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Volumentherapie : Die delikate Balance zwischen zu … · viraler Gastroenteritis, Noradrenalin...

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Volumentherapie : Die delikate Balance zwischen zu wenig und zu viel! 27. AKE-Herbsttagung wieder einmal in St. Wolfgang 17. bis 19. Oktober 2013 [email protected]
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Volumentherapie : Die delikate Balance zwischen

zu wenig und zu viel!

27. AKE-Herbsttagung wieder einmal in St. Wolfgang 17. bis 19. Oktober 2013

[email protected]

Katecholamine ohne adäquate Volumengabe

75-jährige Patienten mit Hypovolämie/ hypovol. Schock nach viraler Gastroenteritis, Noradrenalin-Therapie und inadäquater

Volumengabe

Renale Hypoperfusion und ANV nach Kreislauftherapie bei Sepsis ohne ausreichende Volumengabe

von Afschin Soleiman, Wien

Vasokonstriktor erst nach Volumenoptimierung !

Early Use of Vasopressors after Injury: Caution before Constriction

Sperry JL et al. J Trauma 2008; 64: 9-14

Independent hazard ratio (HR) for early vasopressor (EV) use and aggressive early cristalloid resuscitation at 12 and 24 hours post injury.-

.. ein Volumenmangel, eine Hypovolämie erhöht die Gefahr der Ausbildung von einer „Hypoperfusion“ und Organdysfunktionen…

.. erste Maßnahme in der Kreislauftherapie muss die Volumenoptimierung darstellen, dann erst darf mit der Vasokonstriktorgabe begonnen werden !

Beachte…

Volumenstatus des Intensivpatienten

Early Goal-Directed Therapy in Sepsis

Rivers E. et al, NEJM 2001

Goal-directed therapy in high-risk surgical patients:

a 15-year follow-up study Rhodes A et al. Intensive Care Med 2010; 36: 1327

Kaplan–Meier survival analysis of patients grouped according to study arm Langzeitverlauf der Studie: Boyd O,Grounds RM,Bennett ED A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 1993; 270:2699–2707

…Normovolämie akzeptiert muss angestrebt werden…

aber verbessert eine Hypervolämie, wie

immer behauptet wird, zu einer Steigerung der Organperfusion und damit Funktion???

Frage…

Volumenstatus des Intensivpatienten

Fluid accumulation, survival and recovery of kidney function in critically ill patients

with acute kidney injury Bouchard J et al. Kidney int 2009; 46:422-27

Cumulative probability of survival by fluid overload status. (a) Survival estimates by fluid overload status at dialysis initiation. (P=0.005). (b) Survival estimates by fluid overload status at AKI diagnosis in non-dialyzed patients. (P=0.04).

Volume-related weight gain and subsequent mortality in acute renal failure

patients treated with continuous renal replacement therapy

Fülöp T et al. ASAIO J 2010; 56: 333-7

Association between progressive increases in volume-related weight gain (VRWG) and mortality

Boyd JH et al. Crit Care Med 2011; 39: 259-65

A, Survival curves, adjusted for age, APACHE II score, severity of shock (dose of norepinephrine), for fluid balance quartiles at 12 hrs.

Quartiles 3 and 4 have significant increases in mortality compared with both Q1 and Q2. B, Survival curves, adjusted for age, APACHE II score, dose of norepinephrine for cumulative fluid balance quartiles at day 4.

Fluid resuscitation in septic shock: A positive fluid balance and elevated

central venous pressure are associated with increased mortality

Maitland K et al. N Engl J Med 2011;364: 2483-95

Kaplan–Meier Curves for Mortality at 48 Weeks (bolus= 20-40 ml/kg on admission)

Mortality after Fluid Bolus in African Children with Severe Infection

..results were consistent across subgroups according to severity of shock and status with respect to malaria, coma, sepsis, acidosis, severe anemia

Mazzoni MC et al. Ann Emerg Med 1990; 19: 350-58 nach Friesenecker B

Endothel-Schwellung nach Volumentherapie im Schock

A rational approach to perioperative fluid management

Chappell D. et al. Anesthesiology 2008; 109: 723-40

Electron microscopic view of the endothelial glycocalyx.

