New Volume Therapy[1]

8/6/2019 New Volume Therapy[1]

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VOLUME THERAPYVOLUME THERAPYDr. Monish RautDr. Monish Raut

Dept of Cardiac AnaesthesiaDept of Cardiac AnaesthesiaSir Ganga Ram HospitalSir Ganga Ram Hospital

New DelhiNew Delhi


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Fluid PhysiologyFluid Physiology

Total Body Water 0.6 L/kg 2/3 Intracellular (ICF)

1/3 Extracellular (ECF)

ICF Volume (0.4 L/kg)ECF Volume (0.2 L/kg)

Plasma Volume (0.05 L/kg)

Interstitial Volume (0.15 /kg)

Ratio of plasma volume to interstitialvolume is 1-to-3 [rationale for 3-to-1replacement of blood losses with crystalloid]

Cells 28 LitresCells 28 Litres

Blood volume 3.5Blood volume 3.5

litreslitres

Interstitial fluid 10.5 LitresInterstitial fluid 10.5 Litres


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Provide daily basal fluid requirementsMaintain or achieve normovolemia and haemodynamic

stability

Restitution of the fluid balance between the differentfluid compartments

Maintain adequate plasma COP

Enhance microvascular blood flow

Prevent/moderate cascade system activation and trauma

induced increased blood coagulability

Normalization of oxygen delivery to tissue cells and

cellular metabolism Int J Intensive Care, 1999; 6: 20Baillires Clin Anaesthesiol, 1997; 11: 49.


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Clinical Situations Often Requiring customizedClinical Situations Often Requiring customized

Volume therapyVolume therapy

Management of patients with hemorrhage (e.g., GI bleed, rupturedManagement of patients with hemorrhage (e.g., GI bleed, rupturedAAA, cardiac redo cases , IVC tear, SVC tear )AAA, cardiac redo cases , IVC tear, SVC tear )

Surgery, especially with large blood losses or large third spaceSurgery, especially with large blood losses or large third spacelosses, such as liver transplantation or spinal correction surgerylosses, such as liver transplantation or spinal correction surgery

Management of burn patientsManagement of burn patients

Perioperative management of trauma patientsPerioperative management of trauma patients

Management of cardiopulmonary bypassManagement of cardiopulmonary bypass

Management of patients with sepsis syndromeManagement of patients with sepsis syndrome

Complex situations: Acute Pancreatitis, DKA, Acute Renal FailureComplex situations: Acute Pancreatitis, DKA, Acute Renal Failure

ALI/ ARDSALI/ ARDS


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Critically ill patients do often have complex

hemodynamics (hypovolemia, myocardial depression

or both).

Only in rare case does the diagnosis tell you what is

the main physiological disturbance.

Co-morbidities often complicate the hemodynamic

status.

Critically ill patients often present us with therapeutic

conflicts (e.g., hemodynamic instability and ARDS).

Features unique to Critical

Illness


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Early Optimization of HemodynamicsEarly Optimization of Hemodynamics

improves outcomeimproves outcome

Kern JW and Shoemaker WC

Crit Care Med 30: 1686 1692, 2002

Metaanalysis of hemodynamic optimizaton

in high risk patients

Rivers et al., N Engl J Med 345: 1368 1377,2001

Early goal-directed therapy in the treatment

of severe sepsis and septic shock


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Goals of hemodynamic ManagementGoals of hemodynamic Management

Optimizing Stroke volume /CardiacOutput:

Optimizing Preload:

Avoiding Fluid Overload

Measurement of Preload Assessing Fluid Responsiveness

Measurement of SV/CO

Assessing Pulmonary Edema


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Volume expansion is frequently used inVolume expansion is frequently used incritically ill patients to improvecritically ill patients to improvehemodynamics. Because of the positivehemodynamics. Because of the positiverelationship between ventricular end-diastolicrelationship between ventricular end-diastolicvolume and stroke volume, the expectedvolume and stroke volume, the expectedhemodynamic response to volume expansionhemodynamic response to volume expansionis an increase in right ventricular end-diastolicis an increase in right ventricular end-diastolicvolume (RVEDV), left ventricular end-diastolicvolume (RVEDV), left ventricular end-diastolicvolume, stroke volume, and cardiac output.volume, stroke volume, and cardiac output.

Michard F. Teboul JL. Predicting fluid responsiveness in ICUpatients: a critical analysis of the evidence.Chest. 121(6):2000-8, 2002 Jun.

