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Colloids or crystalloid solutions? Is this (still) the question?

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Presentation on theme: "Colloids or crystalloid solutions? Is this (still) the question?"— Presentation transcript:

1 Colloids or crystalloid solutions? Is this (still) the question?

2 Why Who What When Where W

3 LIFE PRIORITIES PERFUSION O 2 pH electrolytes Schiraldi

4 Adequate tissue oxygenation is known to be key factor in determining tissue survival. Resuscitation efforts in critically ill patients therefore target restoration, normalisation and manteinance of regional blood flow and oxygenation. JL Vincent 2008

5 Adequate volume replacement appears to be a cornerstone in management as restoration of flow is a key component in avoiding tissue ischemia or riperfusion injury. Boldt Dry and die, wet and survive

6 DO 2 = CO* x CaO 2 DO 2 = CO* x CaO 2 # CO CO = stroke volume x FC CaO 2 CaO 2 = (Hb x 1.34 x SaO2) + (PaO2 x )‏

7 myocardial contractility preload afterload Stroke Volume Heart Rate CO SVR Blood Pressure Rhythm HbSpO 2 DO 2 x

8 myocardial contractility preload afterload Stroke Volume Heart Rate CO SVR Blood Pressure Rhythm HbSpO 2 DO 2

9 Currently, there is no consensus on the clinical definition of hypovolemia. In broad terms, patients who improve with fluid therapy are hypovolemic. Static indices of preload have no predictive power in hypovolemia. Crit Care Med 2009 Vol. 37, No. 9

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11 TBW (Total Body Water) 60% of body weight TBW (Total Body Water) 60% of body weight 2/3 ICF 1/3 ECF Na H20H20 ¾ INT 1/4 PL

12 EABV Tissues Perfusion (700 ml)‏

13 capacità di espansione volemica capacità di espansione volemica persistenza in circolo persistenza in circolo effetti sulla cascata di attivazione della SIRS effetti sulla cascata di attivazione della SIRS influenza sul microcircolo influenza sul microcircolo sicurezza sicurezza reazioni avverse reazioni avverse

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15 LIC Fisiologica Bilancio dopo la infusione di 1 litro di soluzione: Intravasale =250 Interstiziale=750 Intracellulare=0 1 litro vasi interstizio LEC

16 Acqua libera (glucosata) Acqua libera (glucosata) Bilancio dopo la infusione di 1 litro di soluzione: Intravasale =85 Interstiziale=250 Intracellulare=665 1 litro vasi interstizio LIC LEC

17 Colloidi Bilancio dopo la infusione di 1 litro di soluzione: Intravasale = 600 – 1000 Interstiziale= 0 – 400 Intracellulare=0 1 litro vasi interstizio LIC LEC

18 Ipertonica (NaCl 7,5 %) Ipertonica (NaCl 7,5 %) Bilancio dopo la infusione di 1 litro di soluzione: Intravasale =7000 Interstiziale= disidratazione Intracellulare= disidratazione 1 litro vasi interstizio LIC LEC

19 Distribuzione relativa di colloidi e cristalloidi a minuti dalla infusione da Haljmae e Lindgren, 2000

20 Fluid Challenge Test Test di espansione volemica

21 …approximately 20 mL/kg of isotonic crystalloid, followed by boluses of up to 1000 mL of crystalloid or 500 mL of colloid given over 30 minutes to achieve adequate resuscitation. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: Crit Care Med. 2008;36:

22 Increasing the infusion rate of an oliguric patient from 100 ml/h to 200 or 300 provides no answer to the question of etiology of oliguria nor does it adequately treat volume depletion. Chernow

23 it is hard to see how their continued use in these patients can be justified outside the context of RCTs As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs. Colloids versus crystalloids for fluid resuscitation in critically ill patients (Review) Perel P, Roberts I Cochrane Database of Systematic Reviews. 3, 2009.

