ศ.พญ. ส ณ ร ตน คงเสร พงศ ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร ศ ร ราชพยาบาล

Transcription

1 Basic Fluid-Electrolyte Disorder & Therapy ศ.พญ. ส ณ ร ตน คงเสร พงศ ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร ศ ร ราชพยาบาล

2 Fluid Management in Critically Ill Patient ศ.พญ. ส ณ ร ตน คงเสร พงศ ภาคว ชาว ส ญญ ว ทยา คณะแพทยศาสตร ศ ร ราชพยาบาล

3 Why Is Important t? Most common management & Rx Most common pitfall & complications May make a difference between organ protection & organ failure Others organ protective activities Indication: replacement Maintenance Insensible & sensible loss Hemorrhage, sepsis

4 Why Is Important t? Influence outcomes Right time to replace Right type Right amount Right evaluation

5 Benefit of fluid replacement Maintenance effective circulatory volume Maintain oxygen perfusion (renal, mesenteric, CNS, cardiac) Optimize oxygen transport & cellular respiration Better quality of recovery Provide electrolyte replacement

6 Risk of ffl fluid replacement Interstitial edema Compartmental t syndrome Impair cellular metabolism Poor wound healing Decrease pulmonary compliance Left heart failure/overload Delayed return of bowel function

7 Body Fluid Distribution

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9 ECF (Extracellular l fluid) Sodium.major cation (140mEq/L), major osmotically active ion in the ECF Total body Na content t determine ECF volume ECF (PV + ISF) PV first ECF space effective plasma volume Hypovolemia decrease effective circulating plasma volume Increase ECF while decrease PV Heart failure Hypoalbuminemia Inflammatory capillary leak syndrome

10 ECF (Extracellular l fluid) ECF (ISF + PV) ISF Second ECF space Third space..edema fluid (cannot be mobilized by diuresis, dialysis, or fluid restriction mobilized ti spontaneously when inflammation subsides.fluid move back to PV eliminate by normal renal homeostasis

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12 Impact of fluid replacement on ECF compartment Various fluid solution expand volume of fluid compartments differentially base on Water content (osmolarity) of the fluid Extent of capillary leak Pre-existing water deficits in the various fluid compartment

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14 Humoral Factor Affecting Fluid Status Renin-angiotensin-aldosterone axis Anti-diuretic hormone (ADH) Atrial natriuretic peptide (ANP) Brain natriuretic peptide (BNP) C-type natriuretic peptide (CNP)

15 Capillary endothelium Water moves freely through vessel wall: water, Na +, K + Impermeable to larger molecule Albumin Semisynthetic colloid eg., gelatin, starches Perioperative factors : Vasoconstriction Vasodilatation Increase capillary permeability eg., sepsis

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17 Vascular barrier

18 Rationale for Intravascular Fluid Replacement Therapy Correction of circulating ECF volume Maintenance of cardiac output & organ perfusion Correction of intracellular l water deficit it Treatment of electrolyte abnormalities Nutrition

19 Current Controversies of Fluid & Volume Management o Amount of Fluid Replacement o Type of Fluid Replacement o Monitoring of fluid responsiveness & adequacy of fluid replacement

20 Amount of Fluid Replacement Controversies: Liberal fluid resuscitation Restricted fluid resuscitation Optimal fluid resuscitation: Goal direct therapy

21 Amount of Fluid Replacement Liberate fluid resuscitation Pro : Maximal tissue perfusion, good urine flow Need to replace third space loss Replace crystalloid 3 times of blood loss Con : Fluid overload Tissue edema» Poor microcirculation flow/perfusion» Poor oxygenation/ventilation Increase close space volume/pressure Degrade endothelial glycocalyx (increase ANP)

22 Most common cause of iatrogenic hypervolemia Very little fluid lost as third space during surgery (eg., ml/kg instead of 10 ml/kg) Jacob M, et, 2009

23 Amount of Fluid Replacement Restricted fluid resuscitation Prevent tissue edema/injury: Major traumatic /condition Trauma Burns Surgery Ischemia Good outcome in colonic surgery How much of the restriction? Low/poor perfusion Low microcirculatory flow Mislead with vasopressor

24 Amount of Fluid Replacement Optimal fluid resuscitation Goal direct therapy as per patients/conditions need Maintain intravasal normovolemia Most recommend Most difficult to do How much optimum? Good monitoring/assessment Goal directed therapy

25 Type of Fluid Resuscitation Controversies: Crystalloid vs Colloid Crystalloid : Isotonic vs hypertonic Colloid : Iso-oncotic vs hyperoncotic What/When should we use?

