Fluid Resuscitation in Critical Care Patients

2013/05/19

佛教慈濟醫院台北分院外科加護病房 周志道

Outlines1. Basics

2. Crystalloid vs. Colloid update

3. Albumin update

4. Standard vs. Delayed fluid resuscitation update

5. Hemodynamic parameters to guide fluid therapy

6. Fluid therapy of severe sepsis 2012

7. Blood substitutes

8. FVII

Hemoconcentration

L. Zgraggen et al. Thrombosis Research (2005) 115, 175—183

Hemorrhagic Shock

J Obstet Gynaecol Can 2002;24(6):504-11

Hypothetical Capillary Endothelial Barriers

Peripheral Capillary Brain Blood Barrier

65A7A

Vascular lumen Vascular lumenInterstitial space Interstitial space

H2OH2O H2OH2O

Na+

Small ion

Na+

Small ion Na+

Small ion

Na+

Small ion

Protein ProteinProtein Protein

C. Tommasino. Anesthesiology Clin N Am 20 (2002):329-346

Effect of Different Solutions on Plasma Volume Expansion

Rizoli: J Trauma, Volume 54(5) Supplement.May 2003.S82-S88

Fluid resuscitation with colloid or crystalloid solutions in critically ill patients (II)

Gill Schierhout; Ian Roberts. BMJ 1998; 316:7136

Colloids versus crystalloids for fluid resuscitation 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 fibrinogen and globulin have been removed

9

Effect of HES Solutions on Hemostasis

Sibylle A. Anesthesiology.2005;103: 654-60

Hydroxyethyl Starch 130/0.42 versusRinger’s Acetate in Severe Sepsis

Perner et al. N Engl J Med 2012;367:124-34.

Hydroxyethyl Starch or Saline for fluid resuscitation in Intensive Care

Mybergh et. N EJ M 2012;367:1901-11

Association of Hydroxyethyl Starch Administration With Mortality and AcuteKidney Injury in Critically Ill Patients Requiring Volume Resuscitation

A Systematic Review and Meta-analysis

JAMA. 2013;309(7):678-688

Association of Hydroxyethyl Starch Administration With Mortality and AcuteKidney Injury in Critically Ill Patients Requiring Volume Resuscitation

A Systematic Review and Meta-analysis

JAMA. 2013;309(7):678-688

A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit

The SAFE Study Investigators, . N Engl J Med 2004;350:2247-2256

Effect of baseline serum albumin concentration on outcome ofresuscitation with albumin or saline in patients in ICU

The SAFE Study Investigators ; BMJ Nov 2006; 333: 1044;

Saline or Albumin for Fluid Resuscitationin Patients with Traumatic Brain Injury

The SAFE Study Investigators* NEJM 2007; 357;9

Saline or Albumin for Fluid Resuscitationin Patients with Traumatic Brain Injury

The SAFE Study Investigators* NEJM 2007; 357;9

Albumin Administration in Patients with Severe Sepsis due to Secondary Peritonitis

C.D. Chou J Chin Med Assoc 2009;5:243-250

Baseline albumin concentration more than 20 g/l.

Baseline albumin concentration of 20 g/l or less

Impact of albumin compared to salineon organ function and mortality of patients

with severe sepsis- The SAFE Study Investigators

Administration of albumin compared to saline did not impair renal or other organ function and may have decreased the risk of death.

Intensive Care Med. 2011 Jan;37(1):86-96

Impact of albumin compared to salineon organ function and mortality of patients

with severe sepsis- The SAFE Study Investigators

Intensive Care Med. 2011 Jan;37(1):86-96

Morbidity in hospitalized patients receiving human albumin: Meta-analysis

Jean-Louis Vincent et al .Crit Care Med 2004; 32(10): 2029-2038

Transfusion practice in the

critically ill: Can we do better?

Restrictive transfusion strategy– Transfusion threshold --- 7.0 g/dL– Maintained between 7.0- 9.0 g/dL

Corwin, Howard L. Critical Care Medicine 2005 ;33(1):232

Canadian Critical Care Trials Group NEJM 1999;304:409-417

Is fresh frozen plasma clinically effective? Stanworth, S. J et al. Br J Hematology 2004 ;126(1):139–152

Study Intervention details

Comparator details

Clinical group Main outcome as reported

Reed et al

(1986)

FFP 2 U every 12 U of blood

PLT 6 every 12 U of blood

Massive transfusion No differences in clinical bleeding outcomes

Boldt (1989)

Trimble (1964)

FFP 2U

FFP 3U

No FFP Cardiac surgery with bypass

No positive effect on blood loss or transfusion requirement

Consten et al

(1996)

FFP 3U Gelufusion 750 ml

Cardiac surgery with bypass

No significant difference in blood loss or requirement

Kasper et al

(2001)

Autologous

FFP 15 ml/kg

Hetastarch 15 ml/kg

Coronary artery bypass grafting

No significant reduction in blood loss or requirement

Wilhelmi et al

(2001)

