Is de vochtbalans in het water gevallen?...& Madsen, M. B. (2016). Restricting volumes of...
Transcript of Is de vochtbalans in het water gevallen?...& Madsen, M. B. (2016). Restricting volumes of...
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31-10-2018
Is de vochtbalans in het water gevallen?
Een retrospectief dossieronderzoek naar de vochtbalans van patiënten met sepsis op de Intensive Care
Carolien Bakker-CrommentuijnCirculation Practitioner i.o.VieCuri Medisch Centrum
Medisch begeleider: dr. D.J. Mehagnoul-SchipperAfdelingsmanager: Martien Massoeurs
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Sint Maartens Gasthuis 1993
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Inhoudsopgave
• Inleiding
• Aanleiding
• Onderzoeksvragen
• Methode
• Resultaten
• Conclusie
• Aanbeveling
• Rol practitioner
• Dankwoord
• Literatuurlijst
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Inleiding
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VieCuri Medisch Centrum
• Verzorgingsgebied 280.000 inwoners
• 375 operationele bedden
• STZ ziekenhuis
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Intensive Care
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• 16 bedden • 7 Intensivisten• 8 Arts-assistenten• 1 Physician Assistant• 6 Practitioners• 55 IC- en 6 MC-Verpleegkundigen
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Intensive Care
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2014 2015 2016 2017
aantal opnames aantal ligdagen aantal sepsis
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Waarom lage vochtbalans?
• Hoge vochtbalans = Hoge mortaliteit
• 50% is niet fluid responsive
• Na 90 minuten minder dan 5 % intravasaal
• Restrictief vochtbeleid verlaagt mortaliteit
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Positieve vochtbalans
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Translocatie bacteriën
Hoge intra abdominale druk
Hoog extra vasculair longwater
Pleuravocht
Nierfalen
Delier Hoge intracraniële druk
Hartfalen
Cytokinen release
Slechte wondgenezing
Cholestase
Ileus
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Beoordelen circulatie
• Huid
• Urine productie
• Lactaat
• ScvO2
• MAP?
10Restoring microcirculation in anesthesia: Impact, usefulness and controversies, Diana Patricia Ñáñez-Varona
Normaal Septische Shock
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Meten fluid responsiveness (I)
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Betrouwbaar Niet betrouwbaar
PLRT CVD
Bolus vocht Echo Vena Cava
MAP
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Meten fluid responsiveness (II)
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CVD Niet betrouwbaar
Echo vena cava TEE
Eind exp occlusie test Verdragen 15 sec.
Fluid challenge ‘Fluid overload’
PLRT Betrouwbaar
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Passive Leg Raising Test
• Meest betrouwbaar met Cardiac Output
• MAP Sensitiviteit 85%, specifiteit 91%
• Spontaan ademen, aritmieën, kleine tidels, IAH
• Duur 1 minuut
• Geen ‘fluid overload’
• Ontwateren
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Aanleiding
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Binnen 3 uur vochtbolus van 30 ml/kg
Kristalloïden en eventueel Albumine 20%
Synthetische colloïden worden afgeraden
Vasopressie middels norepinefrine
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Onderzoeksvragen
1. Op basis van welke parameters is er besloten om vocht toe te dienen, bij IC patiënten met de diagnose sepsis, opgenomen op de IC in Venlo?
2. Vochtbalans na 24 en 48 uur
3. Vloeistoffen
4. Rapportage
5. Richtlijnen en literatuur
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Dep
osi
tph
oto
s.n
l
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Methode
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Methode
• Retrospectief dossier onderzoek
• 2017
• Geregistreerde opname diagnose sepsis
• Dataverzameling EPD
• Statistische analyse
• Vergelijking literatuur
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45 patiënten
7 geëxcludeerd 38 geïncludeerd
10 afgevallen na 24 uur 28 patiënten na 24 uur
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Resultaten
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Vraag 1
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1. Op basis van welke parameters is er besloten om vocht toe te dienen, bij IC patiënten met de diagnose sepsis, opgenomen op de IC in Venlo?
Aantal metingen
Echo cor 9
PiCCO meting 10
PLRT 3
ScvO2 0
Capillaire refill meting 2
Lactaat standaard
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Vraag 2 (I)
2. Wat is de vochtbalans na 24 en 48 uur van IC patiënten
met de diagnose sepsis, opgenomen op de IC in Venlo?