Plasma Volume Expansion


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Scenarios commonly

encountered

2- Patients with high suspicion of septic shock2- Patients with high suspicion of septic shock

3- Patients in the ICU, already resuscitated for several hours or days3- Patients in the ICU, already resuscitated for several hours or days

1- Patients with acute blood losses or body fluid losses1- Patients with acute blood losses or body fluid losses


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After how much & when ? TheAfter how much & when ? The

question is which fluid ?question is which fluid ?


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The Ideal Plasma Volume ExpanderThe Ideal Plasma Volume Expander

InexpensiveInexpensive

No special storage problems; long shelfNo special storage problems; long shelflifelife

Can be made in bulk using existingCan be made in bulk using existing

industrial processesindustrial processesFree of pathogensFree of pathogens

NontoxicNontoxic

Crystalloid vs ColloidCrystalloid vs Colloid


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Fluid loading: which one ?Fluid loading: which one ?CrystalloidsCrystalloids

greater volume is requiredgreater volume is required

incidence of side effect is lowincidence of side effect is low

Salt loading & hyperchloraemic acidosisSalt loading & hyperchloraemic acidosis

ColloidsColloids

First line product?First line product?

RisksRisks

allergyallergy

HepatotoxicHepatotoxic

CoagulopathyCoagulopathy

Nephrotoxic ?Nephrotoxic ?

TransfusionTransfusion

Not for fluid loadingNot for fluid loading

Restrictive strategy ((Hb 7-9 g%)Restrictive strategy ((Hb 7-9 g%)

Task force of the ACCM_SCCM1999


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Time is organ function !!!Time is organ function !!!

Start ofStart oftreatmenttreatmentICU

Burden of organ dysfunction

Prognosis

Pre-hospital ED Ward

Delay in diagnosis


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VOLUME EFFECT OF CRYSTALLOIDSVOLUME EFFECT OF CRYSTALLOIDS


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Crystalloid disadvantagesCrystalloid disadvantages

Lowers plasma osmolalityLowers plasma osmolality

Drive water into interstitial spaceDrive water into interstitial space

Dilution of plasma proteinDilution of plasma proteinDecrease in colloidal osm pressureDecrease in colloidal osm pressure

3 fold amount compared with colloid3 fold amount compared with colloid

Hyperchloremic acidosisHyperchloremic acidosis


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Crystalloid disadvantagesCrystalloid disadvantages

Post-op fluid overload increasesPost-op fluid overload increases

morbidity significantlymorbidity significantly

Post-op weight gainPost-op weight gainPost-op confusionPost-op confusion

Increased duration of post-opIncreased duration of post-op

ventilation/chest complicationsventilation/chest complications


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e.g. 0.9 % NaCl

Ringers Lactate

Colloids

Naturalcolloids

Gelatin

Dextran

HES

Crystalloids

Artificialcolloids

Albumin

Volume replacement - overview

CrystalloidsBlood / plasma

products

Whole blood

RBC

FFP

Plasma proteins


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Requirements of an ideal colloidRequirements of an ideal colloid

No plasmaaccumulation

Complete renalelimination

Excellent safety profile

No tissue storage

Volume replacement - overview

stable and reliable constant plateau effect

be easily controllable

Sufficient volume effect(efficacy and safety)


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ALBUMINALBUMIN

5% Solution - 80% vol expansion5% Solution - 80% vol expansion

25% Solution 200% vol expansion25% Solution 200% vol expansion

Effect for 16-24 hrsEffect for 16-24 hrs

Martino P. colloid and crystalloid resuscitationMartino P. colloid and crystalloid resuscitationThe ICU Book 3The ICU Book 3rdrd edit 2007edit 2007


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AdvantagesAdvantages

Less anaphylactoid,coaguln abnormalitiesLess anaphylactoid,coaguln abnormalities

Volume expansionVolume expansion

AntioxidantAntioxidantInflences acid base statusInflences acid base status

Barron ME : systemic review of comparative safety of colloidsBarron ME : systemic review of comparative safety of colloidsArch Surg 2004Arch Surg 2004


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DisadvantagesDisadvantages

ExpensiveExpensive

Interstitial Edema - Volume overloadInterstitial Edema - Volume overload

Park G. Molecular mech of drug metabolism in criti illPark G. Molecular mech of drug metabolism in criti illBrit J. Anesth 1996Brit J. Anesth 1996


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DextranDextran

Dextran 40 and Dextran 70Dextran 40 and Dextran 70

Volume expansion 100 150%Volume expansion 100 150%Duration for 6 -12 hrsDuration for 6 -12 hrs

Martino P. colloid and crystalloid resuscitationMartino P. colloid and crystalloid resuscitation

The ICU Book 3The ICU Book 3rdrd edit 2007edit 2007


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DEXTRANSDEXTRANS

6% dextran70

10% dextran40

Mean molecular weight

(Dalton).

