Χορήγηση υγρών στον μηχανικά αεριζόμενο ασθενή

Χορήγηση υγρών στον μηχανικά αεριζόμενο ασθενή Α. Ε. ΑΡΜΑΓΑΝΙΔΗΣ Καθηγητής Εντατικής Θεραπείας Διευθυντής Β ΚΛΙΝΙΚΗΣ ΕΝΤΑΤΙΚΗΣ ΘΕΡΑΠΕΙΑΣ Πανεπιστημιακό Γεν. Νοσ. «ΑΤΤΙΚΟΝ»

??? 1. Volume responsiveness 2. Hemodynamic monitoring 3. Type of fluids => Medical decision making

Response to volume challenge??? Volume responsiveness IS NOT related to intravascular pressures

Osman et al CCM 2007

Osman et al CCM 2007

44% n = 1148 data sets 58% 62%

More PV curves

Response to volume challenge??? Volume responsiveness IS NOT Volume status

Inspiratory and Expiratory changes

static vs. dynamic markers Volume responsiveness No information on volume status

SpMax Δ up Baseline ΔDown SpMin SPV

1 2 1 2 >12% 1+2 mean

static vs. dynamic markers Volume responsiveness No information on volume status

Stressed and Unstressed Volume (I) Approximately 70% of blood volume resides in the small venules and veins at low pressure indicating that this region is very compliant. Under resting conditions, only about 1.2 1.4 l (25 30%) of the total blood volume of 5 6 l in the average male actually stretches the vascular walls and the rest of the volume just fills out the round shape of the vessels and is unstressed Magder et al CCM 1998

Stressed and Unstressed Volume (II) The elastic recoil pressure produced by the volume stretching the elastic structures of the vasculature is called the mean circulatory filling pressure (MCFP). Based on Poiseuille s law, VR is equal to MCFP minus Pra and divided by the venous resistance Guyton 1955

Broccard 2012

OXI αγγειοσυσπαστικά σε ανεπαρκή ενδοαγγειακό όγκο υγρών

A reversible self volume challenge

??? 1. Volume responsiveness 2. Hemodynamic monitoring 3. Type of fluids => Medical decision making

Ερωτήματα για την κλινική πράξη; Είναι τεκμηριωμένο ότι σε ARDS η χρήση καθετήρα Swan Ganz 1) αυξάνει την επιβίωση των ασθενών 2) μειώνει την επιβίωση των ασθενών 3) αυξάνει τις επιπλοκές 4) συνδυασμός των 1 και 3 5) συνδυασμός των 2 και 3

Βιβλιογραφικά δεδομένα <2004 Physiologic, experimental and clinical data support fluid restriction to reduce edema formation in ALI/ARDS No evidence of superiority of one type of fluids liberal vs. conservative management Possible disadvantages: decrease CO and hypoperfusion, renal and other organ failure

June 2006 60 days mortality in 1000 patients with ALI, studied within 48 hours and for 7 days, 503 pts conservative group ( dry ) 498 pts in liberal group ( wet ) CVP 4 PAOP 8 vs. CVP 10-14 PAOP 14-18

60 days mortality in 1000 patients with ALI, studied within 48 hours 513 pts with PAC and 488 pts with CVC (the same predefined protocol) CVP and peripheral perfusion vs. PAOP and CO

Συνοπτική παρουσίαση πρωτοκόλλου (προφορτίο και κατηγοροποίηση 4 Χ 4)? CVP (mm Hg) (PAOP=CVP+4-5) With shock Cons Liberal urinary output <0,5 ml/kg/hr >13 >18 Vaso pres. > Fl Without shock urinary output >0,5 ml/kg/hr Ineff C Eff C Ineff C Eff C Diur + Dobu Diur Diur+ Dobu Diur 9-13 15-18 Dobu Diur Dobu Diur 4-8 10-14 Fl > Vaso pres. Fl Fl Fl D Cons < 4 <10 Fl Fl Fl Fl Lib

Cons vs. Liberal Mortality 28,4 vs. 25,5 % (p=0,3) Shock similar % renal function p=0,06 PaO2/FiO2 p=0,07 Arrhythmias 43 (3serious) vs. 19 (3) p=0.001 and electrolytes disturbances 25 vs. 18%, p 0,009

June 2006

? 60 days mortality in 1000 patients with ALI, studied within 48 hours 513 pts with PAC and 488 pts with CVC (the same predefined protocol) CVP and peripheral perfusion vs. PAOP and CO

Mortality 27,4 vs. 26,3 % (p=0,7) Similar % of shock and organ failures, renal function, lung function Complications uncommon 8% PAC vs. 6% CVC more procedures in PAC group, more arrhythmias but no death

Mortality 27,4 vs. 26,3 % (p=0,7) Similar % of shock and organ failures, renal function, lung function Comments: CI normal in 92% of pts, <48 hrs, ALI (ARDS?) pts, shock 37 vs. 32 % PAC/CVC mixed protocols of treatment, which targets?