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=6.814 ml
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Vraag 2 (II)
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42%
39%
16%3%
0 t/m 5 6 t/m 10 11 t/m 15 ≥ 16
Populatie verdeeld in cumulatieve positieve in-vochtbalansNa 24 uur, in liters
• 81% vochtbalans < 10 liter• 19% vochtbalans > 10 liter
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Vraag 2 (III)
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bolus 24 cum 24 bolus 48 cum 48
Spreiding van vochtbolussen en cumulatieve vochtbalans 24 uur en van 24 tot 48 uur
Totaal volume aan vochtbolussen minder dan de helft
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Vraag 3
3. Met welke vloeistoffen worden IC patiënten met de diagnose sepsis, op de IC in Venlo, geresusciteerd?
• Alleen kristalloïden
• Geen albumine
• Eerste 24 uur 2071 ml Ringer lactaat
• Eerste 24 uur 1007 ml NaCl 0.9%
• P=0.013
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Vraag 4
4. Worden de vochtbalansen en parameters volledig gerapporteerd?
• 21% géén gewicht < 48 uur
• 71% geen diagnostiek naar fluid responsiveness
• 2 maal Capillaire Refill Meting
25despositphotos.nl
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Vraag 5
24 uur 48 uur 24 uur 48 uur 24 uur 48 uur
Survivors Non-survivors Algemeen
Acheampong 2015 2233 2324
Sadaka 2014 6500
Sirvent 2015 1710 1791 3154 4394
VieCuri 2017 6554 6756 5028 6814
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5. In welke mate wijken de vochtbalansen van IC patiënten met de diagnose sepsis opgenomen op de IC in Venlo, af van de internationale richtlijnen?
Vochtbalans in milliliters
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Conclusie
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Is de vochtbalans in het water gevallen?
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1. Fluid responsiveness in geringe mate gemeten
2. Geresusciteerd met kristalloïden
3. Vochtbalans na 24 uur 5.028ml en na 48 uur 6.814 ml
4. Rapportage onvolledig
5. Vochtbalans hoger dan gemiddeld
Kunstencultuur.nl
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Discussie
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• Geen eenduidigheid bepalen fluid responsiveness
• Discrepantie praktijk
• Hoe betrouwbaar is de vochtbalans?
• Geen SOFA
• Geen vochtbalans na 3 uur
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Kunstencultuur.nl
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Aanbevelingen
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• Resuscitatie protocol ontwikkelen
• Richtlijnen integreren
• Indicatiestelling echo cor, PiCCO, PLRT, lactaat
• Eenduidigheid bereiken
• De-resuscitatiefase
• Resuscitatie protocol implementeren
• Scholing
• EPD
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Rol Practitioner
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Implemeteren
Scholing geven
Motiveren
Best practiseNetwerken
Reflecteren
Onderzoek
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Speerpunten voor komend jaar
• Ontwikkelen en implementeren resuscitatieprotocol
• Onderzoek naar de-resuscitatiefase
• Introduceren Mottling-score
• Samenwerking Practitioners optimaliseren
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Dankwoord
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Bedankt!
• Ron, Siem & Rosa
• Jannet Mehagnoul
• IC Team
• Care Training Group
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Literatuurlijst 1 • Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., ... & Rochwerg, B. (2017). Surviving sepsis campaign:
international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine, 43(3), 304-377.
• Acheampong, A., & Vincent, J. L. (2015). A positive fluid balance is an independent prognostic factor in patients with sepsis. Critical care, 19(1), 251.
• de Oliveira, F. S. V., Freitas, F. G. R., Ferreira, E. M., de Castro, I., Bafi, A. T., de Azevedo, L. C. P., & Machado, F. R. (2015). Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock. Journal of critical care, 30(1), 97-101.
• Sirvent, J. M., Ferri, C., Baró, A., Murcia, C., & Lorencio, C. (2015). Fluid balance in sepsis and septic shock as a determining factor of mortality. The American journal of emergency medicine, 33(2), 186-189.
• Brotfain, E., Koyfman, L., Toledano, R., Borer, A., Fucs, L., Galante, O., ... & Klein, M. (2016). Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge. The American journal of emergency medicine, 34(11), 2122-2126.
• Sadaka, F., Juarez, M., Naydenov, S., & O’brien, J. (2014). Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality. Journal of intensive care medicine, 29(4), 213-217.
• Rochwerg, B., Alhazzani, W., Sindi, A., Heels-Ansdell, D., Thabane, L., Fox-Robichaud, A., ... & Ip, W. C. (2014). Fluid resuscitation in sepsis: a systematic review and network meta-analysis. Annals of internal medicine, 161(5), 347-355.
