current concept of fluid resuscitation 2013
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Fluid Resuscitation in Critical Care Patients
2013/05/19
佛教慈濟醫院台北分院外科加護病房 周志道
Outlines1. Basics
2. Crystalloid vs. Colloid update
3. Albumin update
4. Standard vs. Delayed fluid resuscitation update
5. Hemodynamic parameters to guide fluid therapy
6. Fluid therapy of severe sepsis 2012
7. Blood substitutes
8. FVII
Hemoconcentration
L. Zgraggen et al. Thrombosis Research (2005) 115, 175—183
Hemorrhagic Shock
J Obstet Gynaecol Can 2002;24(6):504-11
Hypothetical Capillary Endothelial Barriers
Peripheral Capillary Brain Blood Barrier
65A7A
Vascular lumen Vascular lumenInterstitial space Interstitial space
H2OH2O H2OH2O
Na+
Small ion
Na+
Small ion Na+
Small ion
Na+
Small ion
Protein ProteinProtein Protein
C. Tommasino. Anesthesiology Clin N Am 20 (2002):329-346
Effect of Different Solutions on Plasma Volume Expansion
Rizoli: J Trauma, Volume 54(5) Supplement.May 2003.S82-S88
Fluid resuscitation with colloid or crystalloid solutions in critically ill patients (II)
Gill Schierhout; Ian Roberts. BMJ 1998; 316:7136
Colloids versus crystalloids for fluid resuscitation in criticallyill patients ( 2009 Review)
Perel P, Roberts I, Pearson M. Cochrane Databaseof Systematic Reviews 2007, Issue 4..
PPF: Plasma protein fraction is the portion of the plasma remaining after fibrinogen and globulin have been removed
9
Effect of HES Solutions on Hemostasis
Sibylle A. Anesthesiology.2005;103: 654-60
Hydroxyethyl Starch 130/0.42 versusRinger’s Acetate in Severe Sepsis
Perner et al. N Engl J Med 2012;367:124-34.
Hydroxyethyl Starch or Saline for fluid resuscitation in Intensive Care
Mybergh et. N EJ M 2012;367:1901-11
Association of Hydroxyethyl Starch Administration With Mortality and AcuteKidney Injury in Critically Ill Patients Requiring Volume Resuscitation
A Systematic Review and Meta-analysis
JAMA. 2013;309(7):678-688
Association of Hydroxyethyl Starch Administration With Mortality and AcuteKidney Injury in Critically Ill Patients Requiring Volume Resuscitation
A Systematic Review and Meta-analysis
JAMA. 2013;309(7):678-688
A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit
The SAFE Study Investigators, . N Engl J Med 2004;350:2247-2256
Effect of baseline serum albumin concentration on outcome ofresuscitation with albumin or saline in patients in ICU
The SAFE Study Investigators ; BMJ Nov 2006; 333: 1044;
Saline or Albumin for Fluid Resuscitationin Patients with Traumatic Brain Injury
The SAFE Study Investigators* NEJM 2007; 357;9
Saline or Albumin for Fluid Resuscitationin Patients with Traumatic Brain Injury
The SAFE Study Investigators* NEJM 2007; 357;9
Albumin Administration in Patients with Severe Sepsis due to Secondary Peritonitis
C.D. Chou J Chin Med Assoc 2009;5:243-250
Baseline albumin concentration more than 20 g/l.
Baseline albumin concentration of 20 g/l or less
Impact of albumin compared to salineon organ function and mortality of patients
with severe sepsis- The SAFE Study Investigators
Administration of albumin compared to saline did not impair renal or other organ function and may have decreased the risk of death.
Intensive Care Med. 2011 Jan;37(1):86-96
Impact of albumin compared to salineon organ function and mortality of patients
with severe sepsis- The SAFE Study Investigators
Intensive Care Med. 2011 Jan;37(1):86-96
Morbidity in hospitalized patients receiving human albumin: Meta-analysis
Jean-Louis Vincent et al .Crit Care Med 2004; 32(10): 2029-2038
Transfusion practice in the
critically ill: Can we do better?
Restrictive transfusion strategy– Transfusion threshold --- 7.0 g/dL– Maintained between 7.0- 9.0 g/dL
Corwin, Howard L. Critical Care Medicine 2005 ;33(1):232
Canadian Critical Care Trials Group NEJM 1999;304:409-417
Is fresh frozen plasma clinically effective? Stanworth, S. J et al. Br J Hematology 2004 ;126(1):139–152
Study Intervention details
Comparator details
Clinical group Main outcome as reported
Reed et al
(1986)
FFP 2 U every 12 U of blood
PLT 6 every 12 U of blood
Massive transfusion No differences in clinical bleeding outcomes
Boldt (1989)
Trimble (1964)
FFP 2U
FFP 3U
No FFP Cardiac surgery with bypass
No positive effect on blood loss or transfusion requirement
Consten et al
(1996)
FFP 3U Gelufusion 750 ml
Cardiac surgery with bypass
No significant difference in blood loss or requirement
Kasper et al
(2001)
Autologous
FFP 15 ml/kg
Hetastarch 15 ml/kg
Coronary artery bypass grafting
No significant reduction in blood loss or requirement
Wilhelmi et al
(2001)
FFP 4U Hydroxy-ethyl-starch 1000 ml
Coronary artery bypass grafting
No significant reduction in blood loss or requirement
Oliver et al
(2003)
FFP 1U Albumin 5% 200ml
Open heart surgery for children < 10 kg
No significant differences in blood loss or requirement
Bocanegra (1979) Plasma
(high volume)
Plasma
(low volume)
Burn (children) No significant difference in mortality
Liu et al
(1994)
Autologous plasma saver
No FFP Hysterectomy No clinical outcome difference
Leese et al
(1991)
FFP 8 U for 3 d Albumin sol 2000ml
Acute severe pancreatitis No significant difference in clinical outcome/mortality
Boyed et al
(1996)
FFP 2U Conjugated estrogen 50 mg
Renal disease and transplantation
No clinical outcomes reported ( outcomes of coagulation testing)
Menges et al
(1992)
Plasma with blood
Allogenic red cell
Orthopedic hip surgery No significant differences in blood loss or requirement
Limited fluid resuscitation
Bickell WH et al. N Engl J Med. 1994; 331: 1105–1109.
