DrYGeorge - Fluid Balance and Organ Dysfunction 2013 Residen
Transcript of DrYGeorge - Fluid Balance and Organ Dysfunction 2013 Residen
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FLUID BALANCE AND ORGANDYSFUNCTION IN
PERIOPERATIVE AND
CRITICAL ILLNESS
Yohanes George
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Outline: Fluid accumulation is associated with adverse
outcomes
Pathophysiology of Fluid shifts in critical illness
Relationship of fluid accumulation to multi organ
dysfunction
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FLUID ACCUMULATION IS ASSOCIATED
WITH ADVERSE OUTCOMES
INTRODUCTION
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SUMMARY OF CLINICAL STUDIES SHOWING AN
ASSOCCIATION BETWEEN FLUID BALANCE AND
CLINICAL OUTCOME
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NEGATIVE FLUID BALANCE PREDICTS
SURVIVAL IN PATIENTS WITH SEPTIC SHOCK
Alsous et al: CHEST 2000; 117:1749-1754
Conclusion: These results
suggest that at least 1 day of
negative fluid balance (
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PEDIATRIC PATIENTS: HIGHER PERCENTAGES OF FLUID
OVERLOAD (FO) AT DIALYSIS INITIATION LINKED WITH
INCREASED MORTALITY
Goldstein,
Pediatrics2001
Foland, CritCare Med 2004
Gillespie,Pediatr
Nephrol 2004
Goldstein, KI2005
Foland J et al: Crit care Med 2004 Aug: 32 (8): 1771-5
%FO was defined as total input minus output (up to 7 daysbefore CVVH) for both hospital stay and ICU stay
10%
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IN SEPTIC PATIENTS WITH AKI, FLUID OVERLOAD WAS
ASSOCIATED WITH DECREASED AT 60 DAYS
Payen et al. Crtical Care 2008. 12:R74
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ACUTE RENAL FAILURE, STRATIFIED BY TIME OF
INITIATION OF RENAL REPLACEMENT THERAPY (RRT)
Payen et al. Crtical Care 2008. 12:R74
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IN SEPTIC PATIENTS WITH AKI, FLUID OVERLOAD WAS
ASSOCIATED WITH DECREASED SURVIVAL AT 60 DAYS
Payen et al. Crtical Care 2008. 12:R74
ARF (SOFA Score) = Cr > 3.5 mg/dl or UO < 500 mL/day
Early ARF = Occuring within 2 days of ICU admission
Late ARF = Occuring more than 2 days after ICU admission
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EFFECT OF FLUID OVERLOAD IN CRITICALLY ILL
PATIENTS WITH AKI
618 critically ill patients with AKI 396 patients required dialysis
PICARD study Prospective cohort
5 teaching U.S. hospital Between 1999 and 2001
Hypothesis:
Fluid overload in
adult AKI
patients treated
with dialysis
would
independently
contribute to
adverse
outcomes
PICARD Data J Bouchard et al Kidney Int, 2009
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METHODS
Percentage of FO/body weight ( FO)
FO = (daily (total input (L)
total output (L) x 100
body weight (kg)
Data analysis for fluid overload from 3 days beforeconsultation until hospital discharge
PICARD Data J Bouchard et al Kidney Int, 2009
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RESULTS
Survival Non-survival P
Mean %FO at
dialysis initiation
8.8% 14.2% 0.01
Adjusted OR for death with %FO >10% at dialysis initiation:
2.07 (95% CI 1.27-3.37)
PICARD Data J Bouchard et al Kidney Int, 2009
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INFLUENCE OF FLUID ACCUMULATION ON
MORTALITY
PICARD Data J Bouchard et al Kidney Int, 2009
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DIALYZED PATIENTS: KAPLAN-MEIER SURVIVAL
ESTIMATES BY FLUID OVERLOAD STATUS AT DIALYSIS
INITIATION
PICARD Data J Bouchard et al Kidney Int, 2009
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DURATION OF FLUID OVERLOAD
PICARD Data J Bouchard et al Kidney Int, 2009
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EFFECT OF CORRECTION OF FLUID OVERLOAD
PICARD Data J Bouchard et al Kidney Int, 2009
FO < 10 FO > 10 P
Survival rate 65% 44% 0.004
Survival Non-survival P
Mean %FO at
dialysis cessation
13.0% 22.1% 0.004
Adjusted OR for death with %FO > 10% at dialysis cessation: 2.52
(95% CI 1.55-4.08
Effect of fluid overload on survival when FO > 10
at dialysis initiation:
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INFLUENCE OF MODALITY ON FLUID
OVERLOAD
PICARD Data J Bouchard et al Kidney Int, 2009
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SUMMARY OF RESULTS
%FO > 10% at dialysis initiation:
2 fold increase in mortality
Duration and correction of fluid overload
influences mortality rates
%FO > 10% at dialysis cessation:
2.5 fold increase in mortality
Modality choice influences fluid management
PICARD Data J Bouchard et al Kidney Int, 2009
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PATHOPHYSIOLOGY OF FLUID
SHIFT IN CRITICAL ILLNESS
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The Third Space The Old Paradigm
trapped
The third space in its
traditional interpretation is a
functionally separated part ofthe extra-cellular
compartment which cannot
be localised, but primarily
consumes fluid in the
perioperative context.