70,000 40,000

Volume effect (hours)(Approx.).

5 3-4

Volume efficacy(%)(Approx.).

100 175-(200)

Maximum daily

dose(g/kg).

1.5 1.5


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AdvAdv

Vol expansion higher than HES and 5%Vol expansion higher than HES and 5%

albuminalbumin

Improve Microcirculation.Improve Microcirculation.

by decreasing viscosityby decreasing viscosity

by inhibiting RBCs aggregationby inhibiting RBCs aggregation

Martino P. colloid and crystalloid resuscitationMartino P. colloid and crystalloid resuscitationThe ICU Book 3The ICU Book 3rdrd edit 2007edit 2007


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DisadvDisadv

Anaphylactic reactionAnaphylactic reaction

Coagulation abnormalitiesCoagulation abnormalities

Interfer crossmatchInterfer crossmatchARFARF

Barron ME : systemic review of comparative safety of colloidsBarron ME : systemic review of comparative safety of colloids

Arch Surg 2004Arch Surg 2004


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GelatinsGelatins

Succinylated gelatins (gelofusine)Succinylated gelatins (gelofusine)

Urea crosslinked (haemacel)Urea crosslinked (haemacel)

OxypolygelatinsOxypolygelatins

Volume expansion 70 80 %Volume expansion 70 80 %

Duration shorter than alb, HESDuration shorter than alb, HES

Dubois MJ -Periope fluid therapy, 1Dubois MJ -Periope fluid therapy, 1 stst edition, 2007edition, 2007


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GELATINSGELATINS

Urea-cross-linkedGelatin.

( Hemaccel)

Cross linkedGelatin

SuccinylatedGelatin(Gelofusine )

Concentration (%)3.5 5.5 4.0

Mean moleculareight(Dalton)

35000 30000 30000

olumeeffect(hours)(approx)

1-3 1-3 1-3


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HemacelHemacel

Na 145Na 145

K 5.1K 5.1

Ca 6.25Ca 6.25

Cl 145Cl 145

GelofusineGelofusine

Na 154Na 154

K 0.4K 0.4

Ca 0.4Ca 0.4

Cl 120Cl 120


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AdvAdv

CheaperCheaper

No limit of infusionNo limit of infusion

Less renal effect.Less renal effect.

Barron ME : systemic review of comparative safety of colloidsBarron ME : systemic review of comparative safety of colloids

Arch Surg 2004Arch Surg 2004


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DisadvDisadv

Anaphylactoid reactionAnaphylactoid reaction

Effect on coagulationEffect on coagulation

Circulatory dysfunctionCirculatory dysfunction

Tabuchi N. gelatin impair platelet adhesion in cardiac sxTabuchi N. gelatin impair platelet adhesion in cardiac sx

Thromb Haemost 1995Thromb Haemost 1995


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Allergic reactions after applicationAllergic reactions after applicationof colloids (%)of colloids (%)

Allergic reactions after applicationAllergic reactions after applicationof colloids (%)of colloids (%)

prospective multicenter studie (~20.000 patients)prospective multicenter studie (~20.000 patients)

GelatinsGelatins DextransDextrans AlbuminAlbumin HESHES

0,40,4

0,20,2

00

(Laxenaire et al., 1994)(Laxenaire et al., 1994)

Allergicr e

actions

(%)

Allergicr e

actions(%)


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Parameters of HES

Pharmacokinetic and pharmacodynamic of HES iscontrolled by:

Molar substitution

C2/C6Substitution pattern

Molecular weight


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Volume EffectsVolume Effects

The performance of 6% HES as a plasmaThe performance of 6% HES as a plasma

volume expander is very similar to 5%volume expander is very similar to 5%albumin.albumin.