Immediate Delayed Resuscitation Resuscitation P Value Survival to discharge 193/309 (62) 203/289 (70) 0.04 Blood Loss (ml) 3127 4937 2555 3546 0.11 LOS (hospital) (days) 14 24 11 19 0.006
LOS (ICU) (days) 8 16 7 11 0.30
Effects of Delaying Fluid Resuscitation on an Injury tothe Systemic Arterial Vasculature
JAMES F. HOLMES. Et al. ACADEMIC EMERGENCYMEDICINE 2002; 9:267–274
Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after
high-risk surgery
Lobo at et. Critical Care 2011, 15:R226
Delaying Fluid Resuscitation in hemorrhage shock Induce Pro-inflammatory Cytokine Response
失血性休克延遲輸液治療會引發發炎性細胞激素反應陳石池 李建璋 顏瑞昇 許瓊元 陳世英 蘇展平 江文莒
台大醫院 急診醫學部 Chieng-Chang Lee. et al. Anal of EMERGENCY
MEDICINE 2007; 49:37-44
Delayed fluid resuscitation in hemorrhagic shock induces increased production of pro-inflammatory cytokines and the release of cytokine was correlated with the time delayed for resuscitation.
Hemodynamic parameters to guide fluid therapy
Clinical indices of the adequacy organ/tissue perfusion
Hemodynamic parameters to guide fluid therapy
Hemodynamic parameters to guide fluid therapy
Fluid Therapy of Severe Sepsis1. Crystalloids as the initial fluid of choice in the
resuscitation of severe sepsis and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids
(grade 2C).Surviving Sepsis Campaign 2012
Fluid Therapy of Severe Sepsis4. Initial fluid challenge in patients with sepsis-induced tissue
hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).
5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic improvement either based on dynamic (eg, change in pulse pressure, stroke volume variation) or static (eg, arterial pressure, heart rate) variables (UG).
Surviving Sepsis Campaign 2012
健保使用 Human Albumin 適應症 -96/06/01
• 休克病人擴充有效循環血液量 : .Ⅰ 休克病人至少已給生理鹽水或林格爾液等晶類溶液1000 mL 後尚不能維持穩定血流動態,血比容(hematocrit) > 30 % ,或血色素 (hemoglobin) > 10 gm/dL 須要繼續靜脈輸液時,宜優先使用合成膠類溶液,如dextran 、 hydroxyethylstarch 、 polyvinylpyrolidone 等。若無上述合適製劑,可給白蛋白溶液,每一病人用量限 50 gm (20% 50ml *5) 。Crystalloid 1000 ml > Colloid (Dextran ) > Albunmin
Blood Substitutes
•Blood shortages & donor recruitment
•Compatibility –need for cross-matching
•Cost of blood processing
•Shelf-life & storage
•Human error
•Unnecessary transfusions
•Risk of disease transmission
•Cultural & religious objection
Problems associated with blood transfusion
Comparison of the Properties
Property Blood Blood substitutes Volume expanders
Volume expansion
Yes Yes Yes
Oxygen carrying capacity
Yes Yes No
Other therapeutic proteins
Yes No No
Therapeutic life 1-2 months 1-2 days Hours (varies with dose and species)
Storage life 1 month 6-24 months 2 years
Changes during storage
Yes No No
Type specific Yes No No
Viral inactivation No Yes Yes
Size Large Small Small
Viscosity High Low/moderate Low
Deanna J. Nelson Encyclopedia of Pharmaceutical Technology. 2002:236 - 262
• HBOC: hemoglobin-based oxygen carrier
• PFC: Perfluorocarbons
ADVERSE EFFECTS OF HBOCs
• Vasoactivity: Nitric oxide binds to free Hb, – vasoconstricition occurs.
• Hemostasis : Reversal of the inhibition effect of nitric oxide on platelet aggregation.
• Gastrointestinal side effects: such as nausea, vomiting, diarrhea, and bloating. – binding of nitrous oxide to gastrointestinal tissues is the proposed
cause.
• Interfere with laboratory assays. Crit Care Clin 25 (2009) 279–301
Cell-Free Hemoglobin-BasedBlood Substitutes and Risk
of Myocardial Infarction and Death
JAMA. 2008;299(19):2304-2312
Crit Care Clin 25 (2009) 279–301
Mechanism of Action of Recombinant Factor VIIa
Efficacy and Safety of Recombinant ActivatedFactor VII for Acute Intracerebral Hemorrhage
N Engl J Med 2008;358:2127-37.
Efficacy and Safety of Recombinant ActivatedFactor VII for Acute Intracerebral Hemorrhage
N Engl J Med 2008;358:2127-37.
Safety of Recombinant Activated Factor VIIin Randomized Clinical Trials
N Engl J Med 2010;363:1791-800.
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