24 No clinical differences were found between colloids and crystalloids in most of the studies analyzed. Given the significant difference in costs between both groups of expanders and in light of the currently available evidence, crystalloids should be used as first-choice expanders. Health Technology Assessment Database Issue 4,

25 If a colloid has to be chosen, HES could be a cheaper substitute than albumin in most cases; though its benefits have not been proven over jellies, it is the cheapest choice. The main adverse effects shown in HES were with older molecules with high molecular weight and high degree of substitution and not with the newer ones, such as Voluven, however given the evidence available, the use of HES in patients with kidney function impairment should be avoided. Health Technology Assessment Database Issue 4,

26 SAFE (Saline vs Albumin Fluid Evaluation) Study. In nearly 7,000 critically ill patients, there was no difference in outcome between the use of 4% human albumin solution and normal saline. N Engl J Med 2004; 350: 2247–56

27 Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis (VISEP) trial N Engl J Med. 2008;358:

28 The VISEP trial was stopped early for safety reasons. A planned interim analysis showed that among 537 patients with severe sepsis …patients receiving pentastarch were approximately 50% more likely to have acute renal failure develop and were also more likely to require renal replacement therapy. N Engl J Med. 2008;358:

29 The choice of intravenous fluid (colloid versus crystalloid) does not appear to be a major determinant in outcome in septic shock and the use of artificial plasma expanders such as pentastarch should be avoided. Engl J Med 2008; 358:125–139.

30 There are insufficient data to conclude that synthetic colloids are safe in the critically ill or to recommend their use when cheaper crystalloid solutions are available. HES solutions should be avoided in patients with severe sepsis and septic shock Merz,Finfer Controversies in Intensive Care Medicine 2008 ESCIM Europrean Society of Intensive Care Medicine

31 La fisiologica non è fisiologica

32 A balanced view of balanced solutions Convincing evidence for clinically relevant adverse effects of dilutional-hyperchloraemic acidosis on renal function, coagulation, blood loss, the need for transfusion, gastrointestinal function or mortality cannot be found. Crit Care Oct 21;14(5):325.

33 We believe that giving a sufficient quantity of intravenous fluids rapidly and targeting appropriate goals is more important than the type of fluid chosen. Schmidt 2009

34 capacità di espansione volemica capacità di espansione volemica persistenza in circolo persistenza in circolo effetti sulla cascata di attivazione della SIRS effetti sulla cascata di attivazione della SIRS influenza sul microcircolo influenza sul microcircolo sicurezza sicurezza reazioni avverse reazioni avverse

35 high volume maintenance fluids vs. low volume fluids after the initial phase of the management in septic shock The NHLBI ARDS Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354:2564–2575

36 Whereas inadequate volume resuscitation is well recognized to result in organ failure and death, excessive resuscitation places the patient at risk for increased IAP, worsening visceral edema, and cardiopulmonary dysfunction. Cheatham M Crit Care Med (3):

37 World Society of the Abdominal Compartment Syndrome … “reliance on overaggressive fluid therapy may worsen gut wall edema leading to further increases in IAP”. “….in the bacteremic state, restoring APP and not just cardiac output may be important.”

38 New Blood, Old Blood, or No Blood? Adamson JV NEJM ;12

39 Red blood cell transfusion in the critically ill: When is it time to say enough? Corwin, Shorr Crit Care Med ;6:2104

40 TRICC e TRAC

41 A multicenter, randomized, controlled clinical trial of Transfusion Requirements in Critical Care Hebert PC et al: N Engl J Med 1999; 340:409 – 417 TRICC

42 Transfusion Requirements After Cardiac Surgery The TRACS Randomized Controlled Trial Among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity. JAMA. 2010;304(14):

43 The data available would suggest that, in the absence of acute bleeding, Hb of 7.0 –9.0 g/dL are well tolerated by most critically ill patients and that a transfusion threshold of 7.0 g/dL is appropriate. Corwin, Shorr Crit Care Med ;6:2104

44 Salvate il soldato Ryan

45

46 Does CVP predict fluid responsivness? A sistematic review of literature and a tale of seven mares. Mark et al CHEST 2008; 134:

47 CVP should no longer be routinely measured in the ICU, operating room, or ED. CVP should not be used to make clinical decisions regarding fluid management

48 In patients with cardiac depression from anesthesia or sepsis, those with ongoing blood loss, or those with systemic vasodilation, it is certain that no useful relationship between CVP and blood volume exists. Leibowitz, ASA 2009

49 Based on the results of our systematic review, we believe that CVP should no longer be routinely measured in the ICU, operating room, or ED. Mark et al CHEST 2008; 134:

50 Using CVP to guide volume resuscitation fails to acknowledge that this parameter is no better than a coin toss in predicting who will respond to fluids. Durairaj L, Schmidt GA. Fluid therapy in resuscitated sepsis: less is more. Chest ; 133 ( 1 ): Osman D, Ridel C, Ray P, et al. Cardiac fi lling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med ; 35 ( 1 ):


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