Fluid Management in Critical Ill Patient (Ehrenfried Schindler)

7/28/2019 Fluid Management in Critical Ill Patient (Ehrenfried Schindler)

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Dry or wet? Fluid Management in critical illpatients

Ehrenfried Schindler


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Now information about the obligation matter of fluidmanagement in critical ill patients. It was discussion

about who will winCrystalloids or Colloids. From thereceived results is known, that the patient being in

critical condition is better to be dry than wet.under all circumstances volume therapy should be

guided by its effects on organ function and indicators

of the adequacy of tissue oxygenation.


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Tissue

Hypoxia

Inflammation

Volume

Perfusion

Micro-

circulation

Multi Organ Failure


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Colloid

Crystalloid


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Fluid management

in critical ill: who will win?

Crystalloids vs. Colloids

Colloids vs. ColloidsCrystalloid vs. Crystalloid

Dry vs. Wet


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Colloids vs. Crystalloids

Human Albumin = natural Colloid

Artificial ColloidsHydroxyethylstarch (HES)

Gelatin

Dextran


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Maintain or increase oncotic pressure

Significant increase of intravascular volume

Stays in the intravascular department

Better perfusion?

Less tissue edema?

Less mortality?

Increase in outcome?

Benefit of Colloids vs. Crystalloids


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Velanovich V: Crystal loid versus col loid f luid resusci tat ion: a meta-analysis ofmortal i ty.1989 Surgery 105: 65-71Mortality increased with colloids

Schierhout G: Fluid resusc i tat ion w ith col loid o r crystal loid solut ion in c r i t ically i l lpat ients: a systemic review. 1998 Crit Care Med 27: 200-210Compared to Crystalloids 4% increased mortality when Colloids are the primary volumereplacement

Choi P. et al.: (Isotonic) Crystal loid v s. Col loids in f luid resus ci tat ion: a systematicreview. 1999 Critical Care Medicine, 27: 200-210Mortality unchanged In the group of trauma patients significant better results when usingcrystalloids

Number of pulmonary edema without difference

No difference in ICU stay

Bunn F. et al.: Col loid so lut ions for f luid resus ci tat ion. Cochrane Database Syst Review2003(1): CD001319

There is no evidence that one colloid solution is more effective or safe than any other.



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Hands up !!

1. Colloids are more effective than

crystalloids

2. HES is more effective than other colloids3. HES influence outcome more positive

compared to crystalloids, albumin,

dextran or gelatin


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84% think, that Colloids are more effective than crystalloids

77% think, that HES is more effective than other colloids

87% think, that HES influence outcome more positive compared to crystalloids,

albumin, dextran or gelatin

Intraoperative: 75%-90% are using HES and crystalloids for volume replacemen

(Exception: Children and burn patients (albumin and crystalloids)

Intensive care unit: 84% are using HES, 45% are using crystalloids

(Exception: Children and burn patients (albumin and crystalloids)

What do we guess about volume replacement?

Boldt J, Schllhorn T, Dieterich HJ: Volumentherapie in Deutschland eine Ist-Analyse anhand einer

Fragebogenaktion. Ansth Intensivmed 47: 309-317 (2006)


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Increased mortality after albumin administration in critically ill patientsCochrane Injuries Group Albumin reviewers 1998 BMJ

No differences in outcome (new organ failure, duration of ventilation,

renal replacement therapy, length of stay) and mortality after albumin

administration (vs. saline)Wilkes MM: Patient survival after human albumin administration. A meta analysis of randomized, controlled trials. Ann Intern Med

2001: 149-164.

The SAFE (Saline vs. Albumin Fluid Evaluation) Study Investigation. A comparison of albumin and saline for fluid resuscitation in the

intensive care unit. N Engl J Med 2004; 350: 2247-56

More expensive

Risk of infection

Albumin


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Is albumin administration in the acutely ill

associated with increased mortality? Results of the SOAP study

Vincent JL et al. Critical Care, 9:R745-R754 (2005

% albumin

administration


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No albumin

(n=339)

Albumin

(n=339)

Log rank = 7,63

p= 0,006


Cumulative

survival




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In this observational study of 3,147 patients, albumin administration

was independently associated with a lower 30-day survival

Moreover, in 339 pairs matched according to a propensity score, ICU

and hospital mortality rates were higherin patients who receivedalbumin than in those who did not

While albumin administration may be safe in patients requiring fluid for

intravascular volume depletion, these results suggest it may not beharmless in all ICU patients.





