Folyadékterápia. Molnár Zsolt PTE, AITI

HTML
DOWNLOAD

Méret: px

Mutatás kezdődik a ... oldaltól:

Download "Folyadékterápia. Molnár Zsolt PTE, AITI"

Máté Pataki
6 évvel ezelőtt
Látták:

1 Folyadékterápia Molnár Zsolt PTE, AITI

2 A folyadék fontos

3 Javítja a túlélést Early Goal-Directed Therapy (EGDT) (ISI=955) Rivers E et al. N Engl J Med 2001; 345: órányi reszuszcitáció az SBO-n: Kontrol csoport (n=133): O 2 CVP: 8-12 Hgmm MAP: >65 Hgmm EGDT csoport (n=130): U.a. ScvO 2 > 70% Halálozás: 46 vs. 30% (p=0.009) Több infúzió, vvt Több dobutamine

4 Rontja: SOAP tanulmány Vincent JL, et al. Crit Care Med 2006; 34:

5 Élettan

6 Az adósság DO 2 = (SV P) (Hb 1.39 SaO PaO 2 ) ~ 1000ml/p (SaO 2 =100%) CO CaO 2 VO 2 = CO (CaO 2 - CvO 2 ) ~ 250 ml/p (ScvO 2 ~70-75%)

7 Az adósság DO 2 = (SV P) (Hb 1.39 SaO PaO 2 ) ~ 1000ml/p (SaO 2 =100%) CO CaO 2 VO 2 = CO (CaO 2 - CvO 2 ) ~ 250 ml/p (ScvO 2 ~70-75%) A hypovolémiás beteg: Sokk = VO 2 >DO 2 DO 2 VO 2 Élettani végpont: ScvO 2?

8 Hemodinamikai végpont Frank-Starling: A szív törvénye Preload ( előterhelés) SV Kontraktilitás SV Végpont EDV Molnár 99 Starling EH. The Linacre Lecture on the Law of the Heart. London; 1918 Starling EH. J R Army Med Corps. 1920; 34:

9 Hypovolémia klinikai jelei

10 A hypovolémia klinikai jelei Pulzus - MAP Kapilláris újratelődés Óradiurézis Mag perifériás hőmérséklet különbség Moderált vérzés Szenzitivitás: % McGee S, et al. JAMA 1999; 282: 720 Molnár 99

J Trauma 2001; 50: 620-7 Molnár 99 Hűvös végtag = Hypoperfúzió: 39%

11 Start with a Subjective Assessment of Skin Temperature to Identify Hypoperfusion in Intensive Care Unit Patients Kaplan LJ, et al. J Trauma 2001; 50: Molnár 99 Hűvös végtag = Hypoperfúzió: 39% pos. pred. Hűvös végtag + alcsony HCO 3 = Hypoperfúzió: 98% pos. pred.

12 Invazív mérések Artériás vérnyomás (PPV, Δdown) CVP PAOP CO, ITBV/GEDV, SVV ScvO 2 Molnár 99

13 Amit én használok Klinikai jelek MAP Pulzus Diurézis ScvO 2 CVP kinetika ARDS, sokk, súlyos szepszis: CI, ITBV, SVV Molnár 99

14 Mit adjunk?

15 Folyadékterek és infúziós oldatok Ö.V.T. ~ 40L I. c. tér E.c. tér 0.6xTBV ~ 20L I.st.~15L I.v.~5L 1/1 Koll 3/4 1/4 NaCl 4/8 3/8 1/8 5%D

16 Főbb szempontok Folyadékeloszlás: Tehát: Víz (5%D) az ÖVT-ben oszlik el (1/8) Na + az e.c. térben (1/4) Kolloid az i.v térben (1/1) 1 L vérvesztést 4 L izotóniás sóoldattal, vagy 1 L kolloiddal pótolhatunk. Molnár 99

17 Krisztaloid vagy kolloid?

18 Mortalitás Choi PT et al. Crit Care Med 1999; 27: 200

19 SAFE Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247

20 SAFE Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247

21 Krisztalloid vs. HES szepszisben p< Kellum JA. Crit Care Med 2002; 30: Hipoklorémiás metabolikus acidózis Mythen MG et al. Transfus Altern Transfus Med 2001; 3: 15-9 McFarlene C et al. Anaesthesia 1994; 49:

