Current concept of fluid resuscitation 2013

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  • The only statistically significant effect with respect to complication type was an albumin-mediated reduction in renal, hepatic, and gastrointestinal complications
  • Immediate vs delayed fluid resuscitation for hypotensive patients with penetrating torso injuries
  • Twenty-one adult, anesthetized sheep underwent left anterior thoracotomy and transection of the left internal mammary artery. A chest tube was inserted into the thoracic cavity to provide a continuous measurement of blood loss. The animals were randomly assigned to one of three resuscitation protocols: 1) no fluid resuscitation (NR), 2) standard fluid resuscitation (SR) begun 15 minutes after injury, or 3) delayed fluid resuscitation (DR) begun 30 minutes after injury.
  • When the vessel wall is disrupted, subendothelial tissue factor becomes exposed to circulating blood and may bind factor VIIa (Panel A). This binding activates factor X, and activated factor X (factor Xa) generates small amounts of thrombin. The thrombin (factor IIa) in turn activates platelets and factors V and VIII. Activated platelets bind circulating factor VIIa (Panel B), resulting in further factor Xa generation as well as activation of factor IX. Activated factor IX (factor IXa) (with its cofactor VIIIa) yields additional factor Xa. The complex of factor Xa and its cofactor Va then converts prothrombin (factor II) into thrombin (factor IIa) in amounts that are sufficient to induce the conversion of fibrinogen to fibrin.

Transcript

  • 1. Fluid Resuscitation in Critical Care Patients2013/05/19佛教慈濟醫院台北分院外科加護病房 周志道
  • 2. Outlines1. Basics2. Crystalloid vs. Colloid update3. Albumin update4. Standard vs. Delayed fluid resuscitation update5. Hemodynamic parameters to guide fluid therapy6. Fluid therapy of severe sepsis 20127. Blood substitutes8. FVII
  • 3. HemoconcentrationL. Zgraggen et al. Thrombosis Research (2005) 115, 175—183
  • 4. Hemorrhagic ShockJ Obstet Gynaecol Can 2002;24(6):504-11
  • 5. Hypothetical Capillary Endothelial BarriersPeripheral Capillary Brain Blood Barrier65A7AVascular lumen Vascular lumenInterstitial space Interstitial spaceH2OH2O H2OH2ONa+Small ionNa+Small ion Na+Small ionNa+Small ionProtein ProteinProtein ProteinC. Tommasino. Anesthesiology Clin N Am 20 (2002):329-346
  • 6. Effect of Different Solutions on PlasmaVolume ExpansionRizoli: J Trauma, Volume 54(5) Supplement.May 2003.S82-S88
  • 7. Fluid resuscitation with colloid or crystalloid solutions incritically ill patients (II)Gill Schierhout; Ian Roberts. BMJ 1998; 316:7136
  • 8. Colloids versus crystalloids for fluidresuscitation 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 fibrinogenand globulin have been removed
  • 9. 9Effect of HES Solutions on HemostasisSibylle A. Anesthesiology.2005;103: 654-60
  • 10. Hydroxyethyl Starch 130/0.42 versusRinger’s Acetate in Severe SepsisPerner et al. N Engl J Med 2012;367:124-34.