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RESUSCITATION FROM SEPTIC SHOCK

WITH CAPILLARY LEAKAGE:

HYDROXYETHYL STARCH (130 KD), BUT

NOT RINGERS SOLUTION MAINTAINS

PLASMA VOLUME AND SYSTEMIC

OXYGENATION

Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004


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Key conclusion:

HES 130 kD could maintain PV and COP, thereby preserving systemic

oxygenation and hemodynamics.

These results suggest the intravascular persistence of the artificial

colloid in the presence of albumin leakage.



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30 children less than 3 years undergoing cardiac surgery.

Volume replacement with 6 % HES (200/0.5) vs. 20% human albumin (pre-bypass

period).

Outcome measures: HR, MAP, CVP, BGA, colloid osmotic pressure, electrolytes,

fibrinogen, AT III, albumin, platelet count, overall coagulation tests, urine output,

creatinine, blood loss, total use of homologous blood, FFP and platelet

concentrates.

No significant Difference (except Albumine concentration)

Conclusion: LMW-HES ist safe and effective in pediatric cardiac

surgery


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Fluid resuscitation in severe sepsis and septic shock:

Albumin, hydroxyethylstarch, gelatin or ringers solutionlactate:

Does it really make a difference?


Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)


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Feces spillage

Surgical Operation

Randomization

4h RL resuscitation Study until spontaneous death


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although albumin and HES solution were

associated with higher cardiac output and DO2,and lower blood lactate levels than gelatin and

RL, our results suggest that the type of i.v. fluid

used for initial fluid resuscitation has limited

effects on outcome.

Key conclusion:


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Next Round


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Fluid Resuscitation during capillary

leakage: Does the type of fluid make a difference?

Hasibeder WR, Intensive Care Med 28:532-534 (2002

Meta-Analysis: Methodological limitations

old overall treatment changes over years

types, doses, duration of fluid administration varies

highly heterogeneous patient population


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Sepsis in European intensive care units:

the SOAP study

Cohort, multi-center, observational study

198 ICU 24 European countries

total of 3,147 patients



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Sepsis in European intensive care units:

the SOAP study



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Factors of increased mortality

Degree of organdysfunction

Patient age

Cirrhosis

Mean fluid balance


Indicator of

severity,

Independent

predictor of

outcome


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Endothelial Glycocalix

The new Barriere Reef

A Rat ional Approach to


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Perioperat ive Fluid ManagementDaniel Chappell , M.D.,* Matthias Jacob , M.D.,* Klaus Ho fman n-Kiefer, M.D.,* Peter Con zen, M.D., Markus

Rehm, M.D.

Anesthesiology 2008; 109:72340

Determinants of insensible fluid loss.


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FluidInput

Fluid

Shift

3833 ml

Cryst

(ml)Colloid

(ml)

Preop

Bloodvolume

(ml)

Postop

Bloodvolume

(ml)

Blood

(ml)

Urine

(ml)

FluidOutput


Perspiration, protein shift and endothelial

glycocalyx

Jakob M et al., Anaesthesist 2007 56:747764



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Perioperative

Proteine

Input (g)

Proteine

Output (g)

Albumin

InfusionBlood

Loss

PreO

P

Intrav

ascular

Protein

(g)

Post

OP

Intrav

ascular

Prote

in

(g)


Perspiration, protein shift and endothelial

glycocalyx

Jakob M et al., Anaesthesist 2007 56:747764


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Fluid Management in critical ill:

Conclusion


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Albumin should be used with caution in critical ill

patients, although in pt. with low albumin it may be

beneficial dry seems to be more beneficial than wet

Colloids (HES, Gelatin) have some advantages

regarding fluid therapy in sepsis


Conclusion

but


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Conclusion

there is concern about the increased risk of acute

renal failure with HES administration

and


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Conclusion

under all circumstances volume therapy

should be guided by its effects on organfunction and indicators of the adequacy of

tissue oxygenation.

Reinhart K, Nephrol Dial Transplant 11, editorial comment (1996)

and


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mSrali Tu sveli? siTxis menejmentie.Sindleri(sanqt-augustine, germania)moyvanilia siTxis moculobis marTvis sakiTxi kritikulmdgomareobaSi nyof avadmyofebSi. Ganxilulia kristalodurida koloiduri xsnarebis upiratesobis sakiTxi, miRebuliSedegebidan gamomdinare gairkva, rom kritikulmdgomareobaSi myofi avadmyofi umjobesia iyos ufro ,,mSralvidre ,,svel mdgomareobaSi.


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Fluid Management in Critical Ill Patient (Ehrenfried Schindler)

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