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27 Crystalloid vs Colloid resuscitation ti for the Critically Ill patie Crystalloid: Type: Isotonic NSS....non balance solution, hyperchloremic metabolic acidosis..effect on renal function & coagulation LRS..balance, lactic acidosis, metabolic alkalosis : Hypertonic 3%, 7.5% NSS high osmolality, shift fluid from interstitial to intravascular increase plasma volume 5-8 cc/cc Hypernatremia, cellular dehydration Depress immune response Pro: Clean, easily use, less allergy, less accumulation, good urine flow Con: Need more amount, less stay in intravascular, more tissue edema

28 Crystalloid vs Colloid resuscitation ti for the Critically Ill patie Colloid: Type: Natural: Blood, blood component, albumin Synthetic starch: Gelatin, Hydroxy Ethyl Starch (HES) Pro: Stay in the intravascular longer Con: Allergy Anti-inflammatory inflammatory property Accumulation Renal effect Hematological problem

29 Hypertonic Lactate Saline resuscitation Reduced the risk of Abdom Compartment Syndrome in Severely Burned Patients. Oda Oda J. J Trauma, 2006 Patients admitted to our burn unit between 2002 and 2004 with burns > or =40% of the total body surface area without severe inhalation injury were entered into a fluid resuscitation protocol using HLS (n = 14) or lactated Ringer's solution (n = 22). HLS resuscitation could reduce the risk of secondary abdominal compartment syndrome with lower fluid load in burn shock patients

30 Blood Transfusion

31 Transfusion Trigger Controversy in blood transfusion Pro: increase oxygen carrying capacity especially in the patient with territory of organ perfusion or ongoing bleeding optimal Hb concentration to maintain systemic oxygen delivery in critically ill patient is 10 gram????

32 Transfusion Trigger Con: Cell-mediated transfusion immunosuppression, tumor recurrence, postoperative infection Early transfusion is a strong independent risk factor of multiple organ failure Store red cell.decrease deformability on microcirculation

33 Albumin 5% albumin 20%, 25% albumin hyperoncotic..1c.c. increase 18 ml. Natural, MW 66,000 dalton > 90% stay in 2 hours Anaphylactoid, anphylaxis % No problem with coagulation

34 Albumin Natural colloid, 585 amino acid, MW 66 kda (renal threshold kda) Ellipsoid molecule, non-viscous, very flexible, help preserve the structure of RBC Minimal problem with coagulation, Anaphylactoid/anphylaxisanphylaxis % Synthesis in liver (30% of total) can compensate 2-5 time to compensate albumin loss; synthesis depend on - Nutritional status with availability of amino acids and calories - Hormonal environment : growth hormone, adrenocorticotropic hormones, insulin, testosterone Depress albumin synthesis - Inflammatory state, with inflammatory cytokine eg. TNF, IL-6, reduce the availability of albumin messenger RNA, decrease albumin synthesis

35 Vascular barrier

36 Hypoalbuminemia & Critically Ill Patient o Vincent JL, et al Meta-analysis.hypoalbuminemia as an outcome predictor in acutely ill patient o Hypoalbuminemia was a dose dependant predictor of poor outcome o Each 1 g/dl decrease in serum albumin increase the odds of mortality 137%, morbidity 89%, prolonged ICU stay by 28% o Independent of patient s nutritional status & inflammatory status o Gibb J, 1999 NationalVeterans Administration Surgical Risk Study of 54,215 major noncardiac surgery cases, preoperative p serum albumin concentrations were the strongest predictor of surgical mortality and morbidity

37 Hypoalbuminemia Question??? -Hypoalbuminemia causes the worse outcome: provide exogenous albumin -Is the simple marker of more serious disease: improve albumin concentration may have no effect

38 Vincent JL, BMJ The aim of the study was to show that albumin administration is safe or not -All patient who needed a fluid challenge for what evere reason were include, regardless of the underlying condition -It is therefore unreasonable to expect the study to show the benefit of albumin administration -The question that we need to answer is which subgroup of patient are likely to benefit from albumin administration

39 12/18/52 Update fluid mangement for critically ill surgical pts

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41 A further analysis of the SAFE study assesses whether outcomes of resuscitation with saline or albumin are related to baseline serum albumin concentrations, predefined as serum albuminless than or greater than 2.5 g/l.