Eine inadäquate Volumentherapie (Qualität/ Quantität) (zer-)stört die endotheliale Barriere!!

Infusionstherapie

Schädigung der endothelialen Barriere

Eine quantitativ oder qualitativ inadäquate Infusionstherapie schädigt die endotheliale

(Barriere-) Funktion

….wir brauchen Endothelstreichler!

Increased Central Venous Pressure Is Associated With Impaired Renal Function

and Mortality in a Broad Spectrum of Patients With Cardiovascular Disease

Damman K. et al. J Am Coll Cardiol 2009; 53: 597

Event-Free Survival According to Tertiles of CVPHR: 1.22 (95% CI: 1.00 to 1.49), p = 0.0466 for CVP 4 to 6 mm Hg; HR: 1.65 (95% CI: 1.35 to 2.01), p < 0.0001 for CVP >6

mm Hg, both compared with CVP 0 to 3.

O´Mara MS et al. J Trauma. 2005;58:1011-8

Plot of maximal IAP to resuscitation volume in all patients

A Prospective, Randomized Evaluation of Intra-abdominal Pressures with Crystalloid and Colloid Resuscitation in Burn Patients

Elevated intra-abdominal pressure in acute decompensated heart failure: a

potential contributor to worsening renal function?

Changes in Renal Parameters and Changes in IAPRelationship between changes in renal function and changes in intra-abdominal pressure (IAP) (A) and estimated renal filtration gradient (B) in patients with IAP ≥8 mm Hg at baseline

Mullens W et al, J Am Coll Cardiol 2008; 51: 300-06

…changes in IAP were better correlated with changes in renal function than any hemodynamic

variable….

Endotoxemia in chronic heart disease Sharma R. et al. Am J Cardiol 2003; 92: 188-193

Associations between renal function, volume status and endotoxaemia in

chronic kidney disease patients Goncalves S et al. NDT 2006; 21: 2788-94

Correlation between endotoxin levels and fluid status in patients with CKD 3 - 4 (GFR 34 ml/min).

*Fluid overload defined as inferior vena cava diameter of >11.5mm/m2 **defined as collapsing index <40%

Raised Venous Pressure : A Direct Cause of Renal Sodium Retention and Edema

Firth JD et al. Lancet 1988, i: 1121

Effects of increasing venous pressure on GFR, sodium excretion, and fractional sodium excretion in kidneys perfused with a constatn arterial pressure

Positive Fluid Balance in the Immediate Postoperative Period is an Indicator of Acute Kidney Injury in Cardiovascular

Surgery Patients Dass B et al. Clin Nephrol 2012; 77: 438-44

Odds Ratio for AKI by unadjusted and multivariate logistic model

Fluid balance and acute kidney injury

Prowle JR et al. Nat Rev Nephrol 2010; 6: 107-15

Abnormalities that lead to a loss of ultrafiltration pressure in patients with acute kidney injury. Only relatively small pressure changes are required to abolish ultrafiltration

Fluid balance and acute kidney injury

Prowle JR et al. Nat Rev Nephrol 2010; 6: 107-15

Pathological sequelae of fluid overload in organ systems

Konsequenzen Herzinsuffizienz Lungenödem generalisierte Ödeme/ gestörte Gewebsoxygenierung Störung der Wundheilung Störung der Darmfunktionen Motilität/ Ileus Permeabilität / Translokation /Inflammation Erhöhung des intraabdominellen Druckes etc… und NIERENFUNKTIONSSTÖRUNG

„Volumen-Überladungs- Syndrom“

Infusionstherapie

Ein Dogma fällt !

