Folyadékterápia:krisztalloid vagy kolloid?

Molnár Zsolt Aneszteziológiai és Intenzív Terápiás Intézet

Szegedi Tudományegyetem

Élettan

DO2= (SV•P) • (Hb•1.39•SaO2+0.003•PaO2) ~ 1000ml/min

VO2 = CO • (CaO2 - CvO2) ~ 250 ml/min (ScvO2~70-75%)

Folyadék Vér Oxigén

Analgézia, szedáció

Az oxigén adósság

500 1000

250

VO

2 (m

l/min

)

DO2 (ml/min)

Sokk

Kompenzáló mechanizmusok

Kritikus pont

A folyadék fontos…

…életeket menthet,

Mortalitás: 46.5 vs. 30.5% (p=0.009)

…de árthat is: SOAPVincent JL, et al. Crit Care Med 2006; 34: 344–353

Annyit adjunk, amennyire szükség van!Bungaard-Nielsen M, et al. ACTA Anaesthesiol Scand 2009; 53: 843-51

Mit adjunk:

Krisztalloidot vagy Kolloidot?

Mortalitás:Lássuk az evidenciát!

SAFE

Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247

20.9% 21.1%

P=0.34

<22 ml/kg

48 (22-96) ml/kg

Acute Renal Failure: HES-34.9% vs RL-22.8%, p=0.002

• Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.4 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer’s acetate.

• In patients in the ICU, there was no significant difference in 90-day mortality between patients resuscitated with 6% HES (130/0.4) or saline. However, more patients who received resuscitation with HES were treated with renal-replacement therapy.

HES is bad for you…

Molnár ‘99

Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759

Perner A et al. 2012; DOI: 10.1056/NEJMoa1204242

„6S”

„CHEST”

„HES-ítélet” - 2012

Vége a szintetikuskolloid történetnek?

Dellinger RP et al. Intensive Care Med 39. doi: 10.1007/s00134-012-2769-8

Krisztalloidot vagy Kolloidot adjunk?

• Crystalloids:– Robert Lewins – 1832

• INJECTION OF SALINE SOLUTIONS IN EXTRAORDINARY QUANTITIES INTO THE VEINS IN CASES OF MALIGNANT CHOLERA

– Sydney Ringer – 1885

– Alexis Hartmann (1898-1964)

• Albumin– Pearl Harbor - 1941

Mérföldkövek

Molnár ‘99

A szemipermeabilis membránok

J Physiol May 5, 1896 19 (4) 312-326

TBW ~ 40L

Interstitial I.v.

I. c. E.c.

Coll

Cryst.

5%D1/82/85/8

1/43/4

1/1

Megoszlás – kompartment modell

V:R=1:1; 1:4Fact or fiction?

Hogyan működik az élettana klinikai gyakorlatban?

SAFE

Finfer S et al. SAFE study. N Eng J Med 2004; 350: 2247

Alb:1184 ml

Saline:1565 ml25%<

Folyadékterápia indokációja:

„The treating clinician judged that fluid resuscitation was required”

Perner A et al. 2012; DOI: 10.1056/NEJMoa1204242

„Trial fluid…was used when ICU clinician

judged [it] was needed”

HES:1500 ml

RA:1500 mlNS<

Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759

20%< S

„Trial fluid was administered…as determined by the treating clinician

and supported by at least one objectivephysiological criterion”

Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759

HR<90

MAP~75

CVP~9

Lac~2

• Közös vonások:• Indication of fluid-bolus was based on „intuition”

(reflects everyday practice)• Rather than invasive hemodynamic indeces

HES-250

GEL-30 Tehát: az élettan (V:R arány) nem működik az ITO-n

Mi a helyzet „egészségesekben”?

Acta Anaesthesiol Scand 2012; 56: 291–297

Decrease by 60%

Bleeding: 150 ± 33 ml/eventBlood:HES = 1:1

Crit Care Med. 2010 58(2):1-7

10 healthy adults1000 ml fluid/60 min

4x

Mit tanultunk eddig?

