L : Line and Tube อ นตรายป องก นได จากการให สารน า

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1 L : Line and Tube อ นตรายป องก นได จากการให สารน า รศ.นพ.กว ศ กด จ ตตว ฒนร ตน ภาคว ชาศ ลยศาสตร คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม 3 rd Mini Conference: ความปลอดภ ยในผ ป วย ร วมด วย ช วยได ท กคน ว นท ก นยายน 2558 ณ โรงแรมนารายณ ส ลม กร งเทพฯ

2 General considerations I.V. fluid therapy plays a vital role in establishing and maintaining cellular homeostasis in hospitalized patients Less or over fluid administration might be harm

3 (

4 Peri-operative management : UK Inappropriate fluid management : Pre-operative 7.4% Intra-operative 8.4% Mortality(%) Adequate Inadequate Excessive (

5 Difference in criteria definition Year Author Patient Overload criteria Result 1990 Lowell JA. SICU >10% morbidity 2009 Bouchard J ICU with AKI > 10% mortality 2009 Lobo DN. Animal study >3.3% bowel wall edema 2014 Pimanmekaporn T. Peri-op chest >2000 ml (4-7%) CVS complications 2014 Enger TB. Open heart > 90 ptile (8.04%) incidence in Homozygous UMOD gene

6 Maximum weight change

7 Patient enrollment Chittawatanarat K. Therapeutics Clin Risk Manage 2015:

8 Body weight alterations Chittawatanarat K. Therapeutics Clin Risk Manage 2015:

9 Threshold of fluid accumulation Chittawatanarat K. Therapeutics Clin Risk Manage 2015:

10 Type of fluid administration Chittawatanarat K. Therapeutics Clin Risk Manage 2015:

11 Adverse events associated with overload Chittawatanarat K. Therapeutics Clin Risk Manage 2015:

12 Questions of IV administration What Define diagnosis/ clinical scenario and goal When Define time and rate Where Define patient setting (pre-hospital, ER, OR, Ward, ICU) How Define route and monitoring

13 Time dependence considerations Resuscitation Administration of fluid for immediate management of lifethreatening conditions associated with impaired tissue perfusion Titration Adjustment of fluid type, rate and amount based upon context to achieve optimization of tissue perfusion De-escalation Minimization of fluid administration; mobilization of extra fluid to optimize fluid balance

14 Fluid balance Daily fluid balance daily sum of all intakes and outputs Cumulative fluid balance sum total of fluid accumulation over a set period of time Fluid overload cumulative fluid balance expressed as a proportion of baseline body weight. A value of 10% is associated with adverse outcomes; 5% is after SICU admission

15 Fluid recorder in ward/ ICU Daily fluid Accumulation

16 Four phase of fluid resuscitation ROS-D Patient first enrolled on difference stages (

17 Volume status of resuscitation (

18 Rescue phase Characters Principles Goals Time Type Fluid therapy Scenario Details Lifesaving Correct shock Minutes Severe shock Rapid boluses Septic shock, Major trauma

19 Fluid bolus A rapid infusion to correct hypotensive shock. It typically includes the infusion of at least 500 ml over a maximum of 15 min Monitor: (More simple) Minimum : BP, HR, Lactate, ABG, Cap.refill, Urine, Mental status Optimum : Echo/Doppler, CVP

20 Determination of fluid choice Phase of fluid resuscitation Fluid compartment Patient diseases Complication

21 Fluid compartments IV IS Cell 5% BW 15%BW 40% BW ECF=20%BW ICF=40%BW

22 Water without Na fluid crystalloid IV 5% BW All compartment resuscitation IV:IS:IC=1:3:8 IS Cell 15%BW 40% BW ECF=20%BW ICF=40%BW Cellular and IS edema

23 Isotonic Na containing fluid crystalloid IV 5% BW ECF resuscitation IV:IS = 1:3 IS Cell 15%BW 40% BW ECF=20%BW IS edema ICF=40%BW