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43 . Gelatin Polygelin, Succinylte gelatin MW 30,000-40, dalton Good clear Length 3-4 hour No renal or coagulation problem Anaphylaxis or anaphylactoid Dilution effect

44 Gelatins Hydrolysis of bovine collagen Risks associated between new-variant Creutzfeldt-Jakob disease & bovine spongiform encephalitis (BSE)

45 Dextran 40, 70 Clearance is dependant on MW Dextrans molecule < Da are freely filtered at the renal glomerulus 70% of dextran ta 40 will be excrete ete into urine within 24 hours

46 Hydroxyethyl Starchs Has greater volume expansion Longer intravascular persistence than crystalloids Decrease microvascular permeability & capillary leakage by biophysically pulgging endothelial leaks Exerting an anti-inflammatory inflammatory effect Decreasing activation of endothelial l cells

47 Hydroxyethyl Starchs Question about Safety Side effect Clinical use

48 Hydroxyethyl y y Starchs (HES) : Different Products - Different Effects. Westphal M. Anesthesiology Concentration, Molecular weight, Molar substitution (MS), C 2 /C 6 Ratio

49 Concentration: The higher concentration (eg. 6%, 10%), the more volume expansion effect C 2 /C 6 Ratio Molecular weight (MW) Higher C2/C6 Ratio difficult to destroy by alpha amylase - Corn (Waxy maize) starch (C2/C6 Ratio 0.97) - Potato starch (C2/C6 Ratio 0.42) The higher molecular weight, the longer stay in the intravascular, the more accumulation Polydisperse colloid MW KDA rapidly excrete via kidney Oncotic pressure depend on amount of molecule

50 Molar substitution (MS Higher difficult to destroy by alpha amylase - Heta starch (MS 0.6) 1 st generation - Penta starch (MS 0.5) 2 nd generation - Tetrastarch 3 rd generation (Voluven, Volulyte, MS 0.4 Tetraspan ) Lehnann G, 2007 Corn & Potato derive HES solution are not bioequivalent, study using one type may not be valid for another Sommermeyer et al P t t d i HES h hi h i t i i Potato derive HES has a higher intrinsic viscosity than Corn derived HES

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52 Pharmacokinetic & Plasma Concentration

53 HES Different Generation 1 st generation Hexastarch (MS 0.6) 2 nd generation Pentastarch (MS 0.5) 3 rd generation Tetrastarch Voluven MS 0.4 Volulyte, Tetraspan *Enhance degradation, *Minimize - Retention in the circulation & tissue - Renal & coagulation effect

54 HES & Antiinflammation

55 Hydroxyethyl starch 130/0.4 augments healing of colonic anastomosis in a rat model of peritonitis. Wang P, Gong G, Li Y, Li J. Am J Surg Feb;199(2): Aim: Investigate the role of hydroxyethyl starch (HES) 130/0.4 on the wound healing process in left colonic anastomoses in the presence of intraabdominal sepsis Results: Moderate doses (15 ml/kg) of HES 130/0.4 administration significantly prevented this intraperitoneal sepsis-induced impaired anastomotic healing of the left colon. This beneficial effect of HES 130/0.4 can be mainly attributed to its anti- inflammatory and antioxidant properties and beneficial effects of modulating endothelial-associated coagulopathy.

56 HES.. Effect on Coagulation & Platelet Function Kozek-Langenecker S, 2005 HES macromolecule interact with platelet and coagulation cascade Decrease in factors such as Factor VIII and von Willebrand Factor Treib J, 1996 The higher MS the more effect with coagulation cascade & platelet function More effect with higher dose & more hemodilution Elgger B, 2006 Least with rapid degrade HES eg, tetrastarch even with high dose 70 ml/kg in severe hear injury Least effect in 6 days

57 Colloid molecule inhibit platelet function (in carrier solutions without calcium) Dextran > Hetastarch > Pentastarch > Gelatin > Tetrastarch, Albumin Colloid molecule decrease vwf and factor VIII: Dextran > Hetastarch > Pentastarch > Gelatin > Tetrastarch, Albumin Colloid molecule induce hypocoagulability and decrease fibrin polymerization Dextran > Hetastarch > Pentastarch > Tetrastarch > Gelatin > Albumin Effect of colloid molecule on blood loss: Dextran > Hetastarch > Pentastarch > Gelatin, Tetrastarch, Albumin

58 HES.. Effect on Plasma Bilirubin

59 Non of the report of corn derived starch associated with deterioration of liver function compared to control Sander O, 2003 Compare potato derived d HES ( /. /.42 42) )&HES /0.5 Mild to moderate hyperbilirubinemia was a significant adverse events found in potato derived starch impair excretion of bile or increase bilirubin from fragment erythrocyte Potato derived HES is the only tetrastarch to be absolute contraindicated in patients with severe hepatic impairment

