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3. Fluid managementin critical ill: who will win? Crystalloids vs. Colloids Colloids vs. Colloids Crystalloid vs. Crystalloid Dry vs. Wet

5. Colloids vs. Crystalloids Human Albumin = „natural Colloid“ Artificial Colloids Hydroxyethylstarch (HES) Gelatin Dextran

6. Maintain or increase oncotic pressure Significant increase of intravascular volume Stays in the intravascular department Benefit of Colloids vs. Crystalloids

7. 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.“ Colloids vs. Crystalloids Very heterogenous datas, vgl. Bremen 2005 Dietrich.Very heterogenous datas, vgl. Bremen 2005 Dietrich.

8. Hands up !!

9. 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) What do we guess about volume replacement?

10. Increased mortality after albumin administration in critically ill patientsCochrane 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 Albumin

11. “Is albumin administration in the acutely illassociated with increased mortality? Results of the SOAP study”

14. 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.

15. Colloids vs. Crystalloids

16. Colloids vs. Crystalloids

17. Colloids vs. Crystalloids

18. Colloids vs. Crystalloids

19. 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.

20. „Fluid resuscitation in severe sepsis and septic shock: Albumin, hydroxyethylstarch, gelatin or ringer´s solution lactate: Colloids vs. Crystalloids

26. Fluid Resuscitation during capillaryleakage: Does the type of fluid make a difference?

27. Sepsis in European intensive care units:the SOAP study

28. Sepsis in European intensive care units:the SOAP study

29. Factors of increased mortality Degree of organ dysfunction Patient age Cirrhosis Mean fluid balance

30. 26 neonates ( gestational age: 26 – 40 wks) plasma volume expansion for insertion of a central catheter. 10 ml/kg albumin 5% vs. 6% HES 200/0.5. Prospective, randomized, double-blinded. Outcome measurement: increase in creatininemia.

31. 50 % Cristalloid vs. 50 % Colloid as preferred volume replacement

32. Fluid Management in critical ill:Conclusion

33. Albumin should be used with caution in critical ill patients “dry” seems to be more beneficial than “wet” Colloids (HES, Gelatin) have some advantages regarding fluid therapy in sepsis Fluid Management in critical ill:Conclusion

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

35. Fluid Management in critical ill:Conclusion

36. …there are no studies yet, about safety, efficacy or benefit regarding colloid or crystalloid in critical ill children

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