  • 11. Hydroxyethyl Starch or Saline for fluid resuscitation inIntensive CareMybergh et. N EJ M2012;367:1901-11
  • 12. Association of Hydroxyethyl Starch Administration With Mortality and AcuteKidney Injury in Critically Ill Patients Requiring Volume ResuscitationA Systematic Review and Meta-analysisJAMA. 2013;309(7):678-688
  • 13. Association of Hydroxyethyl Starch Administration With Mortality and AcuteKidney Injury in Critically Ill Patients Requiring Volume ResuscitationA Systematic Review and Meta-analysisJAMA. 2013;309(7):678-688
  • 14. A Comparison of Albumin and Saline for FluidResuscitation in the Intensive Care UnitThe SAFE Study Investigators, . N Engl J Med 2004;350:2247-2256
  • 15. Effect of baseline serum albumin concentration on outcome ofresuscitation with albumin or saline in patients in ICUThe SAFE Study Investigators ; BMJ Nov 2006; 333: 1044;
  • 16. Saline or Albumin for Fluid Resuscitationin Patients with Traumatic Brain InjuryThe SAFE Study Investigators* NEJM 2007; 357;9
  • 17. Saline or Albumin for Fluid Resuscitationin Patients with Traumatic Brain InjuryThe SAFE Study Investigators* NEJM 2007; 357;9
  • 18. Albumin Administration in Patients with SevereSepsis due to Secondary PeritonitisC.D. Chou J Chin Med Assoc 2009;5:243-250Baseline albumin concentration more than 20g/l.Baseline albumin concentration of 20 g/l or less
  • 19. Impact of albumin compared to salineon organ function and mortality of patientswith severe sepsis- The SAFE Study InvestigatorsAdministration of albumin comparedto saline did not impair renal or otherorgan function and may havedecreased the risk of death.Intensive Care Med. 2011 Jan;37(1):86-96
  • 20. Impact of albumin compared to salineon organ function and mortality of patientswith severe sepsis- The SAFE Study InvestigatorsIntensive Care Med. 2011 Jan;37(1):86-96
  • 21. Morbidity in hospitalized patients receivinghuman albumin: Meta-analysisJean-Louis Vincent et al .Crit Care Med 2004; 32(10): 2029-2038
  • 22. Transfusion practice in thecritically ill: Can we do better?Restrictive transfusion strategy– Transfusion threshold --- 7.0 g/dL– Maintained between 7.0- 9.0 g/dLCorwin, Howard L. Critical Care Medicine 2005 ;33(1):232Canadian Critical Care Trials Group NEJM 1999;304:409-417
  • 23. Is fresh frozen plasma clinically effective?Stanworth, S. J et al. Br J Hematology 2004 ;126(1):139–152Study InterventiondetailsComparatordetailsClinical group Main outcome as reportedReed et al(1986)FFP 2 U every 12U of bloodPLT 6 every 12U of bloodMassive transfusion No differences in clinicalbleeding outcomesBoldt (1989)Trimble (1964)FFP 2UFFP 3UNo FFP Cardiac surgery withbypassNo positive effect on blood lossor transfusion requirementConsten et al(1996)FFP 3U Gelufusion 750mlCardiac surgery withbypassNo significant difference inblood loss or requirementKasper et al(2001)AutologousFFP 15 ml/kgHetastarch 15ml/kgCoronary artery bypassgraftingNo significant reduction inblood loss or requirementWilhelmi et al(2001)FFP 4U Hydroxy-ethyl-starch1000 mlCoronary artery bypassgraftingNo significant reduction inblood loss or requirementOliver et al(2003)FFP 1U Albumin 5%200mlOpen heart surgery forchildren < 10 kgNo significant differences inblood loss or requirementBocanegra (1979) Plasma(high volume)Plasma(low volume)Burn (children) No significant difference inmortalityLiu et al(1994)Autologousplasma saverNo FFP Hysterectomy No clinical outcome differenceLeese et al(1991)FFP 8 U for 3 d Albumin sol2000mlAcute severe pancreatitis No significant difference inclinical outcome/mortalityBoyed et al(1996)FFP 2U Conjugatedestrogen 50 mgRenal disease andtransplantationNo clinical outcomes reported( outcomes of coagulationtesting)Menges et al Plasma with Allogenic red Orthopedic hip surgery No significant differences in
  • 24. Limited fluid resuscitationBickell WH et al. N Engl J Med. 1994; 331: 1105–1109.Immediate DelayedResuscitation Resuscitation PValueSurvival to discharge 193/309 (62) 203/289 (70) 0.04Blood Loss (ml) 3127 ± 4937 2555 ± 3546 0.11LOS (hospital) (days) 14 ± 24 11 ± 19 0.006LOS (ICU) (days) 8 ± 16 7 ± 11 0.30
  • 25. Effects of Delaying Fluid Resuscitation on an Injury tothe Systemic Arterial VasculatureJAMES F. HOLMES. Et al. ACADEMIC EMERGENCYMEDICINE 2002; 9:267–274
  • 26. Restrictive strategy of intraoperative fluid maintenance duringoptimization of oxygen delivery decreases major complications afterhigh-risk surgeryLobo at et. Critical Care 2011, 15:R226
  • 27. Delaying Fluid Resuscitation in hemorrhage shockInduce 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 EMERGENCYMEDICINE 2007; 49:37-44Delayed fluid resuscitation in hemorrhagic shockinduces increased production of pro-inflammatorycytokines and the release of cytokine was correlatedwith the time delayed for resuscitation.