60 HES.. Effect on Renal function

61 HES.. Effect on Renal function More with high MS HES More with hyperoncotic HES More with high dose Least with tetrastarch

62 Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis. Brunkhorst F, et al. N Engl J Med, J Med, 2008 o o Aim: study role of intensive insulin therapy & study choice of fluid resuscitation in severe sepsis either crystalloid or colloid Method: Muticenter, Multidisciplinary ICU, Randomized, 537 severe sepsis patients, receiving o Intensive e insulin therapy to maintain euglycemia vs conventional insulin therapy o 10% pentastarch (200/0.5) or modified Ringer s lactate solution for fluid resuscitation (keep CVP > 8 mmhg) o Outcome : Death at 28 days, mean score for organ failure

63 RESULTS: Electron microscopic tubular injury score was highest in sheep treated with 10% HES 200/0.5 (P < vs. 6% HES 130/0.4). CONCLUSIONS: In ovine endotoxemic shock, saline-based 10% HES 200/0.5 was linked to impaired renal function and more pronounced tubular epithelial injury when compared with 6% HES130/0 130/0.4 and balanced crystalloids

64 Renal Problem with Colloid Dextrans Hyperoncotic problem? Hyperoncotic reanl failure hydraulic filtration ti Dextrans, 10% HES, 20% albumin

65 PRO: Hydroxyethyl starch can be safely uses in the intensive care patient-the the renal debate. Boldt J. Intensive Care Med 2009 Hyperoncotic HES should not be used in patients who are at risk of developing kidney dysfunction In patient without preexisting kidney dysfunction, there seem to be negative effects of modern HES preparation In septic patients with reduce kidney function (Cr > 2.5 mg/dl dl) HES should be used cautiously

66 Carrier Solution Non balance solution : Na 154 meq/l, Cl 154 meq/l Balance solution : *Na 140 meq/l, K 4 meq/l, Ca 2.5 meq/l, Mg 1 meq/l, Cl 118 meq/l, Acetate 24 meq/l, Malate 5 meq/l *Na 137 meq/l, K 4 meq/l, Mg 1.5 meq/l, Cl 110 meq/l, Acetate 34 meq/l * More benefit for renal & coagulation

67 The Influence of balanced volume concept on inflammation, endothelial l activation, and kidney integrity it in elderly l cardiac surgical patients Boldt et al, Intensive Care Med, 2009 o o Aim: study the benefit balanced fluid replacement regimen for correcting hypovolemia Method: Randomized, d 50 elderly l (>75 years), cardiac surgery, receiving i o o o o Balance 6% HES 130/4.2 plus a balance crystalloid solution (n=25) Non-balance 6% HES 130/4.0 in NSS plus saline solution (n=25) To keep PCWP/CVP mmhg Studied: o Acid base status, inflammation, endothelial activation (soluble intercellular adhesion molecule-1), kidney integrity (kidney-specific proteins glutathione transferase-alpha: alpha: neutrophil gelatinase-associated associated lipocalin) 5 hours after induction of anesthesia, 5 hours after surgery, 1 and 2 days thereafter. o Serum creatinine (scr) was measured approximately 60 days after discharge

68 The Influence of balanced volume concept on inflammation, endothelial activation, and kidney integrity in elderly cardiac surgical patients Boldt et al, Intensive Care Med, 2009 Conclusion: At total t balanced volume replacement strategy including a balance HES & a balance crystalloid solution resulted in moderate beneficial effects on acid-base status, inflammation, endothelial activation, and kidney integrity compared to a conventional unbalanced volume replacement regimen.

69 BACKGROUND AND OBJECTIVE: Haemostasis appears to be less altered with balanced than with unbalanced hydroxyethylstarch t h (HES) preparations. METHODS: Blood from 12 healthy young male volunteers was diluted by 10, 30 and 50% by using either a balanced 6% HES 130/0.42 or a nonbalanced 6% HES 130/0.4. Rotation thrombelastometry was used to assess changes in coagulation RESULTS: extreme haemodilution with HES 130/0.42 dissolved in a balanced solution containing calcium was associated with less negative effects on thrombelastometry and platelet aggregation than HES 130/0.4 prepared in a nonbalanced solution without calcium. Gelatin prepared in a nonbalanced solution showed similar effects on coagulation to balanced HES without calcium.

70 How to Give Fluid Early, fast adequate Frequent evaluation Peripheral IV. Bolus Avoid central line Frequent evaluation of response

71 Evaluation of Fluid Responsiveness

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