The oncotic pressure (30 mm Hg) isThe oncotic pressure (30 mm Hg) is

higher than 5% albumin (20 mm Hg)higher than 5% albumin (20 mm Hg)the increment in plasma volume can bethe increment in plasma volume can be

slightly higher as wellslightly higher as well


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VoluvenVoluvenThe ThirdThe Third

Generation HESGeneration HES

Licensed for up to

50ml/kgbw/day

Only starch approved for

use in pediatrics

Only starch approved for

use in renal failure patients


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VOLUVEN - Less chemicalmodification

... compared to conventional starches (HES 200/0.5) Voluven has a

reduced degree of substitution (by approx. 20 %)

improved substitution pattern (C2 /C6 ratio)

Both modifications together ensure a constant renal excretion andavoid plasma accumulation, even after repeated doses


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Safety of high dosevolume replacement

Influence on haemostasis

and coagulation

Tissue storage

Influence on kidneyfunction

Incidence of anaphylactoid

reactions

HES in children

Influence on oxygen tension& inflammatory response

Hot topics with HES

Original Study with Voluven


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Volume effect of 6% HES 130/0.4(Waitzinger et al., 1998)

Study results

Volume effect ~100%

Plateau effect ~ 4 hours

Volume effect up to 6 hours

hours

Volume effect of 6% HES 130/

0.4

Original Study with Voluven


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Study results

Administered :- 6% HES 130/0.4

(Voluven)

- Ringer`s Lactate

Tissue oxygen tension:

- 59% increase with HES

130/0.4 (Voluven)

- 23% decrease with RL

LMW HES and tissue oxygenationLMW HES and tissue oxygenation


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CanJ Anesth 2003; 50 (10): 1009-1016

Intravascular volume replacementIntravascular volume replacementwith HES 130/0.4 may reducewith HES 130/0.4 may reduceinflammatory responseinflammatory response

This is most likely due to an improvedThis is most likely due to an improvedmicrocirculation with reducedmicrocirculation with reducedendothelial activation and lessendothelial activation and less

endothelial damageendothelial damage

SIRS


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High dosage data with VoluvenHigh dosage data with Voluven

High dose volume replacement using HES 130/0.4 during major urologicHigh dose volume replacement using HES 130/0.4 during major urologic

surgery does not alter coagulation (Ellger et al.)surgery does not alter coagulation (Ellger et al.)

50 ml/kg50 ml/kg

Advantages of Voluven at repitive high dose levels in patients with severeAdvantages of Voluven at repitive high dose levels in patients with severe

craniocerebral trauma (Neff et al.)craniocerebral trauma (Neff et al.) 70 ml/kg70 ml/kg during several daysduring several days

Safety of High Dose volume substitution with 6%HES 130/0.4 in cardiacSafety of High Dose volume substitution with 6%HES 130/0.4 in cardiac

surgery (surgery (Frey et al.)Frey et al.)

48 ml/kg48 ml/kg

Large-dose hydroxyethyl starch (HES) 130/0.4 in elective coronary arteryLarge-dose hydroxyethyl starch (HES) 130/0.4 in elective coronary arterybypass surgery (Kasper et al.)bypass surgery (Kasper et al.)

50 ml/Kg50 ml/Kg


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Sticky issues with starchSticky issues with starch

bleeding tendencybleeding tendency caused by inhibition of factor VII andcaused by inhibition of factor VII andvon Willebrand factor and impaired platelet adhesiveness.von Willebrand factor and impaired platelet adhesiveness.

This effect is seen predominantly with high MW hetastarch, is lessThis effect is seen predominantly with high MW hetastarch, is lesspronounced with medium MW hetastarch, and is absent with lowpronounced with medium MW hetastarch, and is absent with low

MW hetastarch.MW hetastarch.

The coagulation defect is pronounced when more than 1,500 mLThe coagulation defect is pronounced when more than 1,500 mLhetastarch is infused within a 24 hr period. can be minimized byhetastarch is infused within a 24 hr period. can be minimized bylimiting the infusion volume to less than 1,500 mL in 24 hours andlimiting the infusion volume to less than 1,500 mL in 24 hours and

by avoiding the use of hetastarch in patients with an underlyingby avoiding the use of hetastarch in patients with an underlyingcoagulopathy, particularly von Willebrand's disease.coagulopathy, particularly von Willebrand's disease.


