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Dry or wet? Fluid Management in critical illpatients
Ehrenfried Schindler
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Now information about the obligation matter of fluidmanagement in critical ill patients. It was discussion
about who will winCrystalloids or Colloids. From thereceived results is known, that the patient being in
critical condition is better to be dry than wet.under all circumstances volume therapy should be
guided by its effects on organ function and indicators
of the adequacy of tissue oxygenation.
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Tissue
Hypoxia
Inflammation
Volume
Perfusion
Micro-
circulation
Multi Organ Failure
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Colloid
Crystalloid
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Fluid management
in critical ill: who will win?
Crystalloids vs. Colloids
Colloids vs. ColloidsCrystalloid vs. Crystalloid
Dry vs. Wet
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Colloids vs. Crystalloids
Human Albumin = natural Colloid
Artificial ColloidsHydroxyethylstarch (HES)
Gelatin
Dextran
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Maintain or increase oncotic pressure
Significant increase of intravascular volume
Stays in the intravascular department
Better perfusion?
Less tissue edema?
Less mortality?
Increase in outcome?
Benefit of Colloids vs. Crystalloids
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Velanovich V: Crystal loid versus col loid f luid resusci tat ion: a meta-analysis ofmortal i ty.1989 Surgery 105: 65-71Mortality increased with colloids
Schierhout G: Fluid resusc i tat ion w ith col loid o r crystal loid solut ion in c r i t ically i l lpat ients: a systemic review. 1998 Crit Care Med 27: 200-210Compared to Crystalloids 4% increased mortality when Colloids are the primary volumereplacement
Choi P. et al.: (Isotonic) Crystal loid v s. Col loids in f luid resus ci tat ion: a systematicreview. 1999 Critical Care Medicine, 27: 200-210Mortality unchanged In the group of trauma patients significant better results when usingcrystalloids
Number of pulmonary edema without difference
No difference in ICU stay
Bunn F. et al.: Col loid so lut ions for f luid resus ci tat ion. Cochrane Database Syst Review2003(1): CD001319
There is no evidence that one colloid solution is more effective or safe than any other.
Colloids vs. Crystalloids
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Hands up !!
1. Colloids are more effective than
crystalloids
2. HES is more effective than other colloids3. HES influence outcome more positive
compared to crystalloids, albumin,
dextran or gelatin
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84% think, that Colloids are more effective than crystalloids
77% think, that HES is more effective than other colloids
87% think, that HES influence outcome more positive compared to crystalloids,
albumin, dextran or gelatin
Intraoperative: 75%-90% are using HES and crystalloids for volume replacemen
(Exception: Children and burn patients (albumin and crystalloids)
Intensive care unit: 84% are using HES, 45% are using crystalloids
(Exception: Children and burn patients (albumin and crystalloids)
What do we guess about volume replacement?
Boldt J, Schllhorn T, Dieterich HJ: Volumentherapie in Deutschland eine Ist-Analyse anhand einer
Fragebogenaktion. Ansth Intensivmed 47: 309-317 (2006)
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Increased mortality after albumin administration in critically ill patientsCochrane Injuries Group Albumin reviewers 1998 BMJ
No differences in outcome (new organ failure, duration of ventilation,
renal replacement therapy, length of stay) and mortality after albumin
administration (vs. saline)Wilkes MM: Patient survival after human albumin administration. A meta analysis of randomized, controlled trials. Ann Intern Med
2001: 149-164.
The SAFE (Saline vs. Albumin Fluid Evaluation) Study Investigation. A comparison of albumin and saline for fluid resuscitation in the
intensive care unit. N Engl J Med 2004; 350: 2247-56
More expensive
Risk of infection
Albumin
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Is albumin administration in the acutely ill
associated with increased mortality? Results of the SOAP study
Vincent JL et al. Critical Care, 9:R745-R754 (2005
% albumin
administration
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Is albumin administration in the acutely ill
associated with increased mortality? Results of the SOAP study
Vincent JL et al. Critical Care, 9:R745-R754 (2005
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No albumin
(n=339)
Albumin
(n=339)
Log rank = 7,63
p= 0,006
Vincent JL et al. Critical Care, 9:R745-R754 (2005
Cumulative
survival
Is albumin administration in the acutely ill
associated with increased mortality? Results of the SOAP study
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In this observational study of 3,147 patients, albumin administration
was independently associated with a lower 30-day survival
Moreover, in 339 pairs matched according to a propensity score, ICU
and hospital mortality rates were higherin patients who receivedalbumin than in those who did not
While albumin administration may be safe in patients requiring fluid for
intravascular volume depletion, these results suggest it may not beharmless in all ICU patients.
Is albumin administration in the acutely ill
associated with increased mortality? Results of the SOAP study
Vincent JL et al. Critical Care, 9:R745-R754 (2005
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Colloids vs. Crystalloids
RESUSCITATION FROM SEPTIC SHOCK
WITH CAPILLARY LEAKAGE:
HYDROXYETHYL STARCH (130 KD), BUT
NOT RINGERS SOLUTION MAINTAINS
PLASMA VOLUME AND SYSTEMIC
OXYGENATION
Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004
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Colloids vs. Crystalloids
Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004
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Colloids vs. Crystalloids
Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004
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Colloids vs. Crystalloids
Key conclusion:
HES 130 kD could maintain PV and COP, thereby preserving systemic
oxygenation and hemodynamics.
