Albumina nel paziente critico Savona 18 aprile 2007
What Is Unique About Critical Care RCTs patients eligibility is primarily defined by location of care in the ICU rather than by the presence of a specific disease. many clinical entities in the ICU are often non specific constellations of physiologic and biological abnormalities forming syndromes. the pathologic processes affecting critically ill patients, resulting in homeostatic disturbances severe enough to result in ICU admission, are often in their late stages at the time of ICU admission.
What Is Unique About Critical Care RCTs
In hypovolaemia there is no evidence that albumin reduces mortality There is no evidence that albumin reduces mortality in critically ill patients with burns and hypoalbuminaemia and a suggestion that albumin may increase the risk of death.
Clinical Trials and Systematic Reviews Cardiovascular/Shock States Trauma. Septic shock. Perioperative shock states. Pulmonary Central Nervous System Ischemic brain injury. Subarachnoid hemorrhage.
SAFE
Admission pts judged to require fluids to maintain or increase IV. at least one of the following clinical signs: Heart rate greater than 90 beats per minute SBP < 100 mmhg or MAP < 75 mmhg or a 40 mmhg in SBP or MAP. Inotropes / vasopressors to maintain BP. Central venous pressure < 10 mmhg Pulmonary capillary wedge pressure < 12 mmhg Respiratory variation in SBP or MAP > 5 mmhg Capillary refill time greater than one second Urine output less than 0.5 ml/kg for one hour excluded cardiac surgery, liver transplant, burns pts.
treatments Two treatments 4% Albumin 0.9% Sodium Chloride (Saline) Allocated fluids are used for all fluid resuscitation during the first 28 days of the ICU stay. No control of fluids prior to a patient s admission or after discharge from the ICU
outcomes The primary outcome measure is 28-day allcause mortality. Secondary outcomes include length of stay in the ICU length of hospital stay organ dysfunction as measured by the SOFA score physiological measures of response to fluid therapy. Patients with the diagnostic criteria for severe sepsis and acute respiratory distress syndrome at study entry are identified to allow a priori subgroup analysis.
Kaplan Mayer Estimates
Relative risk of death
CCM 1999; 27, pp 200-210 Crystalloids vs. colloids in fluid resuscitation: A systematic review Choi, PT et al
Relative risk of death
Relative risk of death
Ischemic brain injury hemodilution after acute ischemic stroke. Initial dextran trials: disability and survival large trials have failed to confirm these benefits. benefits with starch solutions have not been confirmed one trial stopped for worse outcomes in HES pts. crystalloid vs albumin, mortality and function not different. albumin survival and function in initially euvolemic patients crystalloids outcomes in volume-contracted patients While hemodilution decreases viscosity and optimizes circulatory volume, it may impair tissue oxygen delivery in hypovolemic patients.
Curr Opin Crit Care 2002, 8:128 133
Subarachnoid hemorrhage During hypervolemic treatment is difficult to maintain the desired blood pressure, venous pressure, pulmonary capillary pressure, or whatever one is monitoring. particularly in young, fit people with normal renal function, and large volumes of fluid can lead to electrolyte disturbance (particularly hyponatremia), pulmonary edema, and other complications. Suggested measures to counteract this include fludrocortisone or albumin solution to minimize sodium and fluid loss.
Conclusions What does similar outcome mean? saline is as bad as albumin? albumin is as good as saline? Trauma patients caution (because of ICP) Septic patients investigation full blown ALI/ARDS and sepsis whith altered capillary permeability albumin just redistributes and its colloid osmotic action is decreased or lost patients with mild disease (no more permeability) albumin/furosemide accelerates the edema clearing and shortens the length of stay.
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