therapy is a core issue in critical care, but it's also clear that we need more scientific data, especially when it comes to how and when to remove fluids safely. This is a challenge we'll need to tackle in the coming years. We're not there yet.