These results suggest the intravascular persistence of the artificial
colloid in the presence of albumin leakage.
Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004
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30 children less than 3 years undergoing cardiac surgery.
Volume replacement with 6 % HES (200/0.5) vs. 20% human albumin (pre-bypass
period).
Outcome measures: HR, MAP, CVP, BGA, colloid osmotic pressure, electrolytes,
fibrinogen, AT III, albumin, platelet count, overall coagulation tests, urine output,
creatinine, blood loss, total use of homologous blood, FFP and platelet
concentrates.
No significant Difference (except Albumine concentration)
Conclusion: LMW-HES ist safe and effective in pediatric cardiac
surgery
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Fluid resuscitation in severe sepsis and septic shock:
Albumin, hydroxyethylstarch, gelatin or ringers solutionlactate:
Does it really make a difference?
Colloids vs. Crystalloids
Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)
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Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)
Colloids vs. Crystalloids
Feces spillage
Surgical Operation
Randomization
4h RL resuscitation Study until spontaneous death
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Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)
Colloids vs. Crystalloids
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Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)
Colloids vs. Crystalloids
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Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)
Colloids vs. Crystalloids
although albumin and HES solution were
associated with higher cardiac output and DO2,and lower blood lactate levels than gelatin and
RL, our results suggest that the type of i.v. fluid
used for initial fluid resuscitation has limited
effects on outcome.
Key conclusion:
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Colloids vs. Crystalloids
Next Round
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Fluid Resuscitation during capillary
leakage: Does the type of fluid make a difference?
Hasibeder WR, Intensive Care Med 28:532-534 (2002
Meta-Analysis: Methodological limitations
old overall treatment changes over years
types, doses, duration of fluid administration varies
highly heterogeneous patient population
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Sepsis in European intensive care units:
the SOAP study
Cohort, multi-center, observational study
198 ICU 24 European countries
total of 3,147 patients
Vincent JL et al. Critical Care, 9:R745-R754 (2005
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Sepsis in European intensive care units:
the SOAP study
Vincent JL et al. Critical Care, 9:R745-R754 (2005
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Factors of increased mortality
Degree of organdysfunction
Patient age
Cirrhosis
Mean fluid balance
Vincent JL et al. Critical Care, 9:R745-R754 (2005
Indicator of
severity,
Independent
predictor of
outcome
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Endothelial Glycocalix
The new Barriere Reef
A Rat ional Approach to
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Perioperat ive Fluid ManagementDaniel Chappell , M.D.,* Matthias Jacob , M.D.,* Klaus Ho fman n-Kiefer, M.D.,* Peter Con zen, M.D., Markus
Rehm, M.D.
Anesthesiology 2008; 109:72340
Determinants of insensible fluid loss.
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FluidInput
Fluid
Shift
3833 ml
Cryst
(ml)Colloid
(ml)
Preop
Bloodvolume
(ml)
Postop
Bloodvolume
(ml)
Blood
(ml)
Urine
(ml)
FluidOutput
Determinants of insensible fluid loss.
Perspiration, protein shift and endothelial
glycocalyx
Jakob M et al., Anaesthesist 2007 56:747764
Determinants of insensible fluid loss.
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Perioperative
Proteine
Input (g)
Proteine
Output (g)
Albumin
InfusionBlood
Loss
PreO
P
Intrav
ascular
Protein
(g)
Post
OP
Intrav
ascular
Prote
in
(g)
Determinants of insensible fluid loss.
Perspiration, protein shift and endothelial
glycocalyx
Jakob M et al., Anaesthesist 2007 56:747764
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Fluid Management in critical ill:
Conclusion
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Albumin should be used with caution in critical ill
patients, although in pt. with low albumin it may be
beneficial dry seems to be more beneficial than wet
Colloids (HES, Gelatin) have some advantages
regarding fluid therapy in sepsis
Fluid Management in critical ill:
Conclusion
but
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Fluid Management in critical ill:
Conclusion
there is concern about the increased risk of acute
renal failure with HES administration
and
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Fluid Management in critical ill:
Conclusion
under all circumstances volume therapy
should be guided by its effects on organfunction and indicators of the adequacy of
tissue oxygenation.
Reinhart K, Nephrol Dial Transplant 11, editorial comment (1996)
and
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mSrali Tu sveli? siTxis menejmentie.Sindleri(sanqt-augustine, germania)moyvanilia siTxis moculobis marTvis sakiTxi kritikulmdgomareobaSi nyof avadmyofebSi. Ganxilulia kristalodurida koloiduri xsnarebis upiratesobis sakiTxi, miRebuliSedegebidan gamomdinare gairkva, rom kritikulmdgomareobaSi myofi avadmyofi umjobesia iyos ufro ,,mSralvidre ,,svel mdgomareobaSi.
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Thank you