  • 28. Hemodynamic parameters to guide fluid therapyClinical indices of the adequacy organ/tissue perfusion
  • 29. Hemodynamic parameters to guide fluid therapy
  • 30. Hemodynamic parameters to guide fluid therapy
  • 31. Fluid Therapy of Severe Sepsis1. Crystalloids as the initial fluid of choice in theresuscitation of severe sepsis and septic shock(grade 1B).2. Against the use of hydroxyethyl starches for fluidresuscitation of severe sepsis and septic shock(grade 1B).3. Albumin in the fluid resuscitation of severe sepsisand septic shock when patients require substantialamounts of crystalloids(grade 2C).Surviving Sepsis Campaign 2012
  • 32. Fluid Therapy of Severe Sepsis4. Initial fluid challenge in patients with sepsis-induced tissuehypoperfusion with suspicion of hypovolemia to achieve aminimum of 30mL/kg of crystalloids (a portion of this maybe albumin equivalent). More rapid administration andgreater amounts of fluid may be needed in some patients(grade 1C).5. Fluid challenge technique be applied wherein fluidadministration is continued as long as there ishemodynamic 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
  • 33. 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) > 10gm/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
  • 34. BloodSubstitutes
  • 35. •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 objectionProblems associated with bloodtransfusion
  • 36. Comparison of the PropertiesProperty Blood Blood substitutes VolumeexpandersVolumeexpansionYes Yes YesOxygen carryingcapacityYes Yes NoOther therapeuticproteinsYes No NoTherapeutic life 1-2 months 1-2 days Hours (varies withdose and species)Storage life 1 month 6-24 months 2 yearsChanges duringstorageYes No NoType specific Yes No NoViral inactivation No Yes YesSize Large Small SmallViscosity High Low/moderate LowDeanna J. Nelson Encyclopedia of Pharmaceutical Technology. 2002:236 - 262
  • 37. • HBOC: hemoglobin-based oxygen carrier• PFC: Perfluorocarbons
  • 38. ADVERSE EFFECTS OF HBOCs• Vasoactivity: Nitric oxide binds to free Hb,– vasoconstricition occurs.• Hemostasis : Reversal of the inhibition effect of nitricoxide on platelet aggregation.• Gastrointestinal side effects: such as nausea, vomiting,diarrhea, and bloating.– binding of nitrous oxide to gastrointestinal tissues is the proposedcause.• Interfere with laboratory assays.Crit Care Clin 25 (2009) 279–301
  • 39. Cell-Free Hemoglobin-BasedBlood Substitutes and Riskof Myocardial Infarction and DeathJAMA. 2008;299(19):2304-2312
  • 40. Crit Care Clin 25 (2009) 279–301
  • 41. Mechanism of Action of RecombinantFactor VIIa
  • 42. Efficacy and Safety of Recombinant ActivatedFactor VII for Acute Intracerebral HemorrhageN Engl J Med 2008;358:2127-37.
  • 43. Efficacy and Safety of Recombinant ActivatedFactor VII for Acute Intracerebral HemorrhageN Engl J Med 2008;358:2127-37.
  • 44. Safety of Recombinant Activated Factor VIIin Randomized Clinical TrialsN Engl J Med 2010;363:1791-800.
  • 45. Thanks