• „Működik” egészségesekben

• Mintha nem működne szeptikus betegekben1. Kolloid extravazáció?2. Valóban hypovolémiásak voltak ezek a betegek?

?

Válasz az első kérdésre:A titok nyitja a mikrocirkuláció

Reitsma S, et al. J Vasc Res 2011, 48:297-306

Glycocalyx

Bernard M. et al. Circulation Research. 2003; 92: 592-594

HypervolemiaBruegger D, et al. Am J Physiol Heart Cicr Physiol

2005; 289: H1993-1999

Severe sepsisChappel D, et al. Curr Opin Anaesthesiol

2009; 22: 155-62

SIRS

Glycocalyx

• Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.4 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer’s acetate.

• In patients in the ICU, there was no significant difference in 90-day mortality between patients resuscitated with 6% HES (130/0.4) or saline. However, more patients who received resuscitation with HES were treated with renal-replacement therapy.

HES is bad for you?

Molnár ‘99

Myburh JA et al. 2012; DOI: 10.1056/NEJMoa1209759

Perner A et al. 2012; DOI: 10.1056/NEJMoa1204242

Igen:• Glycocalix sérült

• Extravazáció - toxicitás

Második kérdés:Valóban hypovolémiásak voltak ezek a

betegek?

Mi a fontosabb?

Mikor infundáljunk?Vagy:

Mit infundáljunk?

Invazív hemodinamikai monitorozás

• Otto Frank (1865-1944):• Élettanász (Lipcse)• Zur Dynamik des Herzmuskels, Z Biol 32

(1895) 370

• Ernest Starling (1866-1927):• UCL• Starling erők, hormonok, stb

Úttörők

Molnár ‘99

• Otto Frank, Ernest Starling – 1914: „Law of the heart”– „Within physiological limits, the force of contraction is directly

proportional to the initial length of the muscle fiber”

Molnár ‘99

The goal of resuscitationSV: CO-monitoring

EDV: ?

Hemodynamics

Starling EH. The Linacre Lecture on the Law of the Heart. London; 1918Starling EH. J R Army Med Corps. 1920; 34: 258-262

Stro

ke v

olum

e (m

l)End diastolic volume (ml)

.

normal heartnormal heart

failing heartfailing heart

preload responsiveness

preload unresponsiveness

Stroke volume

Ventricular preload

Statikus paraméterek (CVP, PAOP, GEDV) nem jelezhetik, a folyadék-válaszkészséget

„One size does not fit all!”

Courtesy of Prof. Jean-Loius Teboul

Molnár ‘99 PPmax PPmin

PPPPmaxmax - PP - PPminmin

(PP(PPmax max ++ PPPPminmin) /2) /2PPV =PPV =

(Courtesy of Jean-Louis Teboul)

IPPV = series of Valsalva-maneuvers

A B Ventricular preload

Stroke volume

preload responsiveness

preload unresponsiveness

(Courtesy of Jean-Louis Teboul)

IPPV:

PPV = 15%

PPV = 7%

Osman D, et al. Crit Care Med 2007; 35: 64-8

Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge

• CVP:– Sens: 62% (95% CI, 49–73%)– Spec: 54% (95% CI, 43–65%)

Pre-infusion values

• PAOP:– Sens: 77% (95% CI, 65–87%)– Spec: 51% (95% CI, 40–62%)

Tánczos K, Németh M, Molnár ZAnn. Up. in Int. Care and Em. Med. 2014, pp. 355-65

Solve the hemodynamic puzzle first!2014

2014

Input: ScvO2, CVP, CI, GEDVI, SVV, MAP

Hypovolemic patients Normovolemic patients

Your wish…

Fluid therapy – in just 24 hours!

…won’t come true!

A legnagyobb tanulság...

Auguste Rodin: The Thinker

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