Volumen ist gut für die Niere !

Fluid balance and acute kidney injury

Prowle JR et al. Nat Rev Nephrol 2010; 6: 107-15

Cumulative fluid balances achieved in the FACTT trial of liberal (more-conventional) versus conservative (more-restrictive) fluid management strategies in critically ill patients with acute lung injury

Glassford NJ & Bellomo R Nature Rev Nephrol 2011;7:305

Comparison of mean daily furosemide dose and fluid balance between survivors and nonsurvivors in Grams et al.’s study. a | Difference in

mean daily furosemide dose between survivors and nonsurvivors. b | Difference in daily fluid balance between survivors and nonsurvivors

Paradigmenwechsel: Von feucht zu trocken!

Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with

acute kidney injury Heung M et al. Nephrol Dial Transplant 2012: e-pub

Impact of restrictive fluid balance focused to increase lung procurement on renal function after kidney transplantation

Ninmabres E. et al NDT 2010; 25: 2352-56

Conclusion: ….without impacting either kidney graft survival or DGF development….

Differences in donor management with regard to the CVP value

CVP < 6 mm Hg (n = 88)

CVP ≥ 6 mm Hg (n = 154)

P-value

Use of vasopressor drugs 91% 89.6% 0.84 Hypotension in ICU 38.6% 34.4% 0.45 Fluid balance from BD to OR (ml)

482 ± 1223 840 ± 1575 0.05

Urine output from BD to OR (ml)

308 ± 154 288 ± 154 0.32

BD to OR, brain death to organ retrieval. Values are % or mean ± SD.

Positive Fluid Balance in the Immediate Postoperative Period is an Indicator of Acute Kidney Injury in Cardiovascular

Surgery Patients Dass B et al. Intensive Care med 2010 – e-pub

Estimated Probability of AKI by Fluid Balance Level

Therapeutische Ansatzpunkte …zusätzlich zur Flüssigkeitsrestriktion

Kombination von Diuretika (= mehr als Lasix) Aldosteron-Antagonisten ADH (V2) – Antagonisten (Vaptane) Adenosine-Antagonisten Ascites-Punktion CAPD Ultrafiltration

„Volumen-Überladungs- Syndrom“

Bart BA. et al. N Engl J Med 2012; 367:2296-304

Changes from Baseline in Serum Creatinine and Body Weight at Various Time Points, According to Treatment Group.

Ultrafiltration in Decompensated Heart Failure with Cardiorenal

Syndrome

Avoiding common problems associated with intravenous

fluid therapy Hilton AK et al. Med J Austral 2008; 189: 509-13

Hypothetical curve of the risk of fluid therapy-related complications versus volume of fluid infused

Murphy CV et al. Chest 2009; 136: 102-09

Hospital mortality according to whether or not patients achieved AIFR (adequate initial fluid resuscitation), CLFM (conservative late

fluid management), both, or neither.

The Importance of Fluid Management in Acute Lung Injury

Secondary to Septic Shock

Flüssigkeitstherapie das neue Paradigma

Individuelle Adaptierung bei jedem Patienten aus der Gesamtsituation und anhand von

funktionellen Parametern („Volumenreagibilität“)

Restoration of normal physiology F. D: Moore 1967 „This can never be accomplished by inundation“ (schon GH Evans hat im JAMA 1911 schon davor gewarnt) sowie Kheterpal 2007, Brandstrup 1990, Lowell 1990,Hiltebarnd 2007

….early liberal , late conservative…

am schwierigsten überhaupt…

Klinik (Ödeme, Hautperfusion, Mottling etc.) Radiologie (Lungenstauung, Vena Cave-Breite etc.) ZVD invasive Druckmessungen (Wedge-Pressure, etc.) Ultraschall Labormethoden (Hk, BNP, NT-proBNP etc.) Bioimpedanz (BIA), intrathorakale Impedanz etc. Funktionelle Methoden:

Volumen-Challenge Leg-raising Pneumatische Bein-Kompression

Beurteilung des Volumenstatus bei Intensivpatienten

Volumengabe bei Intensivpatienten: Zu wenig ist schlecht, zu viele auch:

Wo ist das Optimum?

