colloids or crystalloid solutions? is this (still) the question?
TRANSCRIPT
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Colloids or crystalloid solutions?Colloids or crystalloid solutions?
Is this (still) the question?Is this (still) the question?
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Why
Who
What
When
Where
W
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LIFE PRIORITIES
• PERFUSION
• O2
• pH
• electrolytes
Schiraldi
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Adequate tissue oxygenation is known to be key factor in
determining tissue survival.
Resuscitation efforts in critically ill patients therefore target
restoration, normalisation and manteinance of regional blood
flow and oxygenation.
JL Vincent 2008
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Adequate volume replacement appears to be
a cornerstone in management
as restoration of flow is a key component in
avoiding tissue ischemia or riperfusion injury.
Boldt
Dry and die, wet and survive
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DODO2 = 2 = COCO** x CaO x CaO22#
COCO = stroke volume x FC
CaOCaO22 = (Hb x 1.34 x SaO2) + (PaO2 x 0.0031)
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myocardial contractility
preload
afterload
Stroke Volume Heart Rate
COSVR
Blood Pressure
Rhythm
Hb SpO2
DO2
x
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myocardial contractility
preload
afterload
Stroke Volume Heart Rate
COSVR
Blood Pressure
Rhythm
Hb SpO2
DO2
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Currently, there is no consensus on
the clinical definition of hypovolemia. In
broad terms, patients who improve with
fluid therapy are hypovolemic.
Static indices of preload have no predictive power in hypovolemia.
Crit Care Med 2009 Vol. 37, No. 9
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TBWTBW(Total Body Water)(Total Body Water)
60% of body weight60% of body weight
TBWTBW(Total Body Water)(Total Body Water)
60% of body weight60% of body weight
2/3 2/3 ICFICF2/3 2/3 ICFICF 1/3 1/3 ECFECF1/3 1/3 ECFECF
NaNa
H20
¾¾ INT INT1/4 1/4 PLPL
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EABV
Tissues Perfusion
(700 ml)
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• capacità di espansione volemicacapacità di espansione volemica
• persistenza in circolopersistenza in circolo
• effetti sulla cascata di attivazione della effetti sulla cascata di attivazione della SIRSSIRS
• influenza sul microcircoloinfluenza sul microcircolo
• sicurezzasicurezza
• reazioni avversereazioni avverse
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LIC
FisiologicaFisiologica
Bilancio dopo la infusionedi 1 litro di soluzione:
Intravasale = 250
Interstiziale = 750
Intracellulare = 0
1 litro vasi
interstizio
LEC
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Acqua libera(glucosata)
Acqua libera(glucosata)
Bilancio dopo la infusionedi 1 litro di soluzione:
Intravasale = 85
Interstiziale = 250
Intracellulare = 665
1 litro vasi
interstizio
LIC
LEC
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ColloidiColloidi
Bilancio dopo la infusionedi 1 litro di soluzione:
Intravasale = 600 – 1000
Interstiziale = 0 – 400
Intracellulare = 0
1 litro vasi
interstizio
LIC
LEC
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Ipertonica(NaCl 7,5 %)
Ipertonica(NaCl 7,5 %)
Bilancio dopo la infusionedi 1 litro di soluzione:
Intravasale = 7000
Interstiziale = disidratazione
Intracellulare = disidratazione
1 litro vasi
interstizio
LIC
LEC
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INTRAVASCOLARE EXTRAVASCOLARE
Normale permeabilità capillare (PC)
CRISTALLOIDI 25% 75%
COLLOIDI 70% 30%
Aumentata PC
CRISTALLOIDI 15-20% 80-85%
COLLOIDI 60-70% 30-40%
Aumentata PC + disfunzione di membrana
CRISTALLOIDI 10-15% 85-90%
COLLOIDI 50-60% 40-50%
INTRAVASCOLARE EXTRAVASCOLARE
Normale permeabilità capillare (PC)
CRISTALLOIDI 25% 75%
COLLOIDI 70% 30%
Aumentata PC
CRISTALLOIDI 15-20% 80-85%
COLLOIDI 60-70% 30-40%
Aumentata PC + disfunzione di membrana
CRISTALLOIDI 10-15% 85-90%
COLLOIDI 50-60% 40-50%
Distribuzione relativa di colloidi e cristalloidi Distribuzione relativa di colloidi e cristalloidi a 30-60 minuti dalla infusionea 30-60 minuti dalla infusione
Distribuzione relativa di colloidi e cristalloidi Distribuzione relativa di colloidi e cristalloidi a 30-60 minuti dalla infusionea 30-60 minuti dalla infusione
da Haljmae e Lindgren, 2000
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Fluid Challenge TestFluid Challenge TestFluid Challenge TestFluid Challenge Test
Test di espansione volemica
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…approximately 20 mL/kg of isotonic crystalloid,
followed by boluses of up to 1000 mL of
crystalloid or 500 mL of colloid given over 30
minutes to achieve adequate resuscitation.
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign:
international guidelines for management of severe sepsis and septic
shock: 2008. Crit Care Med. 2008;36:296-327.
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Increasing the infusion rate of an oliguric
patient from
100 ml/h to 200 or 300
provides no answer to the question of
etiology of oliguria nor does it
adequately treat volume depletion.
Chernow
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As colloids are not associated with an
improvement in survival, and as they are more
expensive than crystalloids, it is hard to see how it is hard to see how
their continued use in these patients can be their continued use in these patients can be
justified outside the context of RCTsjustified outside the context of RCTs.
Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) Perel P, Roberts I
Cochrane Database of Systematic Reviews. 3, 2009.
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No clinical differences were found between colloids and
crystalloids in most of the studies analyzed.
Given the significant difference in costs between both
groups of expanders and in light of the currently available
evidence, crystalloids should be used as first-choice
expanders.
Health Technology Assessment Database. 2010 Issue 4,
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If a colloid has to be chosen, HES could be a cheaper substitute
than albumin in most cases; though its benefits have not been
proven over jellies, it is the cheapest choice.
The main adverse effects shown in HES were with older molecules
with high molecular weight and high degree of substitution and
not with the newer ones, such as Voluven, however given the
evidence available, the use of HES in patients with kidney function
impairment should be avoided.
Health Technology Assessment Database. 2010 Issue 4,
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SAFE (Saline vs Albumin Fluid Evaluation) Study.
In nearly 7,000 critically ill patients, there was no
difference in outcome between the use of 4% human
albumin solution and normal saline.
N Engl J Med 2004; 350: 2247–56
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Efficacy of Volume Substitution and Insulin
Therapy in Severe Sepsis (VISEP) trial
N Engl J Med. 2008;358:125-139
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The VISEP trial was stopped early for safety
reasons. A planned interim analysis showed that
among 537 patients with severe sepsis
…patients receiving pentastarch were approximately 50% more
likely to have acute renal failure develop and were also more
likely to require renal replacement therapy.
N Engl J Med. 2008;358:125-139
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The choice of intravenous fluid (colloid versus crystalloid)
does not appear to be a major determinant in outcome in
septic shock and the use of artificial plasma expanders
such as pentastarch should be avoided.
Engl J Med 2008; 358:125–139.
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There are insufficient data to conclude that
synthetic colloids are safe in the critically ill
or to recommend their use when cheaper
crystalloid solutions are available.
HES solutions should be avoided in patients
with severe sepsis and septic shock
Merz,FinferControversies in Intensive Care Medicine 2008
ESCIM Europrean Society of Intensive Care Medicine
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La fisiologica non è fisiologica
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A balanced view of balanced solutions
Convincing evidence for clinically relevant adverse
effects of dilutional-hyperchloraemic acidosis on renal
function, coagulation, blood loss, the need for
transfusion, gastrointestinal function or mortality cannot
be found.
Crit Care. 2010 Oct 21;14(5):325
.
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We believe that giving a sufficient quantity of
intravenous fluids rapidly and targeting
appropriate goals is more important than the
type of fluid chosen.
Schmidt 2009
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• capacità di espansione volemicacapacità di espansione volemica
• persistenza in circolopersistenza in circolo
• effetti sulla cascata di attivazione della effetti sulla cascata di attivazione della SIRSSIRS
• influenza sul microcircoloinfluenza sul microcircolo
• sicurezzasicurezza
• reazioni avversereazioni avverse
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high volume maintenance fluids
vs. low volume fluids
after the initial phase of the management
in septic shock
The NHLBI ARDS Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575
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Whereas inadequate volume resuscitation is well recognized to
result in organ failure and death, excessive resuscitation places
the patient at risk for increased IAP, worsening visceral edema,
and cardiopulmonary dysfunction.
Cheatham M Crit Care Med 2008 36(3):1012-1014
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World Society of the Abdominal Compartment Syndrome
… “reliance on overaggressive fluid therapy may worsen gut wall edema leading to further increases in IAP”.
“….in the bacteremic state, restoring APP and not just cardiac output may be important.”
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New Blood, Old Blood, or No Blood?
Adamson JV NEJM 2008 358;12
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Red blood cell transfusion in the critically ill:
When is it time to say enough?
Corwin, Shorr Crit Care Med 2009 37;6:2104
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TRICC e TRAC
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A multicenter, randomized, controlled clinical
trial of Transfusion Requirements in Critical Care
Hebert PC et al: N Engl J Med 1999; 340:409 – 417
TRICC
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Transfusion Requirements After Cardiac Surgery
The TRACS Randomized Controlled Trial
Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.
JAMA. 2010;304(14):1559-1567
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The data available would suggest that, in the
absence of acute bleeding, Hb of 7.0 –9.0 g/dL
are well tolerated by most critically ill patients
and that a transfusion threshold of 7.0 g/dL is
appropriate.
Corwin, Shorr Crit Care Med 2009 37;6:2104
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Salvate il soldato Ryan
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Does CVP predict fluid responsivness?
A sistematic review of literature and a tale of seven mares.
Mark et al CHEST 2008; 134:172-178
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CVP should no longer be routinely measured in the
ICU, operating room, or ED.
CVP should not be used to make clinical decisions
regarding fluid management
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In patients with cardiac depression from
anesthesia or sepsis, those with ongoing blood
loss, or those with systemic vasodilation,
it is certain that no useful relationship
between CVP and blood volume exists.
Leibowitz, ASA 2009
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Based on the results of our systematic review, we
believe that CVP should no longer be routinely
measured in the ICU, operating room, or ED.
Mark et al CHEST 2008; 134:172-178
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Using CVP to guide volume resuscitation fails
to acknowledge that this parameter is no
better than a coin toss in predicting who will
respond to fluids.
Durairaj L , Schmidt GA . Fluid therapy in resuscitated sepsis:less is more . Chest . 2008 ; 133 ( 1 ): 252 - 263 .
Osman D , Ridel C , Ray P , et al . Cardiac fi lling pressures arenot appropriate to predict hemodynamic response to volume
challenge . Crit Care Med . 2007 ; 35 ( 1 ): 64 - 68 .