22 Milyen méretű kolloidot?

23 HES vs GEL: szeptikus sokk + ARDS tb tep t30 t60 ITBVI HES (ml/m 2 ) 798 ± ± 53* 904 ± 70* 854 ± 116* ITBVI GEL 791 ± ± 71* 897 ± 96* 905 ± 92* CI HES (l/min/m 2 ) 3.84 ± ± 1.19* 4.69 ± 1.14* 4.04 ± 1.09 CI GEL 3.82 ± ± 0.85* 4.69 ± 0.77* 4.58 ± 1.25 DO 2 I HES (ml/min/m 2 ) 477 ± ± 183* 598 ± 126* 527 ± 109 DO 2 I GEL 457 ± ± 186* 560 ± 163* 550 ± 178 EVLWI HES (ml/kg) 8 ± 6 8 ± 6 9 ± 7 8 ± 6 EVLWI GEL 8 ± 3 8 ± 3 8 ± 3 8 ± 3 PaO 2HES (mmhg) 207 ± ± ± ±78 PaO 2GEL 182 ± ± ± ± 85 Data are presented as: Mean ± SD. For statistical analysis Two-way ANOVA was used. * P<0.05 compared to baseline values. Molnar Z, Mikor A, Leiner T, Szakmany T. Intensive Care Med 2004; 30:

24 HES vs GEL: szeptikus sokk + IPPV tb tep t30 t60 ITBVI HES (ml/m 2 ) 798 ± ± 53* 904 ± 70* 854 ± 116* ITBVI GEL 791 ± ± 71* 897 ± 96* 905 ± 92* CI HES (l/min/m 2 ) 3.84 ± ± 1.19* 4.69 ± 1.14* 4.04 ± 1.09 CI GEL 3.82 ± ± 0.85* 4.69 ± 0.77* 4.58 ± 1.25 DO 2 I HES (ml/min/m 2 ) 477 ± ± 183* 598 ± 126* 527 ± 109 DO 2 I GEL 457 ± ± 186* 560 ± 163* 550 ± 178 EVLWI HES (ml/kg) 8 ± 6 8 ± 6 9 ± 7 8 ± 6 EVLWI GEL 8 ± 3 8 ± 3 8 ± 3 8 ± 3 PaO 2HES (mmhg) 207 ± ± ± ±78 PaO 2GEL 182 ± ± ± ± 85 Data are presented as: Mean ± SD. For statistical analysis Two-way ANOVA was used. * P<0.05 compared to baseline values. Molnar Z, Mikor A, Leiner T, Szakmany T. Intensive Care Med 2004; 30:

25 HES vs GEL: szeptikus sokk + IPPV tb tep t30 t60 ITBVI HES (ml/m 2 ) 798 ± ± 53* 904 ± 70* 854 ± 116* ITBVI GEL 791 ± ± 71* 897 ± 96* 905 ± 92* CI HES (l/min/m 2 ) 3.84 ± ± 1.19* 4.69 ± 1.14* 4.04 ± 1.09 CI GEL 3.82 ± ± 0.85* 4.69 ± 0.77* 4.58 ± 1.25 DO 2 I HES (ml/min/m 2 ) 477 ± ± 183* 598 ± 126* 527 ± 109 DO 2 I GEL 457 ± ± 186* 560 ± 163* 550 ± 178 EVLWI HES (ml/kg) 8 ± 6 8 ± 6 9 ± 7 8 ± 6 EVLWI GEL 8 ± 3 8 ± 3 8 ± 3 8 ± 3 PaO 2HES (mmhg) 207 ± ± ± ±78 PaO 2GEL 182 ± ± ± ± 85 Data are presented as: Mean ± SD. For statistical analysis Two-way ANOVA was used. * P<0.05 compared to baseline values. Molnar Z, Mikor A, Leiner T, Szakmany T. Intensive Care Med 2004; 30:

26 HES vs GEL: szeptikus sokk + IPPV tb tep t30 t60 ITBVI HES (ml/m 2 ) 798 ± ± 53* 904 ± 70* 854 ± 116* ITBVI GEL 791 ± ± 71* 897 ± 96* 905 ± 92* CI HES (l/min/m 2 ) 3.84 ± ± 1.19* 4.69 ± 1.14* 4.04 ± 1.09 CI GEL 3.82 ± ± 0.85* 4.69 ± 0.77* 4.58 ± 1.25 DO 2 I HES (ml/min/m 2 ) 477 ± ± 183* 598 ± 126* 527 ± 109 DO 2 I GEL 457 ± ± 186* 560 ± 163* 550 ± 178 EVLWI HES (ml/kg) 8 ± 6 8 ± 6 9 ± 7 8 ± 6 EVLWI GEL 8 ± 3 8 ± 3 8 ± 3 8 ± 3 PaO 2HES (mmhg) 207 ± ± ± ±78 PaO 2GEL 182 ± ± ± ± 85 Data are presented as: Mean ± SD. For statistical analysis Two-way ANOVA was used. * P<0.05 compared to baseline values. Molnar Z, Mikor A, Leiner T, Szakmany T. Intensive Care Med 2004; 30:

27 ITBVI/100 ml fluid HES GEL (n=15) (n=15) ITBVI(ml/m 2 ) Data are presented as: Mean ± SD. For statistical analysis Two-way ANOVA was used. Molnar Z, Mikor A, Leiner T, Szakmany T. Intensive Care Med 2004; 30:

28 Kapilláris áteresztés: HES vs HES AER [%] * # * HES 130 kda: - Magasabb PV - Kisebb poz. foly. egyenleg h HES 200 6h HES 130 6h Control Marx G, et al. Crit Care Med 2006; 34:

29 Adjunk albumint?

30 Albumin Cochrane. Br Med J 1998; 317:

31 Albumin Conclusions Because this review was based on relatively small trials in which there were only a small number of deaths the results must be interpreted with caution. Nevertheless, we believe that a reasonable conclusion from these results is that the use of human albumin in the management of critically ill patients should be reviewed. A strong argument could be made that human albumin should not be used outside the context of a properly concealed and otherwise rigorously conducted randomised controlled trial with mortality as the end point. Until such data become available, there is also a case for a review of the licensed indications for albumin use. Cochrane. Br Med J 1998; 317:

32 Albumin Conclusions Because this review was based on relatively small trials in which there were only a small number of deaths the results must be interpreted with caution. Nevertheless, we believe that a reasonable conclusion from these results is that the use of human albumin in the management of critically ill patients should be reviewed. A strong argument could be made that human albumin should not be used outside the context of a properly concealed and otherwise rigorously conducted randomised controlled trial with mortality as the end point. Until such data become available, there is also a case for a review of the licensed indications for albumin use. Cochrane. Br Med J 1998; 317:

33 Albumin Wilkes MM, Navickis RJ. Ann Int Med 2001; 135:

34 Cochrane CONCLUSIONS: For patients with hypovolaemia there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trial. Alderson P et al. Cochrane Database Syst Rev 2004; 18: CD001208

35 Cochrane CONCLUSIONS: For patients with hypovolaemia there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia. The possibility that there may be highly selected populations of critically ill patients in which albumin may be indicated remains open to question. However, in view of the absence of evidence of a mortality benefit from albumin and the increased cost of albumin compared to alternatives such as saline, it would seem reasonable that albumin should only be used within the context of well concealed and adequately powered randomised controlled trial. Alderson P et al. Cochrane Database Syst Rev 2004; 18: CD001208

36 SAFE revisited SAFE Study Investigators. BMJ 2006 (Nov 18); 333:

37 SAFE revisited Irrespective of patients' baseline serum albumin concentration, fluid resuscitation with albumin or saline produced similar outcomes Although albumin does not increase the risk of mortality in patients with hypoalbuminaemia, data do not support its routine use to maintain or increase intravascular volume in critically ill adults SAFE Study Investigators. BMJ 2006 (Nov 18); 333:

38 Összefoglalás - 1 A folyadék fontos, de csak módjával Rivers E et al. N Eng J Med 2001; 345: 1368 Vincent JL et al. Crit Care Med 2006; 34: Salsol: hyperklorémiás acidózist okozhat Kellum JA. Crit Care Med 2002; 30: Király L, et al. J Trauma 2006; 61: Krisztalloid kolloid: kimenetel szempontjából mindegy Choi PT et al. Crit Care Med 1999; 27: 200 Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247

39 Összefoglalás - 2 Albumin: nem való folyadék reszuszcitációra Kolloid: Nem a méret számít SAFE Study Investigators. BMJ 2006 (Nov 18); 333: Liberati A et al. Intern Emerg Med 2006; 1: Marx G, et al. Crit Care Med 2006; 34: Molnár Z et al. Intensive Care Med 2004; 30: A sürgősség dönti el: Gyorsabban be tudok adni 1 egység kolloidot, mint 4 RL-t Molnár Zs

40 Mottó A diagnózis ráér, de a sejtek türelme véges!

Hasonló dokumentumok

Én adok HES-t - PRO. Nardai Gábor Péterfy Kórház és Baleseti Központ SZINT 2013

Én adok HES-t - PRO. Nardai Gábor Péterfy Kórház és Baleseti Központ SZINT 2013 Én adok HES-t - PRO Nardai Gábor Péterfy Kórház és Baleseti Központ SZINT 2013 Én adok HES-t Miért? HATÁSOS-E Kinek?? Mikor? VESZÉLYES-E? Mikor nem? Mennyit? MEGÉRI-E? Milyet? Hogyan? Miért adok HES-t?