1. Société d’Anesthésie de Charleroi www.sacnet.be

2. 12 Février 2008 Anesthésie et ORL : « quid de l’otologie et de la rhinologie ? « M. Van Boven JP Lechat

3. Avril 2008Anti-aggrégants et anti-plaquettaires 14 Juin 2008Atelier Echo

4. « STRATEGIE PERFUSIONNELE PERI-OPERATOIRE »

5. WET or DRY ?

8. WET or DRY ? WEANING Upadya, ICM, 2005 All ICU MV patients Prospective observation Fluid balance

9. Frutos-Vivar, Chest, 2006, 130 Prospective observation All ICU MV patients Fluid balance WET or DRY ? WEANING

10. Alsous, Chest, 2000, 117 Retrospective data collection Septic shock Fluids balance Negative fluid balance predicts survival in septic shock WET or DRY ? SURVIVAL

11. Sakr, Chest, 2005, 128 ALI-ARDS Prospective observation Fluids balance WET or DRY ? SURVIVAL

12. WET or DRY ? Humphrey, Chest, 1990, 97 Retrospective observation ARDS patients Capillary Wedge Pressure The lowest CWP consistent with a adequate CO improves ARDS survival WET or DRY ? SURVIVAL

13. Eisenberg, ARRD, 1987, 136 Prospective data collection All critically ill patients Extravascular lung water WET or DRY ? SURVIVAL

15. Hayes, NEJM, 1994, 330, 1717

16. Q f = K [(P mv – P pmv ) –  (  mv -  pmv )] Pressions Hydrostatiques Pressions Oncotiques

17. Q f = K [(P mv – P pmv ) –  (  mv -  pmv )] Pressions Hydrostatiques Pressions Oncotiques

18. Q f = K [(P mv – P pmv ) –  (  mv -  pmv )]

19. Q f = K [(P mv – P pmv )

21. Rivers E et al. N Engl J Med 2001;345:1368-1377

27. Martin, CCM, 2005

29. Fluid management in ALI. NEJM, 2006, 354, 2564 mean = 24 hours after ALI criteria meeting mean = 43 hours after ICU admission no severe comorbidity -Lung -Kidney -Heart no risk of death within 6 months 11.512 patients screened 10.511 patients excluded

30. Fluid management in ALI. NEJM, 2006, 354, 2564 LIBERALCVP 10-14 mmHg PAOP14-18 mmHg CONSERVATIVECVP <4 mmHg PAOP <8 mmHg

31. Fluid management in ALI. NEJM, 2006, 354, 2564

32. Cumulative at day 7 +6992+/-50 -136 +/- 491

33. Fluid management in ALI. NEJM, 2006, 354, 2564

34. Hemodynamics ! lower mean arterial pressure lower cardiac index Lung function better injury score better oxygenation index lower plateau pressure lower PEEP

35. Fluid management in ALI. NEJM, 2006, 354, 2564 Hemodynamics lower mean arterial pressure lower cardiac index Lung function better injury score better oxygenation index lower plateau pressure lower PEEP Metabolic function higher oncotic pressure, Hgb, albumine levels higher creatinine values metabolic alkalosis (hypoCl - ) electrolyte imbalance (hypoK +, hyperNa + )

36. Fluid management in ALI. NEJM, 2006, 354, 2564 Conservative strategy Improves lung function Shortens duration of MV Shortens ICU LOS

37. « In acute critical illness, treat early to achieve optimal goals and prevent MOF » Kern, CCM, 2002, 30 -Initial net positive fluid balance phase -Diuretic phase Alsous, Chest, 2000, 117

38. « Fluid management is a matter of timing » Otero, Chest, 2006, 130

39. Je me mouille !