Folyadékterápia: krisztalloid vagy kolloid? Molnár Zsolt Aneszteziológiai és Intenzív Terápiás Intézet Szegedi Tudományegyetem
Élettan
Az oxigén adósság Folyadék Vér Oxigén DO2= (SV P) (Hb 1.39 SaO2+0.003 PaO2) ~ 1000ml/min VO2 = CO (CaO2 - CvO2) ~ 250 ml/min (ScvO2~70-75%) Analgézia, szedáció
Kompenzáló mechanizmusok VO2 (ml/min) Kritikus pont 250 Sokk 1000 500 DO2 (ml/min)
A folyadék fontos
életeket menthet, Mortalitás: 46.5 vs. 30.5% (p=0.009)
de árthat is: SOAP Vincent JL, et al. Crit Care Med 2006; 34: 344 353
Annyit adjunk, amennyire szükség van! Bungaard-Nielsen M, et al. ACTA Anaesthesiol Scand 2009; 53: 843-51 Mit adjunk: Krisztalloidot vagy Kolloidot?
Mortalitás: Lássuk az evidenciát!
SAFE 20.9% 21.1% Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247
<22 ml/kg 48 (22-96) ml/kg P=0.34 Acute Renal Failure: HES-34.9% vs RL-22.8%, p=0.002
HES is bad for you 6S Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.4 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer s acetate. CHEST Perner A et al. 2012; DOI: 10.1056/NEJMoa1204242 Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759 In patients in the ICU, there was no significant difference in 90-day mortality between patients resuscitated with 6% HES (130/0.4) or saline. However, more patients who received resuscitation with HES were treated with renal-replacement therapy. Molnár 99
HES-ítélet - 2012 Dellinger RP et al. Intensive Care Med 39. doi: 10.1007/s00134-012-2769-8 Vége a szintetikus kolloid történetnek?
Krisztalloidot vagy Kolloidot adjunk?
Mérföldkövek Crystalloids: Robert Lewins 1832 INJECTION OF SALINE SOLUTIONS IN EXTRAORDINARY QUANTITIES INTO THE VEINS IN CASES OF MALIGNANT CHOLERA Sydney Ringer 1885 Alexis Hartmann (1898-1964) Albumin Pearl Harbor - 1941 Molnár 99
A szemipermeabilis membránok J Physiol May 5, 1896 19 (4) 312-326
Megoszlás kompartment modell TBW ~ 40L V:R=1:1; 1:4 I. c.or fiction? Fact E.c. Interstitial I.v. 1/1 3/4 5/8 2/8 1/4 1/8 Coll Cryst. 5%D
Hogyan működik az élettan a klinikai gyakorlatban?
SAFE Alb: 1184 ml 25%< Folyadékterápia indokációja: The treating clinician judged that fluid resuscitation was required Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247 Saline: 1565 ml
Perner A et al. 2012; DOI: 10.1056/NEJMoa1204242 HES: 1500 ml NS< Trial fluid was used when ICU clinician judged [it] was needed RA: 1500 ml
Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759 20%< S Trial fluid was administered as determined by the treating clinician and supported by at least one objective physiological criterion
Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759 HR<90 MAP~75 Közös vonások: CVP~9 Indication of fluid-bolus was based on intuition (reflects everyday practice) Lac~2 Rather than invasive hemodynamic indeces
HES-250 GEL-30 Tehát: az élettan (V:R arány) nem működik az ITO-n
Mi a helyzet egészségesekben?
Acta Anaesthesiol Scand 2012; 56: 291 297 Decrease by 60% Bleeding: 150 ± 33 ml/event Blood:HES = 1:1
Crit Care Med. 2010 58(2):1-7 10 healthy adults 1000 ml fluid/60 min 4x
Mit tanultunk eddig? Működik egészségesekben Mintha nem működne szeptikus betegekben 1. Kolloid extravazáció? 2. Valóban hypovolémiásak voltak ezek a betegek??
Válasz az első kérdésre: A titok nyitja a mikrocirkuláció
Glycocalyx Reitsma S, et al. J Vasc Res 2011, 48:297-306
Glycocalyx Bernard M. et al. Circulation Research. 2003; 92: 592-594 SIRS Severe sepsis Chappel D, et al. Curr Opin Anaesthesiol 2009; 22: 155-62 Hypervolemia Bruegger D, et al. Am J Physiol Heart Cicr Physiol 2005; 289: H1993-1999
HES is bad for you? Igen: Glycocalix Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.4 had an sérült increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer s acetate. Extravazáció - toxicitás Perner A et al. 2012; DOI: 10.1056/NEJMoa1204242 Második kérdés: In patients in the ICU, there was no significant difference in 90-day mortality between patients resuscitated with 6% HES (130/0.4) or saline. However, more patients who Valóban hypovolémiásak voltak ezek a received resuscitation with HES were treated with renal-replacement therapy. betegek? Molnár 99 Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759
Mi a fontosabb? Mikor infundáljunk? Vagy: Mit infundáljunk?
Invazív hemodinamikai monitorozás
Úttörők Otto Frank (1865-1944): Élettanász (Lipcse) Zur Dynamik des Herzmuskels, Z Biol 32 (1895) 370 Ernest Starling (1866-1927): UCL Starling erők, hormonok, stb Molnár 99
Hemodynamics Otto Frank, Ernest Starling 1914: Law of the heart The goal of resuscitation SV: CO-monitoring EDV:? Stroke volume (ml) Within physiological limits, the force of contraction is directly proportional to the initial length of the muscle fiber End diastolic volume (ml) Molnár 99 Starling EH. The Linacre Lecture on the Law of the Heart. London; 1918 Starling EH. J R Army Med Corps. 1920; 34: 258-262
One size does not fit all! normal heart Statikus paraméterek (CVP, PAOP, Stroke GEDV) nem jelezhetik, a volume failing heart folyadék-válaszkészséget preload responsiveness. preload unresponsiveness Courtesy of Prof. Jean-Loius Teboul Ventricular preload
IPPV = series of Valsalva-maneuvers PP - PP PPV = (PP max max + Molnár 99 PPmax PPmin min PP ) /2 min (Courtesy of Jean-Louis Teboul)
Stroke volume preload responsiveness PPV = 15% preload unresponsiveness PPV = 7% A IPPV: (Courtesy of Jean-Louis Teboul) B Ventricular preload
Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge Osman D, et al. Crit Care Med 2007; 35: 64-8 Pre-infusion values CVP: Sens: 62% (95% CI, 49 73%) Spec: 54% (95% CI, 43 65%) PAOP: Sens: 77% (95% CI, 65 87%) Spec: 51% (95% CI, 40 62%)
Solve the hemodynamic puzzle first! Tánczos K, Németh M, Molnár Z Ann. Up. in Int. Care and Em. Med. 2014, pp. 355-65 2014 2014
Input: ScvO2, CVP, CI, GEDVI, SVV, MAP Hypovolemic patients Normovolemic patients
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