Ehrenfried Schindler

Dry or wet? Fluid Management in critical ill patients

Now information about the obligation matter of fluid management in critical ill patients. It was discussion about who will win Crystalloids or Colloids. From the received results is known, that the patient being in critical condition is better to be dry than wet. under all circumstances volume therapy should be guided by its effects on organ function and indicators of the adequacy of tissue oxygenation.

Volume

Perfusion

Microcirculation

Multi Organ Failure

Tissue Hypoxia Inflammation

Colloid Crystalloid

Fluid management in critical ill: who will win?

Crystalloids vs. Colloids Colloids vs. Colloids Crystalloid vs. Crystalloid Dry vs. Wet

Colloids vs. Crystalloids

Human Albumin = natural Colloid Artificial Colloids Hydroxyethylstarch (HES) Gelatin Dextran

Benefit of Colloids vs. Crystalloids

Maintain or increase oncotic pressure Significant increase of intravascular volume Stays in the intravascular department

Better perfusion? Less tissue edema? Less mortality? Increase in outcome?

Colloids vs. Crystalloids

Velanovich V: Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality.1989 Surgery 105: 65-71
Mortality increased with colloids

Schierhout G:

Fluid resuscitation with colloid or crystalloid solution in critically ill patients: a systemic review. 1998 Crit Care Med 27: 200-210
Compared to Crystalloids 4% increased mortality when Colloids are the primary volume replacement

Choi P. et al.:

(Isotonic) Crystalloid vs. Colloids in fluid resuscitation: a systematic review. 1999 Critical Care Medicine, 27: 200-210
Mortality unchanged In the group of trauma patients significant better results when using crystalloids Number of pulmonary edema without difference No difference in ICU stay

Bunn F. et al.:

Colloid solutions for fluid resuscitation. Cochrane Database Syst Review 2003(1): CD001319
There is no evidence that one colloid solution is more effective or safe than any other.

Hands up !!

1. Colloids are more effective than crystalloids 2. HES is more effective than other colloids 3. HES influence outcome more positive compared to crystalloids, albumin, dextran or gelatin

What do we guess about volume replacement?

84% think, that Colloids are more effective than crystalloids 77% think, that HES is more effective than other colloids 87% think, that HES influence outcome more positive compared to crystalloids, albumin, dextran or gelatin Intraoperative: 75%-90% are using HES and crystalloids for volume replacement (Exception: Children and burn patients (albumin and crystalloids) Intensive care unit: 84% are using HES, 45% are using crystalloids (Exception: Children and burn patients (albumin and crystalloids)

Boldt J, Schllhorn T, Dieterich HJ: Volumentherapie in Deutschland eine Ist-Analyse anhand einer Fragebogenaktion. Ansth Intensivmed 47: 309-317 (2006)

Albumin
Increased mortality after albumin administration in critically ill patients
Cochrane Injuries Group Albumin reviewers 1998 BMJ

No differences in outcome (new organ failure, duration of ventilation, renal replacement therapy, length of stay) and mortality after albumin administration (vs. saline)
Wilkes MM: Patient survival after human albumin administration. A meta analysis of randomized, controlled trials. Ann Intern Med 2001: 149-164. The SAFE (Saline vs. Albumin Fluid Evaluation) Study Investigation. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-56

More expensive Risk of infection

Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study

% albumin administration

Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study

Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study

Cumulative survival

No albumin (n=339) Albumin (n=339)

Log rank = 7,63 p= 0,006

Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study In this observational study of 3,147 patients, albumin administration was independently associated with a lower 30-day survival

Moreover, in 339 pairs matched according to a propensity score, ICU and hospital mortality rates were higher in patients who received albumin than in those who did not While albumin administration may be safe in patients requiring fluid for intravascular volume depletion, these results suggest it may not be harmless in all ICU patients.
Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Colloids vs. Crystalloids

RESUSCITATION FROM SEPTIC SHOCK WITH CAPILLARY LEAKAGE: HYDROXYETHYL STARCH (130 KD), BUT NOT RINGERS SOLUTION MAINTAINS PLASMA VOLUME AND SYSTEMIC OXYGENATION

Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004)

Colloids vs. Crystalloids

Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004)

Colloids vs. Crystalloids

Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004)

Colloids vs. Crystalloids

Key conclusion:
HES 130 kD could maintain PV and COP, thereby preserving systemic oxygenation and hemodynamics.
These results suggest the intravascular persistence of the artificial colloid in the presence of albumin leakage.