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Acid-base equilibriumAcid-base equilibrium after administrationafter administration

of large volumes of an unbalanced solutionof large volumes of an unbalanced solution

HCO3

Cations

Anions

Na+

Cl

PO43

Alb

Lactat

e

SO42, OH

etc.

K+

H+

Ca2+

Mg2+


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Hyperchloremic acidosisHyperchloremic acidosis

Nausea vomitingNausea vomiting

HeadacheHeadache

Delayed first urinationDelayed first urinationDisturbed blood coagulationDisturbed blood coagulation

Impaired cardiac functionImpaired cardiac function

Reduced cardiac outputReduced cardiac output

Malperfusion of kidneys & gutMalperfusion of kidneys & gut

Inactivation of calcium channels in cell membranesInactivation of calcium channels in cell membranes

Inhibition of noradrenaline releaseInhibition of noradrenaline release

B l d 6% HES 130/0 4


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Balanced 6% HES 130/0.4Balanced 6% HES 130/0.4

AdvantagesAdvantages

Due to the same active ingredient as Voluven

the samebeneficial effects for the patients

Balanced electrolyte solution, close to human plasma

Lower chloride content than saline based solutions

Lowest chloride content as compared to all other balancedsolutions

With acetate /Malate as a precursor of bicarbonate in order to

counteract development of hyperchloraemic metabolic acidosis

Carrier solution without Ca2+ ions in order to exclude the risk ofcomplexation of Ca2+ ions with certain anions

Disadvantages?Disadvantages?


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when it comes to selecting the resuscitation fluid doctors are faced with a

range of options. At the most basic level the choice is between a colloid or

crystalloid

solution.


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N Engl J Med 2004;350:2247-56

use of 4 percent albumin or normal saline for intravascular volumeresuscitation in a heterogeneous population of patients in the ICU

Requirements for mechanical ventilation and renal-replacementtherapy, time spent in the ICU and in the hospital during the 28-day study period, and the time until death (among the patientswho died) were also equivalent. The proportion of patients in thetwo groups in whom new singleorgan or multiple-organ failure

developed were similar.


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Crystalloid/Colloid DebateCrystalloid/Colloid Debate

Are colloid more effective than crystalloid?Are colloid more effective than crystalloid?

Are synthetic colloid equally effective &Are synthetic colloid equally effective &

safe as human albumin?safe as human albumin?

Do HES have the best risk/benefit profileDo HES have the best risk/benefit profile

among all colloids?among all colloids?

Is third generations HES safer thanIs third generations HES safer than

olders?olders?

A ll id ff ti thA ll id ff ti th


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Are colloid more effective thanAre colloid more effective than

crystalloid?crystalloid?

Hemodynamics changes by colloids areHemodynamics changes by colloids are

immediate effects and do not lead toimmediate effects and do not lead to

improved clinical outcomes in comparisonimproved clinical outcomes in comparison

with crystalloidswith crystalloids Finfer S. SAFE Trial, NEJM 2004Finfer S. SAFE Trial, NEJM 2004

Brunkhorst FM. VISEP Trial, NEJM 2008Brunkhorst FM. VISEP Trial, NEJM 2008

Wills BA.Comparison of 3 fluids for resuscitation in DSS, NEJM 2005Wills BA.Comparison of 3 fluids for resuscitation in DSS, NEJM 2005Upadhyay M. crystalloid and colloid resuscitation in ped septic shock,Upadhyay M. crystalloid and colloid resuscitation in ped septic shock,

Indian Pediatri 2005Indian Pediatri 2005

A th ti ll id llAre s nthetic colloid eq all


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Are synthetic colloid equallyAre synthetic colloid equally

effective & safe as human albumin?effective & safe as human albumin?

Starches can easily replace albumins as volStarches can easily replace albumins as vol

expander because they are equally safe but lessexpander because they are equally safe but less

expensive.expensive.

Boldt J. albumin based IV volume replacement in elderly pts undergoingBoldt J. albumin based IV volume replacement in elderly pts undergoingabd sx. Anesth Analg 2007abd sx. Anesth Analg 2007

Recent metaanalysis failed to find mortality benefitRecent metaanalysis failed to find mortality benefit

of any type colloid in critically ill.of any type colloid in critically ill.

Perel P. colloid vs crystalloids in critically ill, Cochrane data base ReviewPerel P. colloid vs crystalloids in critically ill, Cochrane data base Review20092009

Bunn F. colloid solutions for resuscitation, Cochrane data base ReviewBunn F. colloid solutions for resuscitation, Cochrane data base Review

20082008

D HES h th b t i k/b fitDo HES have the best risk/benefit


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Do HES have the best risk/benefitDo HES have the best risk/benefit

profile among all colloids?profile among all colloids?