Danke für Ihre Aufmerksamkeit ! [email protected]

Costanzo MR et al. J Card Fail. 2010;16:277-84

Mean in kilograms at 48 hours in the ultrafiltration (red circle), intravenous (IV) bolus diuretic (green circle), and IV continuous diuretic (blue circle) groups; P values = ultrafiltration vs IV bolus

diuretic, ultrafiltration vs IV continuous diuretic, IV bolus diuretic vs IV continuous diuretic

Ultrafiltration is associated with fewer rehospitalizations than continuous diuretic infusion in patients with decompensated

heart failure: results from UNLOAD

Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study

Giglioli C et al. Europ J Heart Failure 2011; 13: 337-46

Trends over time in body weight and fluid balance for patients in the ultrafiltration and diuretic therapy groups

….ultrafiltration facilitates a greater clinical improvement compared with diuretic infusion….

Infusionstherapie

bei jedem Unfall „großlumigen“ Zugang setzten und rasch Volumen zu verabreichen.. perioperativ viel Volumen zu geben, damit es den Patienten besser geht, um die Organfunktionen zu erhalten in vielen anderen Situation (z.B. KM) möglichst viel Volumen zu geben, damit die „Niere rinnt“ bei Intensivpatienten den Kreislauf vorrangig über Volumen zu stabilisieren bei Verbrennungen, große Volumina (z.B. nach Baxter und anderen) zu verabreichen

Ein Dogma über viele Jahre war es....

stimmt das…??

Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a RCT

Lobo DN et al. Lancet 2002; 359: 1812-18

Solid and liquid phase gastric emptying times (T50)

Lobo DN et al. Lancet 2002; 359: 1812-18

Side-effects and complications

N= 10/ 10 Standard group Restricted group Peripheral oedema 7 0 Hyponatraemia 4 0 Hypokalaemia 2 1 Vomiting on day 4 3 0 Confusion after day 1 3 0 Wound infection 1 0 Respiratory infection 2 0 Readmission within 30 days 1 0 Death within 30 days 1 0 Total 17† 1† † p < 0.01

Effect of salt and water balance on recovery of gastro-intestinal function

after elective colonic resection

Effects of intravenous fluid restriction on postoperative

complications: comparison of two perioperative fluid regimens: a RCT Brandstrup B et al. Ann Surg 2003; 238: 641

Complication frequency related to intravenous fluid administration and body weight increase on day of operation. P < 0.001 both for increasing intravenous fluid volume and

increasing body weight

Liberal vs. conservative vasopressor use to maintain mean arterial blood pressure

during resuscitation of septic shock: an observational study

Subramanian S et al. Intensive Care Med. 2008; 34: 157-62

Change in SOFA at 24 h stratified by fluid resuscitation and vasopressor use (p = 0.019)

Renal haemodynamic, microcirculatory, metabolic and histopathological responses to peritonitis-induced septic shock in pigs

Chvojka J et al Crit Care 2008; 12: R164

Early Goal-Directed Therapy in Sepsis

Rivers E. et al, NEJM 2001

Wo ist die Evidenz?

Redfors B al Intensive Care Med 2010; 37: 60-67

Individual data on the relationship between target mean arterial pressure (MAP) and glomerular filtration rate (GFR) In all patients but one, GFR was higher at target MAP of 75 vs. at 60 mmHg. In two patients with diabetes type II (dashed lines), GFR was considerably lower (35–60%) at 90 vs. at 75 mmHg

Effects of norepinephrine on renal perfusion, filtration and oxygenation

in vasodilatory shock and acute kidney injury


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