Fluid resuscitation in specific patient populations: sepsis and traumatic brain injury
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1 Fluid resuscitation in specific patient populations: sepsis and traumatic brain injury John A Myburgh MBBCh PhD FCICM UNSW Professor of Critical Care Medicine The George Institute for Global Health University of New South Wales St George Hospitals, Sydney
2 Leith Infirmary 1831 Thomas Aitchinson Latta c
3 The most wonderful and satisfactory effect is the immediate consequence of the injection. The quantity necessary to be injected will probably be found to depend upon the quantity of serum lost.. Lewins: London Medical Gazette 1832
4 SAFE Study Investigators: NEJM 2004
5 SAFE Study Investigators: NEJM 2004
6 Sepsis P=0.059 (Test for common relative risk) MVLR adjusting for baseline covariates in patients with complete data: 919/1218 (75.5%) 0.71 ( ) p=0.03. SAFE Study Investigators: Int Care Med 2011
7
8 Albumin in malaria 150 Children with severe malaria and metabolic acidosis Assigned to 4.5% albumin or normal saline or control No difference in resolution of base deficit Reduced mortality: 2/56 (3.6%) vs. 11/61 (18.0%); p=0.013 Maitland: Clinical Inf Dis 2005
9 Maitland: New Eng J Med 2011
10 Multicentred open-label RCT Albumin vs saline bolus vs no bolus in febrile hypotensive children n=3141/3600 Primary outcome: Mortality at 48h Mortality at 4 hours Mortality at 4 weeks Maitland: New Eng J Med 2011
11 T H Huxley m That the great tragedy of Science is the slaying of a beautiful hypothesis with an ugly fact
12 Regional variation Finfer : Crit Care 2010
13 HES: effects on renal function Outcome Trials n RR 95%CI Renal replacement therapy to 2.16 RRT : sepsis to 2.1 Author-defined ARF to 1.87 Author-defined ARF: sepsis to 1.96 Dart: Cochrane Collaboration 2010
14 Perner: New Engl J Med 2012
15 Myburgh: New Engl J Med 2012
16 CHEST: sepsis subgroup Myburgh: New Engl J Med 2012
17 Fluids in sepsis No resuscitation fluid has been demonstrated to confer significant clinical benefit in patients with sepsis or severe sepsis The role of bolus fluid resuscitation requires caution Albumin has a potential, yet unsubstantiated role in early sepsis in ICU patients. Hydroxyethyl starch solutions increase mortality and the use of renal replacement therapy and are not recommended..nor are other synthetic colloids or crystalloids.
18 The dose makes the poison Paracelus 1495
19
20 Fluid resuscitation
21 Fluid resuscitation 250 ml 7.5% Normal Saline (n=114) 250 ml Ringers Lactate (n=115) 6m mortality HTS 45% RL 53% Cooper JAMA 2004
22 The SAFE study SAFE Study Investigators New Eng J Med: 2004
23 SAFE: Primary outcome SAFE Study Investigators New Eng J Med: 2004
24 SAFE: Primary outcome P=0.039 (Test for common relative risk) SAFE Study Investigators New Eng J Med: 2004
25 Mortality (%) Mortality (%) Mortality: trauma + TBI subsets p=0.009 Albumin Saline 20 p= / / /240 81/596 38/ / /356 21/ Trauma Without trauma Trauma with TBI Trauma without TBI n=22 n=21
26 Mortality at 28 days Mortality at 2 years SAFE Study Investigators: NEJM 2007
27
28 SAFE TBI II To determine potential mechanisms by which albumin is associated with increased mortality in SAFE TBI, specifically whether it is: 1. associated with development of intracranial hypertension (ICP>20 mmhg) 2. attributable with intrinsic pathophysiological processes 3. attributable to increased therapeutic maneuvers to control ICP that may be toxic (extrinsic processes) either independently or within a tiered therapeutic intensity level. (TIL)
29 Intracranial pressure: mean Myburgh: Under review
30 Intracranial pressure: PMM Myburgh: Under review
31 Intracranial pressure: PMM Myburgh: Under review
32 What about synthetic colloids?
33 CHEST: TBI subgroup Myburgh: New Engl J Med 2012
34 Fluids in traumatic brain injury Albumin is associated with a higher mortality and worse functional neurological outcomes compared to saline for resuscitation of patients with traumatic brain injury in the Intensive Care Unit. The biological mechanism remains speculative, but is likely due to exacerbation of intracranial hypertension in the first week after injury. Whether this is a class-specific or generic colloid effect is unknown On the basis of high-quality evidence, saline is the fluid of choice for resuscitation in traumatic brain injury.
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