Marx G et al. SHOCK, Vol. 21, No. 4, pp. 336341 (2004)

30 children less than 3 years undergoing cardiac surgery. Volume replacement with 6 % HES (200/0.5) vs. 20% human albumin (pre-bypass period). Outcome measures: HR, MAP, CVP, BGA, colloid osmotic pressure, electrolytes, fibrinogen, AT III, albumin, platelet count, overall coagulation tests, urine output, creatinine, blood loss, total use of homologous blood, FFP and platelet concentrates.

No significant Difference (except Albumine concentration) Conclusion: LMW-HES ist safe and effective in pediatric cardiac surgery

Colloids vs. Crystalloids

Fluid resuscitation in severe sepsis and septic shock: Albumin, hydroxyethylstarch, gelatin or ringers solution lactate: Does it really make a difference?

Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)

Colloids vs. Crystalloids

Feces spillage
Randomization

Surgical Operation

4h RL resuscitation

Study until spontaneous death

Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)

Colloids vs. Crystalloids

Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)

Colloids vs. Crystalloids

Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)

Colloids vs. Crystalloids

Key conclusion: although albumin and HES solution were associated with higher cardiac output and DO2, and lower blood lactate levels than gelatin and RL, our results suggest that the type of i.v. fluid used for initial fluid resuscitation has limited effects on outcome.
Fuhong Su et al. SHOCK, Vol. 27, No. 5, pp. 520-526 (2007)

Colloids vs. Crystalloids

Next Round

Fluid Resuscitation during capillary leakage: Does the type of fluid make a difference?

Meta-Analysis: Methodological limitations

old overall treatment changes over years types, doses, duration of fluid administration varies highly heterogeneous patient population

Hasibeder WR, Intensive Care Med 28:532-534 (2002)

Sepsis in European intensive care units: the SOAP study

Cohort, multi-center, observational study 198 ICU 24 European countries total of 3,147 patients

Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Sepsis in European intensive care units: the SOAP study

Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Factors of increased mortality

Degree of organ dysfunction Patient age Cirrhosis Mean fluid balance

Indicator of severity, Independent predictor of outcome

Vincent JL et al. Critical Care, 9:R745-R754 (2005)

Endothelial Glycocalix The new Barriere Reef

A Rational Approach to Perioperative Fluid Management

Daniel Chappell, M.D.,* Matthias Jacob, M.D.,* Klaus Hofmann-Kiefer, M.D.,* Peter Conzen, M.D., Markus Rehm, M.D.

Anesthesiology 2008; 109:72340

Determinants of insensible fluid loss. Perspiration, protein shift and endothelial glycocalyx
Fluid Input Fluid Output

Blood (ml) Preop Bloodvolume (ml) Cryst (ml)

Urine (ml) Postop Bloodvolume (ml)

Fluid Shift 3833 ml

Colloid (ml)

Jakob M et al., Anaesthesist 2007 56:747764

Determinants of insensible fluid loss. Perspiration, protein shift and endothelial glycocalyx

Perioperative Albumin Infusion

Blood Loss

Proteine Output (g)

Pre OP Intravascular Protein (g) Proteine Input (g) Post OP Intravascular Protein (g)

Jakob M et al., Anaesthesist 2007 56:747764

Fluid Management in critical ill: Conclusion

Fluid Management in critical ill: Conclusion

Albumin should be used with caution in critical ill patients, although in pt. with low albumin it may be beneficial dry seems to be more beneficial than wet Colloids (HES, Gelatin) have some advantages regarding fluid therapy in sepsis

but

Fluid Management in critical ill: Conclusion

there is concern about the increased risk of acute renal failure with HES administration

and

Fluid Management in critical ill: Conclusion

under all circumstances volume therapy should be guided by its effects on organ function and indicators of the adequacy of tissue oxygenation. and
Reinhart K, Nephrol Dial Transplant 11, editorial comment (1996)

mSrali Tu sveli? siTxis menejmenti e.Sindleri (sanqt-augustine, germania)

moyvanilia siTxis moculobis marTvis sakiTxi kritikul mdgomareobaSi nyof avadmyofebSi. Ganxilulia kristaloduri da koloiduri xsnarebis upiratesobis sakiTxi, miRebuli Sedegebidan gamomdinare gairkva, rom kritikul mdgomareobaSi myofi avadmyofi umjobesia iyos ufro ,,mSral vidre ,,svel mdgomareobaSi.

Thank you