FFP 4U Hydroxy-ethyl-starch 1000 ml

Coronary artery bypass grafting

No significant reduction in blood loss or requirement

Oliver et al

(2003)

FFP 1U Albumin 5% 200ml

Open heart surgery for children < 10 kg

No significant differences in blood loss or requirement

Bocanegra (1979) Plasma

(high volume)

Plasma

(low volume)

Burn (children) No significant difference in mortality

Liu et al

(1994)

Autologous plasma saver

No FFP Hysterectomy No clinical outcome difference

Leese et al

(1991)

FFP 8 U for 3 d Albumin sol 2000ml

Acute severe pancreatitis No significant difference in clinical outcome/mortality

Boyed et al

(1996)

FFP 2U Conjugated estrogen 50 mg

Renal disease and transplantation

No clinical outcomes reported ( outcomes of coagulation testing)

Menges et al

(1992)

Plasma with blood

Allogenic red cell

Orthopedic hip surgery No significant differences in blood loss or requirement

Limited fluid resuscitation

Bickell WH et al. N Engl J Med. 1994; 331: 1105–1109.

Immediate Delayed Resuscitation Resuscitation P Value Survival to discharge 193/309 (62) 203/289 (70) 0.04 Blood Loss (ml) 3127 4937 2555 3546 0.11 LOS (hospital) (days) 14 24 11 19 0.006

LOS (ICU) (days) 8 16 7 11 0.30

Effects of Delaying Fluid Resuscitation on an Injury tothe Systemic Arterial Vasculature

JAMES F. HOLMES. Et al. ACADEMIC EMERGENCYMEDICINE 2002; 9:267–274

Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after

high-risk surgery

Lobo at et. Critical Care 2011, 15:R226

Delaying Fluid Resuscitation in hemorrhage shock Induce 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 EMERGENCY

MEDICINE 2007; 49:37-44

Delayed fluid resuscitation in hemorrhagic shock induces increased production of pro-inflammatory cytokines and the release of cytokine was correlated with the time delayed for resuscitation.

Hemodynamic parameters to guide fluid therapy

Clinical indices of the adequacy organ/tissue perfusion

Hemodynamic parameters to guide fluid therapy

Hemodynamic parameters to guide fluid therapy

Fluid Therapy of Severe Sepsis1. Crystalloids as the initial fluid of choice in the

resuscitation of severe sepsis and septic shock (grade 1B).

2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and septic shock (grade 1B).

3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids

(grade 2C).Surviving Sepsis Campaign 2012

Fluid Therapy of Severe Sepsis4. Initial fluid challenge in patients with sepsis-induced tissue

hypoperfusion with suspicion of hypovolemia to achieve a minimum of 30mL/kg of crystalloids (a portion of this may be albumin equivalent). More rapid administration and greater amounts of fluid may be needed in some patients (grade 1C).

5. Fluid challenge technique be applied wherein fluid administration is continued as long as there is hemodynamic 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

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) ＞ 10 gm/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

Blood Substitutes

•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 objection

Problems associated with blood transfusion

Comparison of the Properties

Property Blood Blood substitutes Volume expanders

Volume expansion

Yes Yes Yes

Oxygen carrying capacity

Yes Yes No

Other therapeutic proteins

Yes No No

Therapeutic life 1-2 months 1-2 days Hours (varies with dose and species)

Storage life 1 month 6-24 months 2 years

Changes during storage

Yes No No

Type specific Yes No No

Viral inactivation No Yes Yes

Size Large Small Small

Viscosity High Low/moderate Low

Deanna J. Nelson Encyclopedia of Pharmaceutical Technology. 2002:236 - 262

• HBOC: hemoglobin-based oxygen carrier

• PFC: Perfluorocarbons

ADVERSE EFFECTS OF HBOCs

• Vasoactivity: Nitric oxide binds to free Hb, – vasoconstricition occurs.

• Hemostasis : Reversal of the inhibition effect of nitric oxide on platelet aggregation.

• Gastrointestinal side effects: such as nausea, vomiting, diarrhea, and bloating. – binding of nitrous oxide to gastrointestinal tissues is the proposed

cause.

• Interfere with laboratory assays. Crit Care Clin 25 (2009) 279–301

Cell-Free Hemoglobin-BasedBlood Substitutes and Risk

of Myocardial Infarction and Death

JAMA. 2008;299(19):2304-2312

Crit Care Clin 25 (2009) 279–301

Mechanism of Action of Recombinant Factor VIIa

Efficacy and Safety of Recombinant ActivatedFactor VII for Acute Intracerebral Hemorrhage

N Engl J Med 2008;358:2127-37.

Efficacy and Safety of Recombinant ActivatedFactor VII for Acute Intracerebral Hemorrhage

N Engl J Med 2008;358:2127-37.

Safety of Recombinant Activated Factor VIIin Randomized Clinical Trials

N Engl J Med 2010;363:1791-800.

Thanks