37% 37% Fluid strategy 54% PAC vs. CVC 57%

37% 24%

29% - low CO 8%, both 3%

Fluid Balance 503 pts conservative group 136 + 491 ml 498 pts liberal group 6992 + 502 ml Patients in shock conservative 2904 +1008 ml liberal 10138 + 922 ml Patients without conservative 1576 + 519 ml shock liberal 5287 + 576 ml

COMPLICATIONS? Conservative Group More ventilator free days More ICU free days More days free of CNS failure (No difference in renal or other failure)

PAC-guided therapy did not improve survival or organ function but was associated with more complications that CVC-guided therapy CONCLUSION suggest that PAC should not be routinely used for the management of acute lung injury

NO CONCLUSION for Potential beneficial effects in subgroups of patients heart failure, obstructive + restrictive lung disease patients under dialysis and did not optimize the benefits of the PAC vs. CVC

DISCUSSION Because the PAC provides unique physiological information, it has been assumed that the use of this catheter would improve survival and decrease the duration of assisted ventilation and the rate of organ failure among patients with acute lung injury.

CONCLUSION??? PAC-guided therapy did not improve survival or organ function but was associated with more complications than CVC-guided therapy suggest that PAC should not be routinely used for the management of acute lung injury

CONCLUSION??? PAC-guided therapies did not improve survival or organ function but PAC was associated with more complications than CVC-guided therapies suggest that PAC should not be routinely used for the management of patients with early ALI and no other disease or organ dysfunction?

??? 1. Volume responsiveness 2. Hemodynamic monitoring 3. Type of fluids => Medical decision making

Vincent JL Klin Wochenschr 1991: normal permeability or not and type of fluids, amount is more important than type, crystalloids interstital volume and.. Cochrane Injuries Group Albumin Reviewers BMJ 1998 24 studies involving a total of 1419 pts: Albumin containing fluids resulted in a 6 percent increase in the oxygenation absolute risk of death when compared with crystalloid solutions. Dubois M, Vincent JL COCC 2002: demonstrate safety of albumin and even potential benefits Vincent JL CCM 2004: Albumin reduces morbidity Vincent JL Crit Care 2005: Albumin administration was associated with decrease survival. Further Dubois M Vincent JL CCM 2006: Albumin may improve organ function in hypo-albuminemic critically ill patients Vincent JL BMJ 2006: research in patients at high risk of complications is now needed

2004, 350: 2247-56 28 days mortality in ICU patients assigned either in the group albumin 4% (3497 pts) or in the saline group (3500 pts)

The requirement for fluid resuscitation must be supported by AT LEAST one of the following clinical signs a. Systolic blood pressure (SBP) <100mmHg or mean arterial pressure (MAP) < 75mmHg or a 40mmHg decrease in SBP or MAP from the baseline recording Or requirement for vasopressors or to inotropes to maintain blood pressure at those levels. b. Heart rate > 90 beats per minute. c. Central venous pressure < 10mmHg d. Pulmonary artery wedge pressure < 12 mmhg e. Respiratory variation in systolic or mean arterial blood pressure of >5 mmhg f. Capillary refill time > one second g. Urine output < 0.5 ml/kg for one hour

Mortality 30,7 vs. 35,3 % p0,1 Similar % of shock, renal function and organ failures lung function Conclusion albumin or saline? = requires LOS, further days of study factors that may influence the CMV choice etcof fluid for a critically ill patient include: the individual clinician s preference, the tolerability of treatment, its safety, and its cost.

CCM 2005, 33:1681-1687 40 pts assigned either in the group albumin 4% + furosemide (20 pts) or in the group placebo + furosemide (20 pts) for 5 days * treated pts better oxygenation and fluid loss * control pts more often hypotension and organ failures and fewer shock-free days (14 vs. 7) and ventilator free days (5/30 vs. 1/30)

HYPOTHESIS Search for Medicine Based Evidence DATA COLLECTION Test the hypothesis Evidence Based Medicine CONCLUSIONS Explain findings Reform question(s) and new hypothesis?

Προβλήματα στην κλινική πράξη Σωστή μέτρηση αλλά και Κλινική εκτίμηση Κάθε αιμοδυναμική μέτρηση πίεσης αποκτά διαφορετική σημασία εάν ο ασθενής π.χ. : αναπνέει με το Α ή Β mode ανταγωνίζεται τον αναπνευστήρα του ή όχι έχει απόφραξη τραχειοσωλήνα ή όχι έχει βρογχόσπασμο ή υψηλή ΡΕΕΡtot ή όχι έχει ατομικό αναμνηστικό, θετικό ισοζύγιο υγρών κλπ

Evidence Based Medicine and Guidelines for clinical practice (Guidelines = κατευθύνσεις<οδηγίες<κανόνες) Statistics for Medical Research (D.G. Altman) There is no need for the search of precision to throw (common) sense out of the window The clinician must use statistics(+ebm) as the drunken man uses the lamppost: for support rather than for illumination

Evidence Based Medicine Use it for medical decision making, not to avoid thinking Clinician Guidelines expert