• Kelm, D. J., Perrin, J. T., Cartin-Ceba, R., Gajic, O., Schenck, L., & Kennedy, C. C. (2015). Fluid overload in patients with severe sepsis andseptic shock treated with early-goal directed therapy is associated with increased acute need for fluid-related medical interventionsand hospital death. Shock (Augusta, Ga.), 43(1), 68.
• Litton, E., & Morgan, M. (2012). The PiCCO monitor: a review. Anaesth Intensive Care, 40(3), 393-409.
• Hjortrup, P. B., Haase, N., Bundgaard, H., Thomsen, S. L., Winding, R., Pettilä, V., ... & Madsen, M. B. (2016). Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibilitytrial. Intensive care medicine, 42(11), 1695-1705.
• Malbrain, M. L., Marik, P. E., Witters, I., Cordemans, C., Kirkpatrick, A. W., Roberts, D. J., & Van Regenmortel, N. (2014). Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiology intensive therapy, 46(5), 361-380.
• Zhang, Z., Xu, X., Ye, S., & Xu, L. (2014). Ultrasonographic measurement of the respiratory variation in the inferior vena cava diameter is predictive of fluid responsiveness in critically ill patients: systematic review and meta-analysis. Ultrasound in medicine & biology, 40(5), 845-853. 38
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Literatuurlijst 2
• Monnet, X., Marik, P., & Teboul, J. L. (2016). Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive care medicine, 42(12), 1935-1947.
• Perel, A., Saugel, B., Teboul, J. L., Malbrain, M. L., Belda, F. J., Fernández-Mondéjar, E., ... & Maggiorini, M. (2016). The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study. Journal of clinicalmonitoring and computing, 30(5), 511-518.
• Monnet, X. & Teboul J. (2015). Passive leg raising: five rules, not a drop of fluid. Critical Care 19:18, DOI 10.1186/s13054-014-0708-5• Monnet, X. & Marik, P. (2016). Prediction of fluid responsiveness: an update. Annals of Intensive Care ; 6: 111., DOI 10.1186/s13613-
016-0216-7• Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., ... & Hotchkiss, R. S. (2016). The third
international consensus definitions for sepsis and septic shock (Sepsis-3). Jama, 315(8), 801-810.• Angus, D. C., Barnato, A. E., Bell, D., Bellomo, R., Chong, C. R., Coats, T. J., ... & Howe, B. (2015). A systematic review and meta-analysis
of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive care medicine, 41(9), 1549-1560.
• Mouncey, P. R., Osborn, T. M., Power, G. S., Harrison, D. A., Sadique, M. Z., Grieve, R. D., ... & Coats, T. J. (2015). Trial of early, goal-directed resuscitation for septic shock. New England Journal of Medicine, 372(14), 1301-1311
• Finfer, S., Liu, B., Taylor, C., Bellomo, R., Billot, L., Cook, D., ... & Myburgh, J. (2010). Resuscitation fluid use in critically ill adults: aninternational cross-sectional study in 391 intensive care units. Critical care, 14(5), R185.
• Monnet, X., & Teboul, J. L. (2015). Passive leg raising: five rules, not a drop of fluid!.• Monnet, X., Marik, P. E., & Teboul, J. L. (2016). Prediction of fluid responsiveness: an update. Annals of intensive care, 6(1), 111. • Rivers, E. P., Katranji, M., Jaehne, K. A., Brown, S., Abou Dagher, G., Cannon, C., & Coba, V. (2012). Early interventions in severe sepsis
and septic shock: a review of the evidence one decade later. Minerva anestesiologica, 78(6), 712.• Yu, B., Tian, H. Y., Hu, Z. J., Zhao, C., Liu, L. X., Zhang, Y., ... & Li, J. (2013). Comparison of the effect of fluid resuscitation as guided either
by lactate clearance rate or by central venous oxygen saturation in patients with sepsis. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue, 25(10), 578-583.
• Puskarich, M. A., Trzeciak, S., Shapiro, N. I., Arnold, R. C., Heffner, A. C., Kline, J. A., ... & Emergency Medicine Shock Research Network (EMSHOCKNET). (2012). Prognostic value and agreement of achieving lactate clearance or central venous oxygen saturation goals during early sepsis resuscitation. Academic Emergency Medicine, 19(3), 252-258.
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Take home message
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