24 Isotonic Na containing isotonic colloid fluid IV 5% BW IV resuscitation IS Cell 15%BW 40% BW ECF=20%BW ICF=40%BW

25 Cellular dehydration Isotonic Na containing hypertonic colloid IV IV resuscitation IS Cell 20-25% Albumin 5% BW 15%BW 40% BW ECF=20%BW ICF=40%BW

26 Fact of cellular shock during rescue phase Interstitial water depletion Intravascular volume compensation So Crystalloid fluid is first fluid choice Caution Failing organs Interstitial edema esp. pulmonary edema Low energy supply condition or cellular shock Hyperchlorimic normal gap metabolic acidosis

27 Comparison of albumin resuscitation to other fluid regimen in sepsis Guidelines currently suggest (grade2c) that albumin use should be considered as a resuscitation fluid in patients with severe sepsis, particularly if those patients are not responding to crystalloid infusion Delaney AP et al. Crit Care Med 2011;39:

28 Traumatic brain injury (SAFE group) 28 days mortality 24 months mortality The hypotonic and hypooncotic nature of the albumin solution used may also have played a role N Engl J Med 2007;357:

29 Summary of rescue phase Crystalloid first Sepsis : avoid HES, prefer albumin if crystalloid is not work Traumatic brain : avoid albumin Use basic monitoring

30 Volume status of resuscitation (

31 Optimization Characters Principles Goals Time Type Fluid therapy Scenario Details Organ rescue Optimize and maintain tissue perfusion Hours Unstable Titrate fluid infusion conservative use of fluid challenges Intra-operative goal directed therapy Burns DKA

32 Fluid challenge ml over 5 10 min with reassessment to optimize tissue perfusion Monitor: Minimal : BP, HR, Lactate, ABG, Cap.refill, Urine, Fluid balance Optimum: Echo/Doppler, CVP, ScvO 2, Cardiac output, Fluid responsiveness

33 Optimization point Cardiac filling pressure Preload volume

34 Fluid Challenge Test Guided by CVP PCWP Infusion After bolus < 2 < 3 continue > 5 > 7 stop 2 < < 5 3 < < 7 Wait After10min > 2 > 3 stop < 2 < 3 continue

35 Fluid responsiveness Pulse pressure variation Systolic pressure variation Stroke volume variation IVC distensibility Passive leg raising test End expired occlusive pressure

36 1 g/dl of albumin Mortality: OR 2.37 Morbidity: OR 1.89 ICU LOS: 28% Hosp LOS: 71% Resource : 66% Vincent JL, et al. Ann Surg 2003;237:

37 Summary optimization phase Titration fluid and close monitoring Caution of fluid overload Preserve organ function and endothelial function +/- role of oncotic fluid

38 Volume status of resuscitation (

39 Stabilization Characters Principles Goals Time Type Fluid therapy Scenario Details Organ support Aim for zero or negative fluid balance Days Stable Minimal maintenance infusion only if oral intake inadequate NPO postoperative patient Drip and suck management of pancreatitis

40 Fluid infusion Continuous delivery of i.v. fluids to Maintain homeostasis, Replace losses, or Prevent organ injury (e.g. prehydration before operation or for contrast nephropathy) Monitoring Minimum: Same as optimization (attention on balance) Optimum: +/- Echo/Doppler, CVP, ScvO 2, CO

41 Volume status of resuscitation (

42 De-escalation Characters Principles Goals Time Type Fluid therapy Scenario Details Organ recovery Mobilize fluid accumulated Days to weeks Recovering Oral intake if possible Avoid unnecessary IV fluids Patient on full EN in recovery phase of critical illness Recovering ATN

43 Maintenance Fluid administration for the provision of fluids for patients who cannot meet their needs by oral route. This should be titrated to patient need and context This should include replacement of ongoing losses. In a patient without ongoing losses, this should probably be no more than 1 2 ml/kg/ h Monitoring Minimum: Same as optimization (attention on negative) Optimum: +/- Echo/Doppler, CVP, ScvO 2, CO

44 Summary of fluid Accumulation of fluid record >> daily I/O Depend on phase of resuscitation Crystalloid first in rescue phase Colloid later in the others phases Closing of monitoring Avoid fluid overload 10% of dry weight 5% of SICU admission weight