It is currently no more than a
myth to explain the otherwise
apparently unexplainable
perioperative fluid shifting
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Classic
perioperative fluid management
Deficits: Estimate Preop NPO (hourly maintenance x duration) Preop bowel preparation (1-1.5L) Preop blood loss (trauma) or fluid loss (burns) Typically replaced over first 2-4 hours
Maintenance: (4-2-1 rule): 4 ml/kg/hr for first 10 kg of body weight 2 ml/kg/hr for 2nd 10 kg of body weight 1 ml/kg/hr for each kg of body weight above 20 kg
3rdSpace: Third space2-10 ml/kg/hr
Blood loss: 3 to 1 ratio of crystalloid to EBL 1 to 1 for colloid or blood
(or hypertonic saline)
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TRADITIONAL CONCEPT OF PERIOPERATIVE
FLUID LOADING
Chappell D et al. Anesthesiology 2008;109:723
Median blood volume status of 13 patients
with ovarian cancer before and after major
abdominal surgery, receiving a standard
infusion regimen (crystalloids: approximately
12 ml/kg/h; blood loss replaced 1:1 with
colloid)
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5100
3800
2000
1700
750
4621
5800
2450
1. Preoperatively fasted
2. Insensible lost
3. 3rdspace
4. Vasodilatation of anesthesia
Direct blood volume
measurements (double-label
technique)
Fluid shift
Where did they
go?..interstitial
Chappell D et al. Anesthesiology 2008;109:723
TRADITIONAL CONCEPT OF PERIOPERATIVE
FLUID LOADING
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Chappell D et al. Anesthesiology 2008;109:723
Perioperative weight gain
increases with the
perioperative amount of
infused crystalloids
IMPACT OF TRADITIONAL CONCEPT OF FLUID
LOADING
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THIRD SPACE: FACT OR FICTION?
M. Jacob et al. Best Practice & Research Clinical Anaesthesiology 23 (2009) 145157
1. The third-space fluid losses have never been measured directly, and the
actual location of the lost fluid remains unclear
2. Most of the data do not support the existence of a third space.
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FLUID DYNAMICS ACROSS THE CAPILLARY BEDS
The classicalStarling principles of vascular barrier functioning and capillaries on inward-directed colloid
osmotic pressure gradient is opposed to an outward-directed hydrostatic pressure of fluid and colloids. The
thick arrows symbolize the two schematically opposing forces across the vascular wall, the small one the
small net filtration outwards assumed according to this model.
Jv, net filtration; Kf, filtration coefficient; Pc, capillary hydrostatic pressure; Pi, oncotic pressure in the
interstitial space; Pi, hydrostatic pressure in the interstitial space; Pc, oncotic pressure in the vascular lumen;
Pc, hydrostatic pressure in the vascular lumen; s, reflection coefficient
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SCHEMATIC REPRESENTATION OF CAUSES OF
HYPOALBUMINAEMIA IN CRITICALLY ILL PATIENTS
J.-L. Vincent, Best Practice & Research Clinical Anaesthesiology 23 (2009) 183191
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RESPONSE TO FLUID ADMINISTRATION
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RESPONSE TO FLUID ADMINISTRATION
Svensn et al., Anesthesiology (1997), 87
Ki V V
KbKr
(V- V)
V
V= expandable space of volume
V= target volume
Ki = constant fluid infusion rate
K
b
= basal rate of fluid elimination
(perspiration, basal diuresis)
Controlled rate of fluid elimination
proportional by a constantKr
to
the relative deviation ofvfromV
One-compartment Volume of Fluid Space Model
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RESPONSE TO FLUID ADMINISTRATION
Svensn et al., Anesthesiology (1997), 87
Two-compartment Volume of Fluid Space Model
KiV
1
V
1
Kb Kr(V1- V1)
V1
KtV
2
V
2
Secondary fluid space
The net rate of fluid exchange between the 2 compartments is
proportional to the difference in relative deviations from the target
volumes by a constant Kt
capillary cell
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colloids
crystalloid:75-80% leaves vasculature after 20 minutes
5% dextrose
capillary
membranecell
membrane
o Clearance of crystalloid during anesthesia and
surgery is 10-20 of that in awake volunteers
oCrystalloid leaves the plasma space, equilibrates
with interstitial space after 20-30 min
Hahn RG. Anesth Analg 2007; 105-304
Plasma
Volume 4.3%
Interstitial
fluid 15.7
VOLUME KINETICS FOR INFUSION CYSTALLOID IN
HEALTHY VOLUNTEER AND ANESTHESIA
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VOLUME KINETICS FOR INFUSION FLUIDS
Hahn GR, Anesthesiology 2010
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Hahn GR, Anesthesiology 2010
VOLUME KINETICS FOR INFUSION FLUIDS IN
DISEASES
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Hahn GR, Anesthesiology 2010
VOLUME KINETICS FOR INFUSION OF
CRYSTALLOID DURING SURGERY AND PRE-
ECLAMPSIA
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VOLUME EFFECT OF CRYSTALLOID
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WHAT ABOUT COLLOID?