Dextran associated with anaphylacticDextran associated with anaphylactic

reactions,coaguln abnormalities, interfersreactions,coaguln abnormalities, interfers

crossmatch, ARF.crossmatch, ARF.

Barron ME : systemic review of comparativeBarron ME : systemic review of comparativesafety of colloid , Arch Surg 2004safety of colloid , Arch Surg 2004


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Gelatins impair platelet function andGelatins impair platelet function and

reduce vWf and coagulation factor VIII:creduce vWf and coagulation factor VIII:c

Tomi T.,Gelatin and Hydroxyethyl Starch, but Not Albumin, Impair

Hemostasis After Cardiac Surgery.Anesth Analg 2006Anesth Analg 2006.

Gelatins impair renal function similar to

HES 200/0.6 in cardiac surgery.

Boldt J.,Comparison of the effects of gelatin and a modern

hydroxyethyl starch solution on renal function and inflammatory

response in elderly cardiac surgery patients. Brit J Anesth 2008Brit J Anesth 2008.


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HES 450/0.7 and HES 200/0.5 increasesHES 450/0.7 and HES 200/0.5 increases

bleeding in cardiac surgerybleeding in cardiac surgeryHaynes GR.,Fluid management in cardiac surgery. J.CardiothoracicHaynes GR.,Fluid management in cardiac surgery. J.Cardiothoracic

Vasc Anesth 2006.Vasc Anesth 2006.

HES 250/0.45 associated with increasedHES 250/0.45 associated with increased

AKI in cardiac surgery.AKI in cardiac surgery.Rioux JP.,Pentastarch 10% risk factor of AKI following cardiacRioux JP.,Pentastarch 10% risk factor of AKI following cardiacsurgery. Criti Care Med 2009.surgery. Criti Care Med 2009.



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older generations ?older generations ?

HES 130/0.4 associated with significantHES 130/0.4 associated with significantreduction in perioperative blood lossreduction in perioperative blood lossKozek , effects of HES on blood loss in major sx, analysis of RCT,Kozek , effects of HES on blood loss in major sx, analysis of RCT,

Anesth Analg 2008Anesth Analg 2008

Tetrastarches associated with 15%Tetrastarches associated with 15%reduction in blood loss compared toreduction in blood loss compared to

gelatin and pentastarches.gelatin and pentastarches. Chang D., colloid for periop plasma expansion: syst review TransfChang D., colloid for periop plasma expansion: syst review TransfMed 2007Med 2007


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HES 130/0.4 no reported adv effect onHES 130/0.4 no reported adv effect on

renal function.renal function.Boldt J.,influence of vol therapy with modern HES on kidneyBoldt J.,influence of vol therapy with modern HES on kidney

function Crit Care Med 2007.function Crit Care Med 2007.

HES 130/0.4 not an independent riskHES 130/0.4 not an independent risk

factor for adv effect on renal function.factor for adv effect on renal function.SOAP Trial,.Brit J. Anesth 2007.SOAP Trial,.Brit J. Anesth 2007.


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9 clinical trials on renal function9 clinical trials on renal function

demonstrate safety of waxy maize deriveddemonstrate safety of waxy maize derived

HES 130/0.4 and, 2 recently publishedHES 130/0.4 and, 2 recently published

trials confirm that potato derived HEStrials confirm that potato derived HES

130/0.42 has no adv effects on renal130/0.42 has no adv effects on renal

function.function.

Westphal M, HES diff products diff effects, Anesthesiology 2009.Westphal M, HES diff products diff effects, Anesthesiology 2009.

James MFM, tetrastarches in periop setting, Current opin inJames MFM, tetrastarches in periop setting, Current opin inAnesthes 2008.Anesthes 2008.

NO MAGIC BULLET


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Hemodynamic TruthsHemodynamic Truths

Tachycardia is never a good thingTachycardia is never a good thing

Hypotension is always pathologicalHypotension is always pathological

CVP is only elevated in diseaseCVP is only elevated in disease

Volume therapy should always be customized according to the

underlying pathophysiology


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THANK YOUTHANK YOU

New Volume Therapy[1]

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Transcript of New Volume Therapy[1]