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According classical starlings principle, infused iso-oncotic colloids do not change the intravascular
colloid osmotic pressure and cannot cross the
barrier.
Therefore, they should remain theoretically by 100%
within the circulatory space
INTRAVASCULAR VOLUME EFFECT OF COLLOID
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Normovolemia/
hemodilution
Volume loading
Hypervolemia
Not only crystalloids are shifted out of the
vasculature, but also colloids
INTRAVASCULAR VOLUME EFFECT OF COLLOIDS
IN HEALTH AND DISEASES
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Fluid Dynamics Across Capilarry Beds
Revised StarlingPrinciple
M. Jacob et al. Best Practice & Research Clinical Anaesthesiology 23 (2009) 145157
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THE ENDOTHELIAL GLYCOCALIX
Healthy vascular endothelium coated by endothelial glycocalyx a
layer of membrane-bound proteoglycans and glycoproteins.
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THE ENDOTHELIAL GLYCOCALIX
Glycocalyx affect endothelial permeability.
Prevent leukocyte and platelet adhesion.
Decreases inflammation. Bounds plasma proteins and fluids.
700 ~ 1000 mL of non-circulatoryplasma
fixed within.
Maintains oncotic gradientdespiteintravascular and extravascular equilibration.
Jacob M. et al: The endothelial glycocalix affords compatibility of starlings
principle and high cardiac interstitial albumin level. Cardiovasc Res 2007; 73:575-
86
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Levick J. R. J Physiol;2004;557:704-704
STARLING PRINCIPLE NEEDS UPDATE
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POSSIBLE PERIOPERATIVE FLUID MANAGEMENT
TRIGGERS FOR SHEDDING OF THE ENDOTHELIAL
GLYCOCALYX
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hyperglycemia
reperfusion injury
oxidized-LDL
Mechanical stress,
Endotoxin exposure,
Mediator SIRS, and ANP
(Atrial Natriuretic Peptide)Intact glicocalix Loss glicocalix
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Response to Volume Expansion
Volume expansion
Intake of salty food and fluids
excessive IV fluids / hypervolemia
Right atrial distension
increase venous capacitance
secretion of Atrial Natriuretic Peptide (ANP)
increased renal NaCl and H2O excretion
vasodilation
inhibit renin secretion
inhibit aldosterone secretion
Pouta AM: Effect of intravenous fluid preload on vasoactive peptide
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secretion during Caesarean section under spinal anaesthesia.
Anaesthesia 1996: 51.128-132
Responses in the concentrations of ANP in central () and peripheral () veins before and
during spinal anaesthesia for Caesarean delivery after a volume load of 21000 ml of
crystalloid solution (a) and 500 ml of colloid + 1000 ml of crystalloid solution (b). **p 20
All patients
General surgery
Cardiac surgery
* of patients studied that gained weight
*
*
*
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High dose Ringer
s Lacate
Voluven
Low dose Ringer
s Lactate
Voluven
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Post-operative complications
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TAKE HOME MESSAGES
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Type 2 shift - pathologic shift,result of 2 iatrogenic
problems.
Surgical:
Endothelial damage due to mechanical stress, endotoxin exposure,
ischemia-reperfusion injury and SIRS.
Anesthesiolgic:
Acute hypervolemia...!!!! Atrial Natriuretic Peptide
Perioperative fluid shifting
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Preserve endothelial glycocalyx to inhibit type 2
Pathologic shift.
Inflammatory mediators, stress, ischemia-reperfusion injury
can hardly be avoided, minimally invasive surgery
Maintaining vascular normovolemia.
Key to protection of endothelial glycocalyx
Prevent interstitial edema.
Perioperative fluid shifting
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The intravascular deficit after fasting is usually low.
Basal fluid loss via insensible perspiration
approximately 0.5 mL/kg/hr,
Extending to only 1 mL/kg/hr during
major abdominal surgery.
APPROACH TO FLUID MANAGEMENT
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Minimize type 1 shifting
Use crystalloids only when replacing urine production andinsensible perspiration.
Use colloids or blood products for substitution of acute
blood loss
Minimize type 2 shifting
Goal-directed method with available parameters
Conservatively to avoid acute hypervolemia
Use colloids instead of crystalloids.
APPROACH TO FLUID MANAGEMENT
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TERIMA KASIH